Jared Bernstein is offering what he terms to be a compelling idea for offense. It is Medicare for All.
we should also aim higher, building off the compelling fact that other countries already provide universal or near-universal coverage to their citizens while spending about half of what we do as a share of GDP. Their approaches vary, but a common thread unites them: an increased role for the public sector, either as regulator, price-setter, insurer, provider, or some combination thereof….
How to get from where we are to Medicare for All is a huge challenge. Paul Starr recently suggested a smart, incremental step in the Prospect: “Midlife Medicare,” which extends the system to 50- to 64-year-olds without employer coverage. Demos strategist Vijay Das recommends expanding Medicare first to kids.
Here is what I’m struggling with as I read through this argument. Is Medicare for All a means to an end or an end in and of itself?
Medicare is a funky insurance product. It offers roughly 84% actuarial value for the elderly with a very bizarre and idiosyncratic benefit design. It has no catastrophic cap on exposure so a person with a million dollar claim will be at bankruptcy risk. It is disjointed and strange as it is currently built out. It also (mostly) works with the creation of a wrap-around supplemental buy-up market and Medicare Advantage.
The one great advantage Medicare has over most private insurance is that it uses its great buying power to drive down provider rates.
So here is my question that I struggle with. Medicare for All would be system transforming. It would provide near universal coverage for all while blowing up the current healthcare finance system as it is. That means provoking very powerful interests that have a current stake in holding the line with the ACA exchanges and Medicaid expansion. For a Democrat to do this is too invite the SEIU to go to war against the party. It is to invite every provider group to either be neutral or actively opposed. It is to invite mass failure or massive inefficiencies in the newly designed and highly disruptive system to buy out pre-existing stakeholders.
Now if the desired end in and of itself is merely universal coverage with Medicare for All as a plausible means to an end, that is a different story. We have demonstration cases already that near universal coverage can be achieved with stakeholder buy-in from Massachusetts, DC, Iowa and Hawaii. They all go about that near universal coverage in different ways but they work. Tweaks can be made to improve those experiences and increase coverage to 98% or 99% instead of 96% with a safety net of Medicaid presumptive eligibility for everyone who falls through the cracks. But we have local examples of templates that work with local stakeholder buy in already.
Yes, we will need to solve the fundamental Texas problem of their elites not giving a damn, but that problem is a constant for an evolutionary pathway and a disruptive pathway. Is Medicare for All an end in and of itself or merely a means to an end? For me, it is a means to an end. For others, it is an end in and of itself.