Democratic presidential candidates have proposed several ideas they claim would increase health care coverage and simultaneously lower costs, particularly prescription drug costs. While there is great debate on the path to take, one thing is clear: The drumbeat for changes continues to get louder.
Why?
While the Affordable Care Act expanded access to care, many Americans are still left uncovered. According to a Gallup survey conducted earlier this year, 13.7 percent of adults in fourth-quarter 2018 were uninsured, which was an increase of 1.5 percent from a year earlier.
Even the insured majority is antsy about what it perceives to be rising costs of drugs and health services/insurance. Democrats hope to seize on Americans’ anxiety over health care access and cost, thus making health care a central campaign issue for 2020.
Among the Democrats’ ideas, “Medicare for All” has the largest following and has become a household brand. While the model would impact all Americans, few actually know exactly what it entails. Several politically charged terms are being used interchangeably to explain Medicare for All, including universal coverage, single-payer system, government health care, and socialized medicine.
Medicare for All is not the only game in town. “Medicare buy-in” and “Medicare-X” have been proposed as more moderate, incremental steps toward covering all Americans. Several Democratic presidential hopefuls, including former Vice President Joe Biden, support building onto the current health care system instead of upending it.
Let’s take a look at what may become our reality.
What is ‘Medicare for All’?
“Medicare for All” refers to all 327 million Americans receiving their health care through a single government-run plan. Sen. Bernie Sanders (I-Vt.) is often associated with this single-payer health care model, as he brought it to the public eye during the last presidential election.
Every American would receive “free” health insurance under Medicare for All — a pro to the uninsured and those currently struggling to afford health care bills. Hospitalizations, physician visits, mental health, medical devices, lab services, dental and vision would all be covered with no co-pays or deductibles. Prescription drugs would also be covered but would require nominal cost sharing.
Medicare for All would eliminate private insurance coverage, including employer-sponsored insurance, a fact a majority of Americans don’t realize. According to a recent Kaiser Family Foundation survey 55 percent of people are unaware that employer-sponsored insurance would be replaced under the proposal.
While Americans like the idea of a single-payer system, support begins to erode once they realize their current form of insurance may be jeopardized. A Kaiser poll found that support for Medicare for All drops by 21 points if private insurance is eliminated.
Who funds “free” health care? The term “single-payer” refers to the government as the “single-payer” funding health care services to all Americans. According to experts at Mercatus Center at George Mason University, the cost of Sanders’ 2017 plan, which excluded long-term care, would be $55 trillion to $57 trillion over 10 years, with $33 trillion to $39 trillion representing new spending.
However, Democrats say that Medicare for All is affordable. Dean Baker, co-founder of the Center for Economic and Policy Research, says that the bulk of money from employer premiums will be new federal taxes. That is money citizens currently don’t see from their paychecks.
Other options
Headwinds from the industry, budget hawks and voter perceptions mean that Medicare for All has become a polarizing proposal that is unlikely to move forward in the near future. However, some of the more moderate alternatives to a single-payer system such as Medicare buy-in and Medicare-X may be viable next steps toward expanding coverage. Both of these would give Americans the option to keep their current insurance, which is a major issue voters have with Medicare for All.
Medicare buy-In is sponsored by Sen. Amy Klobuchar (D-Minn.). It allows individuals between ages 55 and 64 who are not yet eligible for the current Medicare program to buy into the program. The presidential hopeful once discussed allowing Americans to buy in to Medicaid, as well.
Presidential candidate and former Vice President Joe Biden supports a “public option” as a way to build upon coverage gains achieved under the ACA. Under his plan, Biden would provide premium-free access to a Medicare-like program for Americans who live in states that opted out of Medicaid expansion and for any American wanting a lower premium on the current ACA exchange.
The Biden plan would lower provider, hospital and prescription drug prices for enrollees via negotiations conducted by the government. Enrollees would be protected from surprise and burdensome health care charges, as the plan would cap spending to 8.5 percent of income for enrolled families. Biden’s plan would also resurrect the mandate penalty.
Medicare-X is essentially a public option, as well. Legislation sponsored by Sens. Tim Kaine (D-Va.), Michael Bennet (D-Colo.), and Rep. Brian Higgins (D-N.Y.) would allow Americans to keep their current insurance but would add a separate public option plan, based on Medicare, to the ACA marketplace.
Presidential candidate Sen. Kamala Harris (D-Calif.) is a supporter of Medicare for All, but may have struck a middle ground, as she describes plans to provide supplemental private insurance.
Moving forward
Expanding access to Medicare — through a buy-in for older Americans who haven’t yet hit 65 years of age — has the potential to get voter and legislative buy-in and could be a realistic path to filling the coverage gap in our current system. Medicare for All would be a complete overhaul. While it makes for a great brand, it may be a bridge too far for Americans who largely support the existing employer-subsidized health care system.
New presidents like to come in with big ideas. Many seem to forget Congress is key to enacting legislation. The Senate composition is likely to remain Republican in 2020 such that anything like single-payer would not be achievable under current rules.
This conversation will no doubt continue to shape the 2020 presidential platforms and continue to consume much of Capitol Hill’s oxygen for the foreseeable future.
Lexi Souder is a summer intern at Capitol Street and is studying public health at the Johns Hopkins University, and Ipsita Smolinski is managing director of Capitol Street, where she advises clients on national health care policy and emerging trends.
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