A panel of health policy experts helps
you make decisions along five key dimensions.
By AUSTIN FRAKT and AARON E. CARROLL FEB.
21, 2019
“Medicare for all” is popular, and not just among Democrats. Most
Republicans favor giving people under 65 at least the choice
to buy into Medicare.
But when people hear arguments against
it, their support plummets. It turns out that most people don’t really know
what Medicare for all means. Even asking three policy experts might yield three
different answers.
By our count, there are at least 10 major proposals to expand Medicare or
Medicaid.
Some, like Senator Bernie Sanders’s bill, would create a
single health care plan for all American residents. Others, like Senator Debbie
Stabenow’s Medicare at 50 Act, would expand Medicare
eligibility, but not to everyone. Still others would make Medicare or Medicaid
a health care insurance option for many more Americans without necessarily eliminating
private coverage.
Collectively the proposals vary in at
least five fundamental ways, and you can vote on each category below to compare
your responses with those of other readers and to see which proposals come
closest to your views. We’ve also asked 11 health policy experts to weigh in on
each choice. (The ideological composition of the panel spanned generally from
center to left because, for now, this is a Democratic intraparty debate.)
Panelists’ verdict
Nearly all the experts favored
universal coverage.
Background
Universal coverage is found in every
developed country except the United States, where 10 percent to 14 percent
(depending on the survey) of the population is uninsured,
down from a high of about 18 percent before the Affordable Care Act’s coverage
expansion.
Pro/Con
For some panelists, the decision was
simple. “Universality is essential,” said Harold Pollack, a professor of social
service administration at the University of Chicago. “At bottom, this is a
moral issue.”
“Any decent society provides universal
health care,” said Dr. Marcia Angell, a senior lecturer at Harvard Medical
School.
While many Americans loathe the idea of
losing choice, opting in doesn’t always work. “Some people will fail to sign up
for coverage, even if it’s free,” said Sherry Glied, a health economist at
N.Y.U. “People who don’t sign up may eventually need and benefit from care, and
we want them to get it, so we want to make enrolling in coverage as easy as
possible.”
Nuances/Politics
“Universal” may not apply to everyone,
perhaps leaving out undocumented residents. Some panelists favor a system in
which people can opt out of coverage, which would undermine universality. There
is a workaround, though, according to Dr. Ashish Jha, a physician with the
Harvard T.H. Chan School of Public Health: “Asking people who opt out to pay a
tax is a reasonable way to ensure that if they end up having catastrophic
spending, society has a pool of funds to pay for it.”
Universality has trade-offs. It’s
costly, part of why it has always faced political resistance. “Expanding
coverage to a subset of the population, for example those nearer retirement
age, will be cheaper and more politically palatable,” said Ellen Meara, a
health economist and a professor at Dartmouth. “The desire for incremental
approaches led us to create Medicare, Medicaid and the Children’s Health
Insurance Program, each targeted to specific subgroups of the population.”
Panelists’ verdict
Most agreed that if they were starting
from scratch, they would not create a system with employer-based coverage. But
most also said plans that eliminate it now are politically infeasible.
Background
Most adults under 65 get health
insurance through their jobs or through a job of a working family member. Many
are happy with their coverage and might rebel if forced to drop it.
Pro/Con
One disadvantage of coverage through
work is that it can cause some people to stay in jobs they don’t want. One advantage is
that private coverage can offer benefits that public plans like Medicare don’t.
Many other countries, even those with universal
public coverage like Canada and Britain, also allow employers to offer
additional coverage. “Americans like choice, and flexibility,” said Elizabeth
Bradley, a public health scholar and president of Vassar College.
Other experts said it was time for
employer-based coverage to go. A profusion of coverage options “generates
complexity that drives up administrative costs,” said Dr. Steffie
Woolhandler, a physician and a professor at Hunter College.
“We should transition away from
employer-based private coverage,” Ms. Meara said.
“Employer-based coverage should be
ended,” Dr. Angell said.
Nuances/Politics
“From a political perspective, people
with coverage from large, high-wage firms are going to be a potent force
against taking it away,” Ms. Glied said.
Although he argued in favor of
eliminating employer plans, John McDonough, a Harvard professor who helped
write the Affordable Care Act, agreed that doing so would be politically
difficult or even impossible: “It’s hard to turn around an ocean liner.”
Mr. Pollack concurred: “Any proposal to
ban employer-based coverage would self-immolate.” Nevertheless, job-based
coverage has some undesirable features. “Employers typically lack the
bargaining power with providers to really discipline prices or health care
delivery,” he said. “And the tax subsidization of employer coverage is
regressive.”
Dr. Don Berwick, a senior fellow at the
Institute for Healthcare Improvement, sees a way to meld work-based coverage
within a single-payer system. “If employer-based coverage is retained, that
does not make a single-payer approach impossible,” he said. “Employers could
contribute to the single, common payment pool, as they do today to premiums for
private plans.”
