At the Health Affairs blog, I co-authored a piece with RAND’s Mark Friedberg and Jodi Liu asking a very simple question: When someone says Medicare for All, what do they mean?
For policy analysts, such high-level proposals quickly draw a question: “What do they really mean by Medicare?” Medicare has multiple components: traditional Medicare (Part A and Part B, also called original Medicare or fee-for-service Medicare), Medicare Advantage (Part C), and Medicare prescription drug plans (Part D). Each of these components requires a separate premium, and Parts C and D plans are offered by private insurers…..
There are serious holes in the insurance design features of Medicare in that there is no out of pocket maximum and low incentives for care coordination. Drugs and physical health services may or may not be seen as complements or substitutes as appropriate. These problems are often ameriolated if not resolved by beneficiaries buying Medigap plans or integrated Medicare Advantage plans.
As there is significant political movement towards a variety of Medicare for All proposals, we need to know what we are talking about. Is it Medicare as it is with new age qualifications? Is it a comprehensive no cost sharing cover everything proposal where the only thing that ties it to Medicare is branding and claims processing infrastructure? Is it something in between?
We must know what these answers are in order to actually figure out how things could work and how the transitions that need to be managed could be managed. The tough work of converting a slogan into policy requires honesty.
Baud
It’s a slogan right now. Sooner or later, there will be concrete proposals, at which time I assume the unity will disintegrate.
Cameron
My understanding when I first heard the phrase was that it was referring to Canadian Medicare; I’m not sure who told me that.
Rusty
This was always part of the problem with the Bernie movement. They pick a solution instead of a problem. The problem is people don’t have healthcare. Good politics is you have a principe of wanting universal healthcare, and then work the politics of what is acheivable to get there. If it’s single payer, fine. If it’s a mix of public and private, fine. What can pass? Picking the solution makes the politics harder and restricts flexibility and ability to find a better solution. I suspect a lot of people that say Medicare for all really mean universal healthcare.
rikyrah
Just a slogan. Those who want it, can’t explain how to pay for it.
magurakurin
excellent article. thanks as always. Your knowledge and expertise is greatly appreciated.
Ohio Mom
I think lots of people younger than Medicare age have a (mistaken) hazy idea it’s free. They are similarly deluded in thinking that it won’t be as complicated as dealing with private insurance (not being aware that there are private companies involved).
I watched my retired CFO BIL and my sister, who runs a volunteer tax assistance program for seniors because she likes fine print, grapple with choosing among their Medicare choices. Now they were obsessed with making the “best” choice, and lots of other people wouldn’t have the ability to be as thorough as they were. Less sophisticated consumers might be more easily satified.
I’m not looking forward to all that, with the exception of knowing coverage for my pre-existing conditions will never be questioned.
Ohio Mom
Anyway, it’s an important question you’re asking, David. Will look forward to hearing about your findings.
Major Major Major Major
It’s basically a slogan that polls well (doesn’t it?). I completely agree that it’s problematically light on substance… but I wonder how much that matters at this point during a political/messaging struggle. Will people get hung up on the implementation, will it get “lie of the year” when the signed law is not in fact “Medicare for all?” Yes, but… are those good problems to have?
David Anderson
@Major Major Major Major: There are a lot of trade-offs that are embedded in the multiple flavors of “Medicare for All”.
Assuming the Dems have a reasonably large primary field, those trade-offs will be highlighted.
Baud
@Major Major Major Major: Depends. Obamacare was a massive improvement but too many people chose to dismiss it until the Republicans were in a position to destroy it. If that happens again, it’s not a good problem.
Baud
@David Anderson: The Dem primary field will be unreasonably large.
Steeplejack
@Baud:
Yes, since most people don’t know much about Medicare until they’re about to go on it, “Medicare for all” is (often) a place-holder for “affordable insurance for everybody, preferably without corporate gouging.” Although there seems to be a faction that literally wants everybody put on Medicare right now.
David Anderson
@Steeplejack: That tension between your first sentence and your last sentence is key.
Major Major Major Major
@Steeplejack:
For the sage of Vermont said that we shall have Medicare for all, which in His wisdom shall mean, Medicare, for all…
@David Anderson: I think that’s a pretty alright place to air them.
