Improved Medicare For All or Watered-Down Medicare For All?

Medicare For All supporters hold signs during an event on healthcare September 13, 2017 on Capitol Hill in Washington, D.C. Photo by Alex Wong/Getty Images (source)

by Thomas Neuburger

This is a follow-up to my recent piece on Medicare For All and the challenge it presents to the Democratic Party (see "Medicare For All — The Democratic Party Audition for 2020").

It's already been announced that a bill will be written and hearings held. Rep. Pramila Jayapal is spearheading that effort:

The new Democratic majority in the House will hold the first hearings on Medicare-for-All legislation, a longtime goal of the party’s left, after Speaker Nancy Pelosi lent her support for the process.

“It’s a huge step forward to have the speaker’s support,” said Rep. Pramila Jayapal (D-Wash.), who will be the House sponsor of the legislation, usually denoted as HR 676. “We have to push on the inside while continuing to build support for this on the outside.”

Some version of universal health care has been a Democratic goal for decades. The Expanded and Improved Medicare for All Act, first introduced in 2003 by then-Rep. John Conyers Jr. of Michigan, has become the vehicle for Democrats who want to bring single-payer, Canada-style health care to the United States.

That legislation was typically sidelined, even when Democrats had power; in 2009 and 2010, when the House passed the Affordable Care Act, the “Medicare-for-All” package was not part of the discussion. But in his 2016 campaign for president, Sen. Bernie Sanders (I-Vt.) championed Medicare for All. The following year, for the first time, a majority of House Democrats co-sponsored HR 676.

Note the title of Conyers' bill — the "Expanded and Improved Medicare for All Act".

Why "Improved Medicare" For All?

Conyers' bill was called "Expanded and Improved Medicare for All" because Medicare is currently deficient in a number of ways. Nancy Altman of Social Security Works explains (emphasis mine):

[S]eniors who are currently enrolled in Medicare would benefit enormously. The cost of prescription drugs for seniors is skyrocketing. Out-of-pocket health care costs are projected to consume half of the average Social Security check by 2033. Medicare for All would eliminate co-pays and deductibles. It would take on Big Pharma and dramatically lower prescription drug costs for the entire nation. No longer would seniors be forced to turn over a huge chunk of their hard-earned Social Security benefits to pharma CEOs and for-profit hospital executives. No longer would seniors have to cut their life-saving medicines in half to afford money for food.

Medicare for All would also improve Medicare’s benefits for seniors. The current program does not cover several essential health care needs, including dental, vision and hearing. This forces too many seniors to suffer avoidable isolation caused by inability to see and hear. It weakens the health of too many seniors who are unable to obtain the dental work necessary to allow adequate nutrition. Improved Medicare for All adds these benefits.

Perhaps the biggest gap in Medicare is its failure to cover long term care. By adding more home health care services that allow people to age at home and institutional care for those who have no other choice, Improved Medicare for All would make an enormous difference in the lives of millions of seniors and their families. It would also benefit every state that covers some of these services under Medicaid.

There are other areas that could be improved as well. Conyers' bill did not cover reproductive health. In addition, reimbursements to primary care physicians, in my anecdotal experience, is woefully low, so much so that many primary care physicians are forced to raise prices on their non-Medicare patients to cover the underpayment from Medicare, while others have been forced to decline Medicare patients entirely. (This comment applies only to primary care physicians, not high-priced surgeons and the like.)

Unwarranted Fears?

There are already concerns on the horizon about the new bill. According to one report, it may not contain key elements of Conyers' longstanding Medicare For All bill, HR 676: "Some in the single payer movement see the abandonment of HR 676 as a betrayal of years of grassroots activism, activism that drew 124 co-sponsors to HR 676 in the House last year. Now, with Democrats in charge of the House, the Medicare for All single payer bill is being rewritten, watered down and renumbered." Within the piece, Margaret Flowers of Health Over Profit is quoted as saying the new bill "maintains the for-profit providers in the system."

