Medicare for All: A voter's cheat sheet

Medicare for All: A voter's cheat sheet
© Greg Nash

The discussion of "Medicare for all" in June’s two Democratic primary debates was both gratifying and confusing. While it was heartening to see agreement on the principle of universal health care as a human right, the debate format eliminated any opportunity for nuance.

That’s why we’re clarifying seven critical issues raised in the debates, and which will likely return during the campaign. Full disclosure: We support Medicare for all and we think that with a clear understanding of the facts, most people will too. 

1. What is Medicare for all? 

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It’s a system with a single, public, nonprofit health insurer, instead of the dozens of private and public insurers we have now. It is not “government-run health care.” It is “government-run health insurance.” Like with Medicare today, health care would be provided by independent doctors and hospitals.  

Everyone would be covered for life by a single comprehensive benefit package and would choose their own doctors. Private insurance premiums and out-of-pocket costs would disappear, replaced by taxes that are fair and progressive (richer people pay more). Simplified insurance rules and billing would reduce paperwork costs while negotiations would reduce drug prices. Overall, we would save money while covering everyone.

2. What is a Medicare expansion, as opposed to Medicare for all? 

Several candidates (e.g., Michael BennetMichael Farrand BennetHillicon Valley: Facebook considers political ad ban | Senators raise concerns over civil rights audit | Amazon reverses on telling workers to delete TikTok Senators raise concerns over Facebook's civil rights audit House Democrats chart course to 'solving the climate crisis' by 2050 MORE and Pete ButtigiegPete ButtigiegIn politics, as in baseball, it ain't over till it's over Biden campaign hires top cybersecurity officials to defend against threats Biden strikes populist tone in blistering rebuke of Trump, Wall Street MORE) mentioned a public option, such as a Medicare buy-in. A public option could be offered on state health insurance exchanges, providing what might appear to be a cheaper alternative to private insurance. But it won’t solve our problems. A buy-in would leave the complicated multi-payer system in place, so the opportunities for savings on paperwork and pharmaceuticals would disappear. Moreover, the health insurance industry would use every tactic it knows to push the sickest people into the public option, jeopardizing the financial stability of the program.  

3. How do you define "working" when it comes to health care? 

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Rep. John DelaneyJohn DelaneyCoronavirus Report: The Hill's Steve Clemons interviews Rep. Rodney Davis Eurasia Group founder Ian Bremmer says Trump right on China but wrong on WHO; CDC issues new guidance for large gatherings The Hill's Coronavirus Report: Kansas City Mayor Quinton Lucas says country needs to rethink what 'policing' means; US cases surpass 2 million with no end to pandemic in sight MORE (D-Md.) said, let’s “keep what’s working” in our current system. What does that mean? Today, millions of Americans remain uninsured or underinsured — with exorbitant deductibles and out-of-pocket costs on top of their ever-rising insurance premiums. 

Medical bankruptcy is common, even among the insured — as Sen. Elizabeth WarrenElizabeth WarrenProgressive Mondaire Jones wins NY primary to replace Nita Lowey Dunford withdraws from consideration to chair coronavirus oversight panel Biden campaign announces second round of staff hires in Arizona MORE (D-Mass.). And people with employer-sponsored private insurance? They lack health-care security. If they lose their job, they lose their insurance. If “working” means decent and reliable coverage, private health insurance is definitely not cutting it. 

4. Which health-care choices really matter? 

Beto O’Rourke said “Choice is fundamental” as an argument to retain commercial insurance. Yet it is our choice of doctor (not insurance company) that is fundamental to our care and that’s exactly the freedom that commercial insurance denies us — for profit.  

5. What do we mean by private insurance under Medicare for all? 

When asked, “Who would get rid of private insurance?” Bernie SandersBernie SandersBiden aspires to become America's auto-pen president Progressive Mondaire Jones wins NY primary to replace Nita Lowey OVERNIGHT ENERGY: Biden pledges carbon-free power by 2035 in T environment plan | Trump administration has been underestimating costs of carbon pollution, government watchdog finds | Trump to move forward with rollback of bedrock environmental law MORE, Warren, Bill de BlasioBill de BlasioTrump stirs controversy with latest race remarks Vandal dumps red paint on Black Lives Matter mural in front of Trump Tower The Hill's Coronavirus Report: Fauci says focus should be on pausing reopenings rather than reverting to shutdowns; WHO director pleads for international unity in pandemic response MORE, and Kamala HarrisKamala Devi HarrisHillicon Valley: Facebook considers political ad ban | Senators raise concerns over civil rights audit | Amazon reverses on telling workers to delete TikTok Senators raise concerns over Facebook's civil rights audit Biden's marijuana plan is out of step with public opinion MORE raised their hands. Harris later clarified that she wouldn’t want to abolish private insurance altogether. She has a point: Medicare for all could co-exist with private insurance for supplemental services, like fancier hospital rooms, or alternative therapies. However, private insurance for core medical benefits would be unnecessary. In fact, keeping it would undercut the savings we could enjoy from reducing insurance complexity and pharmaceutical prices.

6. What’s a "glide path?”  

Buttigieg endorsed a “glide path,” that is, taking intermediate steps to Medicare for all. This makes sense if the timeline is short and the steps are direct. For example, filling in Medicare's existing coverage gaps and adding all 50-65 year-olds would be excellent first steps. Alternatively, we could move quickly to help everyone suffering today. It only took about a year to roll out Medicare in 1966, without the use of the Internet or computers. 

7. How will doctors and hospitals fare under Medicare for all?  

Delaney suggested that if hospitals were paid Medicare reimbursement rates, they’d go bankrupt. This is a misrepresentation. First, under most Medicare for all plans, hospitals would be paid lump sums to cover operating costs. Second, payments would be negotiated to assure financial viability. Raising the specter of hospital closures is a scare tactic. 

While Medicare for all may sound complex, it boils down to this: Everyone would get comprehensive health coverage for less money than we’re spending now. Don't let the confusing debate rhetoric fool you. It really is that simple. 

James G. Kahn, M.D., is an emeritus professor of health policy at the University of California San Francisco. Dr. Elliot Marseille, DrPH, is CEO of Health Strategies International.