Baud
As a reminder, Baud!Care! covers your pets. All other health care proposals are neoliberal schemes to favor Big Veterinary.
Procopius
@Steeplejack:
I think that’s going to cause huge battles. Personally I don’t want to see the “insurance” metaphor used at all. The sausage doesn’t get ground this way, but I want to set the goal as “any and all medical care, from the most trivial to the most catastrophic, delivered with no payment required at the point of delivery.” Well, on second thought I suppose it will need to have some insurance aspects, as Social Security did after 1983 and the Greenspan Commission (RWNJs love to claim that the U.S. Treasury Bonds are “worthless IOUs” so the Trust Fund is actually insolvent, but they are lying). The important thing is that payment be regular, foreseeable, and not a crushing burden. I like what I’ve heard about the British National Health System before the Tories wrecked it.
narya
I agree with Rusty–I think most people want universal healthcare. That said, I think a lot of the opposition is intentional obfuscation and opposition by corporations that fear they have the most to lose. There’s also the effort by the Republicans who are in the pockets of their corporate overlords (“All of them, Katie”) who want to keep people poor and hurting; people who are worried about getting the kid to the doctor or putting food on the table are people who aren’t trying to jump through hoops to vote.
MattF
Can I just mention that, when you’re retired, Medicare Part B premiums come out of your Social Security benefit? I suspect that many of you young’uns may not realize that. I certainly didn’t.
Also, for the record, Medicare Part D (the drug benefit) can be complicated. In my own case, Medicare part D is included in a secondary-insurance retiree benefit from my former employer, so the Part D premium is included in a regular payment to my former employer, of all people.
So, yeah, ‘Medicare for all’ could mean quite a number of different things for me.
FlipYrWhig
My pie in the sky idea has been to federalize all primary care — essentially “VA for all” with some sort of “MediCorps” providing services after having been given basic training funded and run by the federal government. That would be the way to handle public health crises too. It seems to me that there are *plenty* of people who could be made into satisfactory health providers in that old-timey country-doctor way, thereby solving the problem of healthcare access. Then again I have no idea how much such a thing would cost.
Tony Daniel
David Anderson,
I think your point about no maximum out of pocket with traditional Medicare is something that most people, including those on Medicare, don’t fully comprehend. This was the primary factor in my choosing a Medicare Advantage plan. Sure, I’ve got a bit more exposure. But, If I have a major, catastrophic illness, I’m not subject to the no limit out of pocket exposure.
I think if Medicare for all were similar to Advantage plans, it would get the private insurers more agreeable to the concept. Plus, it would provide affordable coverage for those not already eligible for Medicare type coverage. It would also broaden the risk pool by adding more healthy individuals to the mix.
MomSense
I think what they really want is Medicaid for all but that sounds like that icky poor people’s health care.
Freemark
Any politician who publicly espouses any particular specifics on which ‘version’ we will attempt to implement would be an idiot. Right now we need people to get behind the idea of universal health care. Medicare is what Americans are most familiar with that would do that. We know it works because it already works in every other country that has it. We know we can pay for it because we already spend more than any other country per person. Getting into specifics right now would allow the enemy to attack those specific items rather than the idea and specifics are going to change anyway when legislation, that can pass, begins to be written.
Betty Cracker
@narya:
Bingo — there’s dishonest sloganeering and hidden agendas from every angle. The reality is that we have an incredibly complex and expensive healthcare access delivery system based on employer and tax-funded benefits. “Medicare for All” is a slogan that will have to be unpacked at some point, but given the complexity of the issue, maybe slogans are a necessary evil now. “Medicare for All” does defang the “Venezuela-style socialized medicine” bugaboo from the right to some extent, which is a good thing.
Barbara
Here is how I try to explain this: Think of every separate kind of health care program as a river. Every program you participate in as an individual or an insurer or a provider requires you to get in your canoe or kayak and row. Some of these rivers are like Class 4 rapids, others are less onerous; some are more onerous for providers and less onerous for beneficiaries and vice versa. But the more rivers you have to navigate the harder you have to work just to get to where you want to go. We could utilize any one of these rivers as the base or default way for people to get health care but putting everyone in the same kind of boat in the same river would help us whichever one we choose. I, personally, don’t like the base Medicare benefit because it silos care between hospital, doctor and drugs — the first two being simply an artifact of the way Blue Cross companies were organized in the 60s as hospital and doctor’s insurance. Doing it this way builds tremendous complexity and fragmentation into the Medicare program. Most Medicare beneficiaries also buy private insurance to supplement the gaps in Medicare coverage.
