Stupid Idea For David To Destroy

David’s post below got me thinking on single payer vs. universal coverage — I’m with David (and Elie). Don’t care how we get to health care for all Americans, as long as we get there.

So here’s my stupid idea: a move in stages.*

Stage one: Medicare For All Kids.  Same program, just for every kid up to the age of 18–or 26, to match current ACA practice.

The reasoning in my wholly non-expert addled brain being twofold: first, kids are, as a group, cheap to cover, so the financial lift here is presumably manageable.  Second: this has an aspirational frame that can be used to persuade.  I don’t know about you, but I’ll take (I took) risks on my own behalf I would never have done had I my son to keep safe when I started my own small business.  I don’t know how many people have deferred or abandoned dreams because they couldn’t go insurance-naked for their kids.

That’s anecdata, but David Leonhardt made much the same argument way back in 2010 in defense of the bill that became Obamacare. Medicare For All Kids, presented as a way to unleash Americans’ entrpreneurial spirit, would be a proposition on which I think Democrats could go to town.

The next stage is to take the step that didn’t find our David’s 218-51-5 support in the last go-round:  Medicare (buy-in?) For All Over 55.  This is a form of public option, and it would expand the single-payer approach to more and more of those either utterly unable to take on health risk themselves (kids, the post-work elderly) and those whose age-adjusted risk is growing to the point where it threatens to become unmanageable.   Again, this would require persuasion, but the idea that older but not old folks who might face, say, a 2008-like crisis of employment should find a ready avenue to coverage is, again, a case that can be made (by a better political rhetorician than me).

That leaves 27-55 year olds on their own — or rather, within the existing Obamacare/expanded Medicaid universe.  But it establishes a template for a single payer form of coverage without requiring a wholesale change over of a system with tons of interested parties and rent-seekers eager to defend their turf.

So — to steal Ta-Nehisi Coates’ old line: talk to me like I’m stupid.

What’s wrong with a crabwise walk towards increasingly universal health care, along these lines or better ones? For both politics and policy, what would be wrong w. introducing, say a Medicare For All  Kids bill in this Congress, just to get that ball rolling?

David? Anybody?

*”We shall fight in France, we shall fight on the seas and oceans, we shall fight with growing confidence and growing strength in the air, we shall defend our island, whatever the cost may be. We shall fight on the beaches, we shall fight on the landing grounds, we shall fight in the fields and in the streets, we shall fight in the hills; we shall never surrender.”

Image: Edvard Munch, The Sick Child, 1907

69 replies
  1. 1
    JPL says:

    I like the idea of phase in, and think that the idea of having healthier younger on medicare would extend the life of the current program. Here’s the problem, removing them from Obamacare could raise the existing rates of that program. Maybe it needs to be open to both age groups at the same time.

    OT.. The picture reminds me of the series “The Sinner”.

  2. 2
    gkoutnik says:

    Third reason for doing Medicaid for All Kids first: healthier kids mean healthier adults later on. This is non-controversial; early intervention pays massive dividends.

  3. 3
    ruemara says:

    I don’t think anyone on this blog would disagree. I don’t think most Dems would disagree. I think the 70+ year old Bernista I know who came at me about how we don’t want incremental progress any more and we deserve radical change through Bernie, who I had to call out as being a 70+ year old white man from America who was wealthy enough to retire to a small, perfect tropical country talking to a black woman in America from a small tropical colony, he and his ilk will have a problem with that. And they are not capable of listening to reason because illogic has built them a fan base and an income source.

  4. 4
    Tom Levenson says:

    @JPL: Could be. But adults would no longer be seeking family care, which would have an impact on both Obamacare and employer plans. But again, I’m a h/c policy idiot, so what do I know?

  5. 5
    Miss Bianca says:

    Well, I like this plan, so that obviously means it’s got some fatal flaw or other.//

    Reposted from previous thread, because I liked this link so much: a guide to why “single payer” is going to be such a heavy lift in actual fact (and part of the reason I liked it so much is that it basically confirmed every insight I’ve ever gotten from reading David’s posts):

  6. 6
    JPL says:

    @Tom Levenson: lol Just idle thoughts on my part!

