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Expand Medicaid, not Medicare, to provide Americans with health care safety net

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The “Medicare for all” plans touted by several leading Democratic candidates for president would take away individual freedom with respect to health care. Former vice president Joe Biden is right to offer a compromise. We need to expand access in a way that limits the impact on individual freedom and protects the quality of health care available in the United States. 

There is a big difference between the government providing a safety net for those who need it, and the government becoming the only provider of health insurance. Both limit individual freedom, but the latter does so much more severely. If the government becomes the only health insurance provider, then individuals would be forced to accept what it provides. If a safety net is provided, all individuals must pay for it but they retain the right to acquire commercial health insurance. 

Consider, for example, the right to counsel in the Sixth Amendment of the U.S. Constitution. As originally written, this is a negative right and the government cannot prevent a criminal defendant from being represented by counsel. However, after the Supreme Court’s 1963 decision in Gideon v. Wainwright, the right to counsel became a positive right and the government became obligated to provide counsel for indigent defendants. 

However, this is very different than if the government decided to provide a right to counsel by requiring every criminal defendant to use counsel provided by the government. As things stand today, there is a right to counsel but criminal defendants do not have to accept the lawyer provided by the court; they are free to hire (and pay for) counsel of their own choosing to represent them.

The current proposals for the creation of a right to health care via Medicare for all would eliminate private health insurance, thereby requiring individuals to accept government-issued health care. This is not a safety net; it is a cage that would take away individual freedom. Moreover, Medicare for all would severely harm the quality of U.S. health care.

Retaining individual freedom with respect to health care will protect the quality of available health care. The contrived liberal narrative — that “U.S. health care is no better than that in other countries; in fact, it is worse and costs more” — is extremely misleading.

Some studies do indicate that the U.S. performs worse than other high-income countries in certain population health measures. For example, a study in JAMA found that life expectancy in the U.S. was the lowest of the 11 countries and infant mortality was the highest. However, these measures are misleading and omit important health determinants where the U. S. leads the world,  such as access to life-saving new drugs and investment in advanced medical technologies.

Those touting Medicare for all also fail to mention that the U. S. has superior outcomes for the most serious medical conditions — for example, lower mortality from heart attacks and strokes and higher survival rates for many cancers.

Infant mortality statistics are misleading because they are measured differently in other countries and these differences make U.S. outcomes appear relatively worse. For example, the U.S. counts every live birth when calculating its infant-mortality statistics, while France includes only babies born after 22 weeks of gestation. Also, it is common practice in several countries to register as live births only those infants who survived for a specified period beyond birth. When adjustments are made for these differences, the U.S. statistical ranking improves significantly. 

The same is true of life expectancy statistics. One study found that the largest source of variation among countries in life expectancy was attributable to behavioral and metabolic risk factors. Researchers have noted that the size and diversity of the U.S. population makes comparisons with small, homogenous countries inherently misleading.

While there are clear excesses in the costs of U.S. health care, it is naive to think that there is no relationship between the high cost of U.S. care and the high quality of care available. The best way to bring down the cost of care is to increase price and quality transparency, and thereby increase market competition.  

Individuals should remain free to reject Medicare for all — or whatever the new government-issued health plan may be called. Individuals should remain free to contract with their doctors for a specific price for their care, or to purchase commercial health insurance.

A good way to structure a safety net-style “right to health care” would be through an expansion of the Medicaid program. This would drastically reduce the cost of the proposal by limiting its availability to those who otherwise cannot afford to provide their own health care.

George A. Nation III is a professor of law and business in the Perella Department of Finance at Lehigh University. Prior to his academic career, he practiced corporate and commercial law in Philadelphia. His recent research concerns health care policy and pricing.

Tags Health policy Joe Biden Medicaid Medicare for all single-payer healthcare

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