Ruckus
@Rusty:
@Ohio Mom:
I’ve been asking similar questions ever since I first hear the words “Medicare for All.”
Medicare is not a great system, it is not free nor is it cheap in the long run. It is some what cheaper, lots cheaper than nothing if you have issues – which being old you do and you will. But it is not particularly great coverage, it doesn’t work all that well because you have to find a doc who will provide service and healthcare will eat up most retirement monies. Which is what happens to a massive amount of people who have serious health issues. Everything they have must be basically gone before it actually works, and that ain’t pretty.
What Medicare is, is better than the alternative before it, which was nothing. What does anyone think the rates for healthcare would be if we put seniors in the general population without Medicare and with the ACA? Less? Let’s get serious, Medicare for All is a slogan, absolutely nothing more. If tomorrow, our healthcare payment system was changed to Medicare for All, the screams would be heard around the world from the millions of people who found out how it really works.
p.a.
Of course different histories, polities etc. but the histories of how other 1st World countries got to where they are could be instructive as to what to/not to do/try. Especially I assume UK’s and Canada’s, other Anglo: Oz & Kiwi.
Whose oxes got gored?
BC in Illinois
When I hear “Medicare for All,” I think of the debates for Obamacare.
I wasn’t in favor of “Obamacare”; I was in favor of Healthcare for All.
I think that a lot of the people who are for “Medicare for All” are in favor of Healthcare for All. Period. Just* figure out how to do it.
We want what the rest of the civilized world has, where if you get sick, you won’t lose your house. I really don’t care if we do it in the way that Germany or Canada or the UK or Switzerland or Sweden or Japan do it. Just* do it.
I am on Medicare, along with a Medicare supplement, chosen (without a lot of expertise) from options provided by my former employer. I live on Social Security, a pension from the former employer, and other money that Mrs. BC and I can earn. 9 1/2 months ago, I had (by some definitions) a heart attack. When you add up all the costs — hospitalization, heart catheterization, stents, cardiac rehab, pills — the bills come out to about $100,000. Take away Medicare and I would probably have lost the house. (I knew someone pre-ACA who received all the care she needed for cancer. Never turned away. After her death, her husband — bankrupt — lost his house. That was the old system.)
“Medicare for All” is a slogan that differentiates between those who consider that the old, lose-you-house system was just fine and those who consider it unacceptable. My local re-elected congresswoman, when asked what she thought about voting to remove healthcare from 20 million people, responded that she had brought “Freedom!” (She literally saw herself as a warrior, “like in Braveheart.”)
The debate will be a hard and as complicated and as intentionally muddled and as over-larded with “money talks” (thank you Citizens United ) as the ACA debate. For my money, the operative words are “For All.” How to do it is a debate worth having — but a debate ONLY worth having among those who are “For All” — those who are interested in having EVERYBODY not lose their house.
Medicare? It works for me. (But how many are in my position of pension, Social Security, extra income, Medicare, Medicare supplement, etc.?) Figure out how to do something similar — for everybody. Other nations do it. Pick a nation and steal their system. Just* do it.
*I realize that the word “just” has a lot of work to do.
??? Goku (aka Amerikan Baka) ??
@Ohio Mom:
I’m not that familiar with Medicaid, either. It’s apparently more popular, probably because of the Medicaid expansions. Do you think it work better to be expanded into a national healthcare program that covers all Americans?
Eric U.
I am not sure what time is best to nail down the details of Medicare for all. Maybe we are getting close. I think the biggest lessons to take from the ACA is not to worry so much about being revenue neutral, and make sure there are fewer people that get screwed. A lot of work needs to be done to make sure it’s not complicated to enroll. I prefer a Medicare (or Medicaid) buy-in not tied to income. The main reason I don’t like Medicaid is that it can be messed up by republicans at the state level. If we can take the best features of both and we don’t get rid of private insurance, I think that’s a good start. Taking over medical care entirely, like the bill in California was going to do, seems like a good way for Democrats to lose power for a couple of decades.