Panelists’ verdict
Mixed
Background
One major objective of the Affordable
Care Act was to give a reasonable option to people who didn’t qualify for
public programs and could not obtain employer-based coverage. Medicare also has
an individual market, through Medicare Advantage — private plans that offer
alternatives to the public and traditional Medicare program.
Pro/Con
“Having choices among plans, with insurers
competing to provide plans that meet enrollees’ needs, can be a driver of
innovations in benefits that respond to consumer demand, improved quality and
lower premiums,” said Kate Baicker, a health economist at the University of
Chicago.
Ms. Meara concurred with these
advantages, but brought up a key problem with an individual market with many
competitors: “Variation across health plans in approaches to quality and costs
can translate into a hassle for doctors, hospitals and other health care providers.”
She pointed out that the large variety
of payers in the U.S. system had led to over 1,700 distinct quality measures
and a wide variety of billing requirements.
A reason to have both public and
private options in one market is to provide choice. “For a country as large and
diverse as ours, a single plan for all would be unworkable,” Dr. Jha said.
Yet for some, the downsides overwhelm
the value of choice. “Individually purchased private coverage, like job-based
coverage, generates inequality and complexity,” Dr. Woolhandler said.
“I would prefer a single-payment system
more like traditional Medicare for everyone,” Dr. Berwick said. “It would not
be a perfect solution at all, but it would have the enormous advantage of
simplicity and lower transaction costs.”
Nuances
The A.C.A. marketplaces are quite
different from Medicare Advantage, though both are individual markets. Details
matter, our experts said.
“In part, the marketplaces struggle
because we didn’t throw enough money at them,” Mr. Pollack said. “Medicare
Advantage is a much better experience, largely because both parties have
collaborated to support it with generous subsidies. And less competitive
Medicare Advantage market areas have the backstop and competition provided by
traditional Medicare, a public option for seniors.”
Panelists’ verdict
Most of our experts saw a role for some
premiums, in some cases because they thought a “no premiums” approach was
politically unrealistic.
Background
Americans are accustomed to paying at
least some of the premium of a health insurance plan, although some people on
Medicaid or with A.C.A. marketplace coverage pay none.
Pro/Con
Dr. Woolhandler argued for a fully
tax-financed system: Everyone could be automatically covered “whether or not
they’re able to (or remember to) pay their premiums.” Additionally, “using the
existing tax collection system is far more efficient than setting up a
duplicative apparatus to collect premiums.”
Dr. Berwick said: “Moving to
tax-financed health care makes the most sense logically. One advantage of a
tax-funded system is the opportunity to engage in socially progressive
financing, with wealthy people bearing a greater share of the costs.”
Ms. Bradley said “a mix is likely
necessary.”
Nuances/Politics
Paul Starr, a professor of sociology
and public affairs at Princeton, favors tax financing, but a look at the
numbers convinced him that it was not realistic. If taxes were to replace all
private premiums as well as out-of-pocket spending (as in some single-payer
plans), the government would have to nearly double what it now collects in
personal income tax. “There’s no precedent in American history for a tax
increase of that magnitude,” he said. “It’s not going to happen.”
Mr. McDonough reminded us that when
Vermont considered a tax-financed single-payer system, sticker shock killed it.
The required tax increase “was recognized by then-governor and single-payer
champion Peter Shumlin as political suicide.”
Ms. Meara and Dr. Jha pointed out that
premiums become necessary once you allow some choice in coverage through
markets. More generous coverage is more expensive and would warrant some
premium payment.
Finally, Ms. Baicker thought tax
financing should be focused on low-income people: “My preference would be to
have public programs that focus on lower-income populations, rather than using
taxpayer dollars for high-income people who could afford coverage on their
own.”
Panelists’ verdict
All but two of our panelists supported
some type of cost sharing.
Background
In addition to premiums, most Americans
are accustomed to paying for some health care through deductibles and
co-payments. High deductibles have become one of the biggest criticisms of
A.C.A. plans.
Pro/Con
Most of the panelists and most of the
proposals would keep cost sharing, but Dr. Woolhandler and Dr. Angell preferred
to eliminate it. “There should be no co-payments or deductibles,” Dr. Angell
said.
“Cost sharing penalizes the sick and
poor, who forgo vital as well as unneeded care, and suffer grave financial
harms,” Dr. Woolhandler said. “Experience in some nations proves that cost
sharing is not necessary to control costs.” On the contrary, she argued,
collecting co-payments and deductibles just adds a costly, administrative
burden.
A downside of cost sharing is that it “can lead
to patients and families delaying necessary care or skimping on prevention,”
Ms. Bradley said.
