By Krishnan Narasimhan M.D.
February 28, 2019
As the 2020 presidential campaign is getting into high gear with a host of candidates, health care continues to take center stage. Specifically, the Medicare-for-all proposals from Democratic candidates and members of Congress have become a key issue. These proposals could represent the biggest access change in health policy since the Affordable Care Act.
It pays for physicians to understand and be engaged in health policy as it will dictate their practice life, their patient’s health, and the future of health care. However, unraveling competing proposals is not always easy. Let’s take a deeper look.
What is Medicare-for-all anyway? It is hard to pin down, but generally politicians are describing proposals that aim to achieve universal health care. They take two different general approaches to get to this goal. The first is to eliminate all private insurance and cover all Americans through the government (single payer or Medicare-for-all). The second is to allow all Americans to buy into a government insurance program (either Medicare or Medicaid) or choose private insurance (the public option or Medicare buy-in).1
These single payer proposals would create one government health plan and eliminate all private insurance. The plans seek to cover everyone under one plan and aim to have more robust benefit packages than under current Medicare plans. The current bills eliminate cost sharing completely including premiums, co-payments, or deductibles. The financing of these plans is far less developed. Current financing options include raising income and estate taxes on high earners and increasing corporate fees.
These public option proposals give individuals or employers the option to buy into Medicare or Medicaid. All the bills would allow individuals who currently buy insurance on the individual market to be able to buy a Medicare or Medicaid plan. Some would allow small employers to buy in as well. One mechanism is to expand coverage by lowering the eligibility age for Medicare to age 50. These proposals expand access in covering the uninsured but do not cover everyone. Employer-sponsored coverage would continue as it currently exists; it would cover essential health benefits and have varying degrees of cost sharing.
How does the public feel about Medicare-for-all? The Kaiser Family Foundation tracking poll from January 2019 found that 56% of Americans favor a national Medicare-for-all plan. However, favorability varies widely once specific arguments about the plan are laid out, ranging from +45 for a universal guarantee in coverage to -44 for delays in medical treatments. On the other hand, buy-in programs enjoy public approval for reducing the age of eligibility (75%), Medicaid buy-in (75%), and Medicare buy-in (74 percent).2
Physician and Health System Leaders’ Opinions
In an NEJM Catalyst survey of executives, clinical leaders, and clinicians, 49% identify single-payer as the best outcome for future payment reform. Clinicians are more supportive (55%) compared to health care executives (39%). Single payer enjoyed more support among younger physicians. A recent survey conducted by the consulting firm Merritt Hawkins for Physicians Foundation showed similar findings with 56% of physicians supporting single-payer, up from 42% in the same survey from 2008.3
These proposals are early in their gestation, and as the campaign goes on, expect to see an evolution. Medicare-for-all has become the big health care issue of the 2020 election and it is not going anywhere soon. Future blog posts will discuss financing, physician perspectives, and potential winners and losers. Stay engaged and check here for updates as the debate continues.
Krishnan Narasimhan M.D. is an academic family medicine physician and an associate professor in the Howard University Department of Family Medicine with a focus on health policy, health systems, access issues, primary care capacity, and medical education. He serves on the Board of Directors for Doctors for America and as president-elect of the DC Academy of Family Physicians. He has led multistate physician coalitions in the policy debate on health reform and primary care infrastructure. He has a health policy fellowship from Georgetown University.
*OPINIONS EXPRESSED BY OUR GUEST AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.