MattF
@??? Goku (aka Amerikan Baka) ??: I think that before Medicaid expansion, Medicaid had a negative association with ‘lazy’ people who got themselves declared ‘disabled’ and therefore eligible for Medicaid benefits. The ACA may have changed, or at least challenged that– but perceptions are hard to change.
tobie
@BC in Illinois: The basic design for Obamacare was ‘stolen’ from Germany. It may not be the most efficient system in Europe–I’m not in a position to judge–but it works there and was considered to be the easiest system to transition to as a largely employer provided health insurance system. Only a very small slice of the population gets its insurance on the exchanges in the US. Most get it through their employer or through Medicare and Medicaid. Whatever solution we come up with will have to be sold to those two groups. Sleazy De Santis tried to scare seniors in FL with Gillum’s proposed Medicare for All. I wonder if Guaranteed Healthcare for All would be a more effective slogan.
The Golux
One thing that has always puzzled me is that employers that provide health insurance as a benefit generally aren’t in favor of something like Medicare For All or the “Public Option”. Wouldn’t they prefer the “freedom” of not having to deal with their employees’ health at all?
ETA – FYWP forgot my nym. Bah!
Barbara
@??? Goku (aka Amerikan Baka) ??: Medicaid is a state/federal program that protects categories of people who are indigent, and then, after the expansion, with income levels up to 133% of FPL (federal poverty level). Medicaid is also the ONLY program that pays for long term nursing home care for elderly people. In some states, that’s the minority of people but the majority of expenditures. The knock on Medicaid is that providers are not paid enough. This is also the knock on Medicare. One stops to wonder how it is that they are so miserly, when these programs collectively account for something like 40% of health care expenditures and providers nonetheless seem to be well-paid. At any rate, like Medicare, as Medicaid insures more politically aware and active people things like payment levels are malleable and not set in stone.
Thoroughly Pizzled
Just call the final program Medicare for All regardless of how it’s implemented. I think the German-style/Obamacare system will prevail, just with coverage expanded to the entire population. And we can throw in the public option and Medicare buy-in too.
daveNYC
@Eric U.:
I think this is understating things. Revenue Neutral is a freaking trap that waters down policy and does nothing to stop attacks on it from the tax-and-spend angle.
The Golux
My comment got eated because FYWP can no longer remember my nym.
Yutsano
Want the best system for the US? Look at what Australia does. Copy that as much as possible. A public/private split like that would send no one home absolutely happy but would keep there from being too many winners and losers.
StringOnAStick
If we could buy-in to Medi-anything, my husband and I would go to part time today. Our state still has protections for pre-existing conditions (which we both have), but until the ACA is safe and coverage for pre-existing conditions is truly set in stone, we can’t take the risk of getting off of his company-provided plan.
Americans should travel more outside the US just so they can see the reaction when they get to explain to people with humane health care systems that in the US your health insurance is only affordable through your employer, and if you lose your job you can easily be judged un-insurable at any cost. That is … instructive.
Sam Dobermann
@Barbara: Barbara has covered Medicaid well. It’s my thought that after we work on a few problems* we could go to an expansion of Medicaid by raising the income level cutoffs over a period of time. Like up to 200% of poverty level (pl) then 250% … or more gradually. After a while those above the level will be clamoring for it.
No system will cover everyone; Medicare only covers 95% of Seniors, so 5% are not covered — and that took many years. The ACA actually brought the uninsured rate down to 9% in just a few years, an incredible feat. So those sneering about the number left uncovered need a reality check.
Medicare is extremely expensive overall now. For each person the premium is $134 per month. That’s each. A couple wd be $268/mo. For those with higher incomes the premiums are higher going up to $428.60, That’s per person per month, $856 for a couple. Part A is free IF you qualify. Details are at Medicare.gov.
However Medicare premiums do not cover the costs of the coverage. By law the premiums one pays covers 25% of costs; the federal government pays 75% of what would be the premium. So basically the cost of insuring a person is 134 + 402 = $536 per month per person.
So for Medicare the government is paying $402 per person & that is times how many millions? And the over 65 cohort is rising!
