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 BennetBuilding back better by investing in workers and communities Biden signs bill to help victims of 'Havana syndrome' Colorado remap plan creates new competitive district MORE and Pete ButtigiegPete ButtigiegSunday shows preview: Supply chain crisis threaten holiday sales; uncertainty over whether US can sustain nationwide downward trend in COVID-19 cases Buttigieg hits back after parental leave criticism: 'Really strange' The Hill's 12:30 Report - Presented by The Conference of Presidents of Major Italian American Organizations - US opens to vaccinated visitors as FDA panel discusses boosters 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? 

Rep. John DelaneyJohn DelaneyDirect air capture is a crucial bipartisan climate policy Lobbying world Coronavirus Report: The Hill's Steve Clemons interviews Rep. Rodney Davis 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 WarrenMisguided recusal rules lock valuable leaders out of the Pentagon Biden's soft touch with Manchin, Sinema frustrates Democrats Hillicon Valley — Presented by LookingGlass — Congress makes technology policy moves 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? 

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When asked, “Who would get rid of private insurance?” Bernie SandersBernie SandersPressure grows for breakthrough in Biden agenda talks Sanders, Manchin escalate fight over .5T spending bill Sanders blames media for Americans not knowing details of Biden spending plan MORE, Warren, Bill de BlasioBill de BlasioEMILY's List announces early endorsement of Hochul More than 200 women, transgender inmates to be transferred from Rikers Island Achieving equity through mediocrity: Why elimination of gifted programs should worry us all MORE, and Kamala HarrisKamala HarrisRepublicans would need a promotion to be 'paper tigers' Democrats' reconciliation bill breaks Biden's middle class tax pledge We have a presidential leadership crisis — and it's only going to get worse 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.