The Goal Is Universal Coverage, Not Any Particular Form Of Universal Coverage

With one quibble we’ve already discussed plenty this week, I strongly endorse Josh Holland’s piece on healthcare reform:

But that momentum is tempered by the fact that the activist left, which has a ton of energy at the moment, has for the most part failed to grapple with the difficulties of transitioning to a single-payer system. A common view is that since every other advanced country has a single-payer system, and the advantages of these schemes are pretty clear, the only real obstacles are a lack of imagination, or feckless Democrats and their donors. But the reality is more complicated.

For one thing, a near-consensus has developed around using Medicare to achieve single-payer health care, but Medicare isn’t a single-payer system in the sense that people usually think of it. This year, around a third of all enrollees purchased a private plan under the Medicare Advantage program. These private policies have grown in popularity every year, in part because the field has been tilted against the traditional, government-run program. Medicare Advantage plans must have a cap on out-of-pocket costs, for example, while the public program does not. Around one-in-four Medicare enrollees also purchase some sort of “Medigap” policy to cover out-of-pocket costs and stuff that the program doesn’t cover, and then there are both public and private prescription drug plans.

The array of options can be bewildering—it’s a far cry from the simplicity that single-payer systems promise.

At the same time, Medicare-for-All is really smart politics. Medicare is not only popular, it’s also familiar. Many of us have parents or grandparents who are enrolled in the program. And polls show that a significant majority of Americans now believe that it’s the government’s “responsibility to provide health coverage for all.”

But from a policy standpoint, Medicare-for-All is probably the hardest way to get there. In fact, a number of experts who tout the benefits of single-payer systems say that the Medicare-for-All proposals currently on the table may be virtually impossible to enact. The timing alone would cause serious shocks to the system. Conyers’s House bill would move almost everyone in the country into Medicare within a single year. We don’t know exactly what Bernie Sanders will propose in the Senate, but his 2013 “American Health Security Act” had a two-year transition period. Radically restructuring a sixth of the economy in such short order would be like trying to stop a cruise ship on a dime.

Harold Pollack, a University of Chicago public-health researcher and liberal advocate for universal coverage, says, “There has not yet been a detailed single-payer bill that’s laid out the transitional issues about how to get from here to there. We’ve never actually seen that. Even if you believe everything people say about the cost savings that would result, there are still so many detailed questions about how we should finance this, how we can deal with the shock to the system, and so on.”

It’s obvious to me that the gradual expansion of public insurance is a much more likely path to universal healthcare than the immediate abolition of all private insurance. Maybe I’m wrong about that, although the next argument that persuasively deals with the political problem of eliminating employer-provided insurance people generally like will be the first. But given that any of the alternative models in other liberal democracies would be a major improvement over the status quo, it’s deeply silly to take all but one option off the table.