That’s why Republicans are fighting to cut Medicare. It really is a huge budget buster. Someone said the Democrats are concerned about access & the Republicans about costs. Both really need to be our concern.
So before we can go any further we do need get costs down. Recall that Vermont tried to go single payer and found they could not do it as it would be too expensive. If one little monochromatic state without expensive hospitals could not do it you can’t expect the whole US to be able to eat it.
Obama pointed out there were 3 legs of a stool that needed attention: Access, Quality and Cost. The ObamaCare part of the ACA gives access, at least it would if all states expanded Medicaid. That is covered in Titles I & II. There are 7 more titles which work on the other two areas: increasing quality and reducing costs*. Strangely they go together. As you increase quality you reduce costs.
Until you reduce costs you will never get to a place of increased access with simplicity.
I’m going to put off discussing what’s covered in the rest of the ACA for another time. Suffice it to say that great strides in reducing costs have been made since the ACA (not just ObamaCare) went into effect. Actually some improvements for the health care system were in the Stimulus Bill (ARRA) passed early in 2009.
Ohio Mom
@Tony Daniel:
I have long tried to imagine what Medicare’s “no maximum out-of-pocket” looks like in real life. People must go bankrupt, why don’t we hear about them?
Is just about everyone on an Advantage plan for that reason? Is the “no maximum” a trick to get everyone into an Advantage plan?
Ohio Mom
@??? Goku (aka Amerikan Baka) ??: My experience with Medicaid is very limited. Ohio Son is on it as a disabled person who has qualified for a Medicaid Waiver. The Waiver provides him with Medicaid and also funding for such things as respite care, day programs and work coaching. The Waiver is a complicated program that I can hardly begin to explain here.
So far, Medicaid has worked fine for us but it is Ohio Son’s secondary insurance; he’s still covered under Ohio Dad’s policy.
When he ages put of Dad’s coverage, I expect to run into problems finding doctors who will accept just Medicaid. I’m under the impression that most medical practices have quotas on the number of Medicaid patients they will accept because they lose money on every one on their roster.
Add to that the fact that a lot of people with disabilities have complex medical needs, and the red ink on the doctor’s books gets a lot redder.
Another thing to know about Ohio Medicaid for disabled people is that if you do not have a Waiver (which is common because there are a limited amount of Waivers and there is a long waiting list for them), and are eligible for Medicaid by virtue of qualifying for SSI, you must join a Medicaid HMO (which you don’t have to do if you get Medicaid through a Waiver).
I suppose that might make it easier to find a doctor but you might not find one who is a good match for your specific disability-related needs.
Of course, every state administers Medicaid differently. What I think I am trying to get across is that Medicaid is just as much of a thicket as any other part of the US health insurance system. Medicaid for all would not be a panacea, at least not without lots of changes. Including paying doctors more.
jl
If we don’t go Swiss, go Australia!
There should be more discussion of different countries’ experiences and practices, particularly those who have chosen programs that contain costs, produce among the best population health levels in the world, and at the same time very efficiently increase population health for all age groups over time.
So, go Swiss! Or, go Australia!
I think Australia’s version of a Medicare for all system.should be studied closely for lessons. The Aussies even call it Medicare.
Edit: good to remember that several countries used Germany’s pioneering efforts at establishing social insurance in the 19th century as a model. Switzerland started off by modelling their first social health insurance system on Germany’s in 1912.
Older
I would recommend FEHB For All, personally (TriCare is the roughly equivalent for members of the military). Way back when I was a statistician and working for the government and familiar with large numbers and all, I worked it all out. Including how to fund it. My job had nothing to do with insurance, so I never talked to any one higher up about it. I figured, if I could do it, others could do it, but I never head anyone propose it.
The biggest advantage is that it’s much less confusing than ACA. In spite of my background, I can’t get my head around Obamacare, and I feel very lucky to be an FEHB subscriber.
Dan B
@Sam Dobermann: Thanks for the details you’ve provided.
My Rep is the lead for Medicare for all. I’ve got connections to some folks in her coalition so might be able to get her attention. My first wish is that the label be changed to “guaranteed healthcare” so we’re not debating Medicare or Medicaid. I also feel it would provide some room to talk about the reduced paperwork that doctors in England and other countries enjoy.