  7. 7
    eclare says:

    @Tom Levenson: Yes, that is my question, if people younger than 26 were removed from employer plans, what does that do to the cost of employer plans? Or were you just talking about people under 26 who had no other options? I think incremental is key, as well, besides the human effect, we’re talking 1/6 of the US economy.

  8. 8
    efgoldman says:

    Sounds doable to me, procedurally. Politically might be another matter altogether. “Those people” (obviously) will get benefits as well.

  9. 9
    jl says:

    I like to think of things from the ‘four legged stool’ perspective”
    leg one: guaranteed issue / no underwriting (individual medical history doesn’t enter rate calculation for basic coverage)
    leg two: universal coverage (nice cop version) / individual mandate (bad cop version)
    leg three: risk adjustment and subsidy system to correct residual cherry picking and low income people who cannot afford basic coverage)
    leg four: basic minimum coverage is some form of adequate comprehensive coverage (recent GOP swindle attempt made me think a fourth leg was necessary).

    So, figure out a way to get to the four legs, without an interim when there are only two or three and stool falls down before you get it built.

    Don’t worry about what you call it until you get the plan worked out.
    After that, pick one of half a dozen buzzwords and use that. Don’t explain any more detail than you need to in order to get the thing implemented.

    I was very very pissed at both Hillary and Bernie for how they approached health care.
    Hillary wanted to drag everyone through how every bolt and bracket was was going to work on micro adjustments to the current PPACA, and lectured people not to hope for anything more.
    Bernie repeated, and is still repeating three buzzwords, and really nothing else at all.

    So, any discussion that follows the those patterns irritates me greatly.

  10. 10
    Tom Levenson says:

    @eclare: All kids. The argument of principle being that whatever one’s views about self reliance and so on, there’s a long standing and wise tradition of making sure those incapable of taking care of themselves don’t suffer. That’s a big part of why the idea of health care for the post-employment elderly is one that, still, commands easy majority support in the US. Similarly, kids can’t provide for themselves.

    The argument from the Randians among us would be that their parents should (as one’s kids might be expected to do when those same parents get old…). But I think that politically as well as morally the case that no child should suffer for her parents’ missteps is strong, as is the idea that we gain as a society if we empower folks at the height of their adult powers to take risks that they couldn’t contemplate if to do so would leave their sons and daughters exposed to any mischance.

    So yeah: all of them.

  11. 11
    MomSense says:

    The crabwise walk is how Canada achieved single payer. It’s how most countries do.

    The funding for SCHIP expires at the end of this month and that program is so critical for poor and middle class families. It is not getting the attention it deserves. I’m really afraid we are going to lose it.

    I guess I am all for gradual expansion of Medicare/Medicaid but it’s a bit hard to get energized for that fight when I don’t see enough citizens rallying to fight an imminent threat to health care for children right now.

    Please text RESIST to 504-09 to fax your Congress critters to fund SCHIP.

  12. 12
    Tom Levenson says:

    @jl: So, to be clear, do the suggestions above violate your four stool framework?

  13. 13
    RSR says:

    It’s the new donut hole. I think it makes a decent presentation: covered for the first 25 years of life, covered for the last 25+, you’re responsible for the 30 years in the middle by getting a job.

    I mean, it makes a decent proposal to those who think people need to ‘earn’ health care. I’d rather everyone was covered prenatal through their passing without regard to station or employment.

  14. 14
    ruckus says:

    Those burners may just be unreachable. Notice what I called them, burners. They want their version of perfect or they want to burn it down. They are no more mature adults than the bigots. Just like their leader.

  15. 15
    trollhattan says:

    @Tom Levenson:
    Methinks NYC schools going to free lunches for all is a non-trivial comparison, if orders of magnitude less complicated.

  16. 16
    rikyrah says:

    Lower Medicare age to 50
    So, that will mean, 27 to 49 is all we will have to deal with.