Nuances
Ms. Glied articulated a common
sentiment among many of the experts we interviewed: “Co-pays deter excessive
use of the system, but the biggest effects are moving from zero to something.”
If that “something” is too big, it is
“effectively just a tax on those with pre-existing conditions.”
“So the design of cost-sharing, like
any incentive scheme, must be carefully considered so that it reduces overuse
without limiting necessary care,” Ms. Bradley said.
This, known as value-based insurance design, was favored by many
experts, including Ms. Meara, Ms. Baicker, Dr. Jha and Dr. Berwick.
Comparing 10 Major Health Care
Proposals
|
Proposal
|
Univ. coverageUniversal coverage
|
End job plansEnd employer plans
|
End indiv. mktsEnd indiv. markets
|
End monthly feesEnd premiums
|
End cost sharingEnd cost sharing
|
|
DeLauro/Schakowsky
|
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Schakowsky/Whitehouse
|
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Bernie Sanders
|
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Jayapal/Progressive Caucus
|
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Higgins/Kaine/Bennet
|
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Lujan/Schatz
|
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Merkley/Murphy
|
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Stabenow/Peters
|
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Center for American Progress
|
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Urban Institute Fellows
|
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Expert consensus
|
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Your choices
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We acknowledge that there are other key
variations beyond these five big questions, like which benefits are covered and
whether and how the government might regulate health care prices. There are
also plenty of nuances among the proposals (which we hope to follow up on).
Some plans, including the one offered
by Senator Sanders, as well as the Medicare for America Act, backed by
Representatives Rosa DeLauro and Jan Schakowsky, would provide universal
coverage. Others, like the Healthy America Program from fellows at the Urban
Institute, would not necessarily do so.
Most proposals would retain
employment-based coverage and individual markets. These include Medicare X (Representative Brian Higgins, Senator
Tim Kaine, Senator Michael Bennet); the Choice Act (Ms. Schakowsky, Senator Sheldon
Whitehouse); and the Choose Medicare Act (Senators Jeff Merkley and Chris Murphy).
Most plans would also keep premiums,
though some would have subsidies for low-income families. But a few, including
from Representative Pramila Jayapal and the Congressional Progressive Caucus,
would do away with premiums entirely.
Almost all proposals would keep cost
sharing, with some shedding it for those below the poverty threshold.
Medicare for all is not the only way to
achieve major coverage expansion. Several panelists, including Ms. Glied and
Mr. Pollack, like the idea of a public option or federal fallback plan —
perhaps a Medicare-like plan that competes with other, private coverage. A
proposal from the Center for American Progress includes versions of
this idea.
Ms. Meara suggested a related idea,
similar to one that Representative Ben Ray Luján and Senator
Brian Schatz have proposed: “A more realistic path would make some basic set of
benefits available — like a Medicaid buy-in — leaving open a path for those
wishing to spend more to do so.”
Mr. Starr said the next Democratic
president would not repeat the mistake of exhausting his or her political
capital on health reform. Mr. McDonough agreed, saying coverage expansion
debates have a way of “sucking up all the political oxygen.” He would like to
see “space for consideration” on education, taxes, climate change, ethics and
campaign finance reform, “and so much else.”
If Democrats win in 2020, there is sure
to be a tension between ideas reflected in Dr. Woolhandler’s declaration that
“health care is a human right” and Mr. McDonough’s warning that pursuing a
fully government-run Medicare for all might “pre-empt progress on everything
else.”
Marcia Angell, former editor of the New
England Journal of Medicine, and senior lecturer in the Department of Global
Health and Social Medicine at Harvard Medical School
Kate Baicker, a health economist and
dean of the University of Chicago’s Harris School of Public Policy
Don Berwick, former administrator of
the Centers for Medicare and Medicaid Services, and president emeritus and
senior fellow of the Institute for Healthcare Improvement
Elizabeth Bradley, a public health
scholar, president of Vassar College and a professor of science, technology and
society
Sherry Glied, a health economist, and
dean and professor at the Wagner School of Public Service, New York University
Ashish Jha, physician and director of
the Harvard Global Health Institute, and professor at the Harvard T.H. Chan
School of Public Health
John McDonough, former Senate staffer
involved in writing and passage of the A.C.A. and professor of practice,
Harvard T.H. Chan School of Public Health
Ellen Meara, a health economist and the
Peggy Y. Thomson professor of evaluative clinical sciences at the Dartmouth
Institute for Health Policy and Clinical Practice
Harold Pollack, professor of social
service administration, University of Chicago
Paul Starr, professor of sociology and
public affairs, Princeton University
Steffie Woolhandler, a primary care
doctor, a distinguished professor at Hunter College, and a lecturer in medicine
at Harvard. She co-founded Physicians for a National Health Program
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