These fears are unwarranted according to those who have seen the bill. First, it's not being written in secret; many people have seen it and are participating in the process, including strong progressive advocacy groups like Social Security Works. Second, the bill states explicitly that profit-driven healthcare is the problem and works to codify the elimination of profits from the healthcare system.

In that sense, the charge that the bill "maintains for-profit providers in the system" is both right and wrong. For-profit providers, for example, hospitals, do have a role in the new system, but profits are eliminated from their reimbursement. And the for-profit insurance industry is eliminated entirely from the Medicare For All system — no coverage gaps, no public-private partnership arrangements. This is a rather elegant solution, in my opinion, far better than the "industry buyout" proposals in earlier bills.

Alex Lawson, SSW's executive director, told me by email today that "Jayapal’s bill, which I have been in the redrafting group for, is the best Medicare For All bill out there right now. This process with Jayapal’s office has been the most inclusive and responsive process I have ever seen on the Hill."

Watered-Down Medicare For All

This brings us to the great fear of many in the health care community — that if Democratic pro-industry politicians are unable to defeat a true Medicare For All bill, they will offer "more practical" alternatives that appear to solve the problem but are weaker and watered down.

The benefit to politicians of passing a watered-down bill is obvious. It allows the compromised in Congress to claim they're in favor of a very popular policy (70% of all Americans support it) while actually working to make sure no industry ox is gored when the final bill passes. Supporting a weaker bill creates the appearance of progressive action without most of the benefits.

Look again at the fear that Rep. Jayapal's bill "maintains the for-profit providers in the system." The concern, though wrong, is the right concern. Medicare For All should provide complete coverage by itself, coverage robust enough that anyone who depends on Medicare alone has all she needs to maintain good health and get good cost-free care when needed. If the wealthy wish more than that, private supplemental coverage would certainly be available at market prices. But private coverage should have no part in providing necessary coverage for the non-wealthy.

In a properly designed system, Medicare would therefore replace private insurance for most people, which means that under a plan like this, the private health insurance industry could lose up 95% of its current customers — by design. That's the only way the system can do what it's supposed to do.

No industry, no matter how venal, wants to lose most of its customers, and this industry is no different — they're going to fight like demons to hold on.

What shape is that fight starting to take? This shape, according to Politico (emphasis added): 

Democrats, with their eyes on 2020, have introduced at least eight plans for expanding health coverage beyond Obamacare’s gains. They range from modest Medicare reforms to more ambitious restructurings that would extend government-run care to millions of new patients — an array of options that fall short of campaign trail promises for full Medicare for All.

That spectrum includes Sen. Debbie Stabenow (D-Mich.)'s bill allowing patients to buy into Medicare starting at age 55 — which Brown also supports — and Tim Kaine (D-Va.) and Michael Bennet (D-Co.)'s plan to create a Medicare-style public option to compete with private insurers on up to bigger revamps, like Sens. Jeff Merkley (D-Ore.) and Chris Murphy (D-Conn.)'s expansion [of] Medicare eligibility to nearly all Americans. Sen. Brian Schatz (D-Hawaii) would let everyone purchase Medicaid. Those options have been characterized by supporters as more practical alternatives to the completely government-run system popularized by Sen. Bernie Sanders (I-Vt.) and Rep. Pramila Jayapal (D-Wash.).

That's quite a range of options. Note that Jayapal's proposal is equated to Sanders' proposal, a "completely government-run system." Note also that most or all of the lesser proposals leave the for-profit insurance industry more or less intact.

The Problem Can't Be the Solution

The private health insurance industry cannot be left intact. About this, Lawson is adamant, writing:

Private insurance is the problem. Co-pays, deductibles, out of network, denied care, uninsured, these are all concepts that we need to eliminate in order to build a healthcare system. These are all ways the private insurers take more of our money while denying our care. We need to eliminate corporate insurance, the problem cannot be the solution, it can’t even be a piece of the solution.

Private insurance is just another way Wall Street can stick their hands in our pockets and steal our money, leaving millions sick, anxious and broke.

No one who truly supports "Improved Medicare For All" should disagree.