  17. 17
    rikyrah says:

    Yep..healthier adults

  18. 18
    jl says:

    And Tom’s plan sounds good to me.
    There is no ‘pure’ system anywhere in the world.
    Australia has a very good system called Medicare for All.
    A more complete buzzword would be ‘Medicare for all with high risk threshold individual expenditure caps and supplemental voluntary private health insurance system’
    So, not really single payer.

    Average actuarial value is a little over 80 percent for Medicare for All system plus private supplemental policies. Availability of supplemental insurance, a more regulated version of our Medicare gap insurance, and individual high risk expenditure caps, plus some other gimmicks make the average 20 percent out of pocket more predictable, and widely spread around, not concentrated in high risk population.

  19. 19
    eclare says:

    @Tom Levenson: I agree 100% in principle, but I still wonder what that would do to parents who get employer based insurance. If their rates surge because younger and healthier people are no longer in the plan, I don’t know how you overcome that. And the employer based system still covers the vast majority of people. I think if you just covered young people who had no other option, that would be an easier lift.

    Again, excellent points, and in any other civilized country we wouldn’t be having this discussion, but that could be a lot of losers. Will wait to see if David weighs in.

  20. 20
    trollhattan says:

    Am sure Republicans want to do the opposite–raise it instead.
    “People are living longer, so it’s too expensive to cover 65YOs. We’ll raise it to 67, then to 70 over ten years.”
    “But, with less medical coverage people will die sooner, not later.”
    “Then let’s do it in five years!”

  21. 21
    Petorado says:

    I like the Medicare for all kids, but I also think it would be a good idea to a add basic level of healthcare for every single American to the bill. Including immunizations for all and a basic level of preventative care would be an other inroad into being able to bargain down prices on known quantities of drugs and services on a national scale. It would add a steady layer of annual income for providers, and reduce the known expenditures for insurance companies who can then focus more on risk, hopefully reducing deductibles and broader insurance rates. It would be a start at chipping away at the present system and lead to better overall health.

  22. 22
    gorram says:

    Off topic, but I thought everyone might get a kick out of this article. (There’s a bit of rude language, sorry.)

  23. 23
    David Anderson says:

    Works for me

  24. 24
    jl says:

    @Tom Levenson:

    IMHO, Not enough detail. I like the general outlines, and think a staged approach is intriguing and would like to subscribe to the newsletter.
    I think one and two and four are OK, given what the ‘Medicare for all’ buzzword means in the US

    Main gaps are for leg three. I think starting with kids is good (assuming we can beat back upcoming GOP efforts to mess that up). People will fund kids.

    I think more thought needs to be given to leg three for this step in the staged expansion of coverage. This sounds like national high risk pool:

    ” This is a form of public option, and it would expand the single-payer approach to more and more of those either utterly unable to take on health risk themselves (kids, the post-work elderly) and those whose age-adjusted risk is growing to the point where it threatens to become unmanageable. ”

    What is the political will and feasible funding scheme to finance adequate care?

  25. 25
    Baud says:

    As a reminder, only Baud!Care! covers your pets.

  26. 26
    boatboy_srq says:

    The trouble with this idea is that the Conservatists are already proven capable of throwing the next generation under the bus to get their sweet, sweet tax cuts. If Medicare for Kids were marketable the Education for Kids would be a no-brainer – and instead we have fights over funding education in every school district and every state house every year, and we have a hoamskuler running the US Dept of Education. The only times we hear Conservatists express concern for children, it’s in the form of some adult-specific non-traditional-gender-identification issue or some complaint about the school curriculum or some other indirect means of attacking some group other than the kids themselves.

  27. 27
    Mnemosyne says:


    I think you could avoid a huge surge in adult rates by folding prenatal and maternity care in with Medicare for Kids. After all, they’re future kids, so they should be taken care of while they’re still in the womb, right?

    I think that would also increase the slipperiness of the slope that we’re hoping leads to universal care.

  28. 28
    jl says:

    @Baud: High risk pool beer spill accident funding! 100 percent actuarial value. Don’t forget that.

