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 BennetSanders doubles down on 'Medicare For All' defense: 'We have not changed one word' Democratic candidates face hard choices as 2020 field winnows The Hill's Campaign Report: Democratic field begins to shrink ahead of critical stretch MORE and Pete ButtigiegPeter (Pete) Paul ButtigiegSunday shows preview: Trump ratchets up trade war with China Democratic candidates face hard choices as 2020 field winnows Steyer calls on DNC to expand polling criteria for debates 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 Kevin DelaneySanders doubles down on 'Medicare For All' defense: 'We have not changed one word' Democratic candidates face hard choices as 2020 field winnows The Hill's 12:30 Report: Stocks sink as Trump fights with Fed, China 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 Ann WarrenTrump preps conspiracy theory to explain faltering economy Sanders, Warren back major shift to fight drug overdoses Rendell: Biden 'baked in' as Democratic nominee 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 SandersTrump preps conspiracy theory to explain faltering economy Sanders doubles down on 'Medicare For All' defense: 'We have not changed one word' Sanders, Warren back major shift to fight drug overdoses MORE, Warren, Bill de BlasioBill de BlasioSanders, Warren back major shift to fight drug overdoses Democratic candidates face hard choices as 2020 field winnows If the Democratic debates were pro wrestling, de Blasio is comic relief MORE, and Kamala HarrisKamala Devi HarrisSanders doubles down on 'Medicare For All' defense: 'We have not changed one word' Obama reveals his summer playlist Democratic candidates face hard choices as 2020 field winnows 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.