As Republicans debate whether to launch one more doomed and deeply unpopular attempt to repeal the Affordable Care Act, Democrats are starting to think about how to address the public's real concerns about health care. Americans want to build on what exists, not tear it down, and they want the security of knowing that quality, affordable health care will always be there.t
A new proposal in the American Prospect, titled Medicare Part E for Everyone, delivers on the government responsibility to provide universal coverage that most Americans support, with a uniquely American solution that starts with what’s working and fixes what’s not.
Almost all of the rest of us are covered through government programs like Medicare, Medicaid and the Veterans’ Administration. But Medicare has gaps in coverage and has high out of pocket costs. Some people live in states with very limited Medicaid programs and others who have Medicaid may have trouble finding health care providers to care for them.
The 28 millions who are still uninsured are blocked from getting coverage by high premiums and complicated eligibility rules.
If guaranteeing affordable coverage is one goal of universal health care, the other is making health care affordable to the nation as a whole. A government guarantee of quality, affordable coverage needs to include measures that effectively limit health care cost increases.
In the current issue of the American Prospect, Yale Professor Jacob Hacker, puts forth a proposal that would achieve those two pillars of universal health coverage by building on Medicare and employer-based insurance. Hacker’s proposal would guarantee that everyone has good, affordable health coverage from work, Medicare or Medicaid
To guarantee that everyone is covered, Hacker proposes establishing a new part of Medicare for people under 65, called Part E for everyone. As Hacker writes:
The central feature of Medicare Part E is guaranteed insurance. All Americans would be presumed to be covered. They would not need to go through complicated eligibility processes or hunt down coverage that qualified for public support or even re-enroll on an annual basis. Once someone was in Part E, they would remain in Part E unless and until they were enrolled in a qualified alternative — whether an employment-based health plan with good benefits or a high-quality state Medicaid program.
He goes on to explain how his proposal departs from single-payer plans that would cover everyone in a Medicare-like program.
Thus, the centerpiece of Medicare Part E is the same as that of single-payer: a guarantee that Medicare is there for everyone. Unlike single-payer, however, Medicare Part E seeks to improve employers’ role rather than replace it. It does so by establishing new standards for employment-based plans and requiring that all employers contribute to Medicare if they do not provide insurance directly to their employees.
A key part of Medicare Part E is that it would make health insurance more affordable for everyone, but requiring lower out-of-pocket costs in Medicare and employer-based coverage. In doing so, Hacker addresses the biggest concern people have about health coverage today, that high deductibles and other out-of-pocket costs are a barrier to getting the care they need and a real burden on family budgets.
By making Medicare Part E the benchmark plan for the country, Hacker’s plan also helps control health care costs throughout the nation. Historically, Medicare has done a much more effective job of controlling health care spending than private insurance.
As Hacker points out, Medicare Advantage plans – the private insurance plans that are chosen by about one-out-of-every three seniors on Medicare — “operate in a market in which their main competitor is Medicare, with its relatively low rates. Thus, they can pay rates close to Medicare’s, and still get providers to participate in their networks.” Medicare Part E would serve the same function for the employer and private group markets nationally.
Hacker’s proposal would also extend Medicare’s pricing purchasing to prescription drugs, the prices of which are much higher in the U.S. than anywhere else because we are the only developed country in which government doesn’t control how much we pay for prescriptions.
I’ve provided the broadest outlines of Part E here; there’s much more in the American Prospect piece and Hacker has a more wonky version that he’s glad to share. But the key question for any proposal is how it will fare in a prolonged political fight. By building on our current health coverage system, Hacker’s approach starts with a strong political base and avoids two huge challenges to a single-payer plan.
The first challenge is that single-payer would mean taking away the health care that most people have now, whether employer coverage or Medicare Advantage plans.
We need to take the history of every health care fight in our country for more than 100 years seriously. These efforts were defeated by the fear of losing what you have, which will be a driven relentlessly by wide-array of well-financed opponents.
The second barrier is the huge tax increases needed to replace the cost of covering the 178 million people who now get employer coverage. By keeping employer coverage in place, or requiring employers to pay into Medicare Part E if they prefer, the cost of universal coverage is much less than under a single-payer plan, although revenue would still need to be raised to make health coverage affordable and assure that everyone is covered.
The Republican attempt to repeal the Affordable Care Act is a major reason that Democrats have good reason to be optimistic about their electoral chances in November.
But to earn the trust of Americans as a governing party looking toward 2020, Democrats will need to meet the deepest concerns people have about how they will be able to care for and support their families and provide a better future for their children.
An American solution that delivers on a guarantee of quality, affordable health care will need to be high on a Democratic vision for an America that works for all of us.
Richard Kirsch is the director of Our Story: The Hub for American Narratives and the author of "Fighting for Our Health: The Epic Battle to Make Health Care a Right in the United States." Follow him on Twitter@_RichardKirsch.