  29. 29

    @Baud: Samwise gets insurance through my employer.

  30. 30
    trollhattan says:

    With burlap?

  31. 31
    Another Scott says:

    I like it, but if we’re going to cover all kids, then we need to cover pre-natal care. That means covering young women (up to, say, 45?). Do we really want to exclude pre-natal coverage from women who are trying to get healthy before they get pregnant?

    I’m only about 75% serious about the above. I do think pre-natal care is just as important as covering all kids (presumably a Super-SCHIP fully funded by the federal government would be a way to do it without calling it Medicare, if that’s an issue).

    Devil’s in the details.

    I do think we need some-sort of phase-in. Expanding SCHIP and making it a federal program (why should kids in different states have different coverage?) makes sense. Covering pregnant women makes sense. Covering contraception (for men and women) makes sense. I think moving the Medicare age down makes sense. We know how to do the above, we know how much it will cost, and we know where to get the money (from the people who have taken the vast majority of the wealth created in the USA since ~ 1980). But the problem is always the politics.



  32. 32
    japa21 says:

    @David Anderson: Jeez, now Tom’s going to get a big head since he got your unconditional support. He’ll be impossible to live with. Couldn’t you have found a little flaw?

  33. 33

    @gorram: Lol, ‘Shitler Youth’, perfect

  34. 34
  35. 35
    eclare says:

    @Mnemosyne: Makes sense to me! And that is a big expense. Glad your writers’ retreat is going well.

  36. 36
    jl says:

    @David Anderson:

    ” Works for me ”

    Your thoughts on the part that sounds like a national high risk pool? That was weak link for me.

  37. 37
    Alain the site fixer says:

    Folks, the dreaded video ad is back. If it makes noise, please let me or John know – and which advertiser the noise is touting! Without that info, we can’t do squat.

  38. 38
    Cacti says:

    I like the idea of Insane Clown POTUS from the previous thread.

    Whatever it is, call it the “Obamacare Repeal and Replacement Act” just to eff with GOPers.

    Make them argue why it’s bad to “Repeal and Replace Obamacare”. It would make their heads explode.

  39. 39
    Alain the site fixer says:

    @Alain the site fixer: And “All of them, Katie” doesn’t count!

  40. 40

    @Alain the site fixer: My Balloon-Juice tabs are back to being the highest CPU processes on my machine, and I’m running two web servers.

  41. 41
    Baud says:

    @Major Major Major Major: It’s processing our weighty comments.

  42. 42
    jl says:

    @Alain the site fixer: There’s always an old white haired buy babbling with the sound off. As long as it doesn’t jam up loading, I don’t care.

  43. 43
    eclare says:

    @gorram: A bag of cotton wool is edgier than you lot….

  44. 44
    SatanicPanic says:

    Sure, but call it the Not Bernie Act or Juicers will hate it.

  45. 45
    Chyron HR says:


    “I am proud to present my Medicare for All bill, which recognizes that the sole obstacle to Medicare for All is the continued existence of the Democratic party and calls for it to be immediately disbanded. Thank you all for your unquestioning support.”

  46. 46
    Alain the site fixer says:

    @Major Major Major Major: Don’t blame me, blame the boss!

    Seriously, I’m going to be testing some new ads and we’ll see how that all goes. We want less-annoying, well-paying ads. That was easier in the past! But for now, it’s a good money-maker and so it will stay until John wants it gone.

    I’m looking at some other advertising solutions, so if you – or anyone reading – has some good ideas, please let me know via the Contact a Front Pager form in Quick Links at the top of the page. Ads suck, but some are worse than others, and sometimes, those are what pay the bills. It’s how many City Paper-type pubs succeeded when they were young, in the 1970’s an 80’s (though I’m glad we’re not running “Adult Services” advertising, let me tell you!)

  47. 47
    Baud says:

    @SatanicPanic: More accurate than single payer!

  48. 48
    SatanicPanic says:

    @Baud: OK I’ll stop trolling now

  49. 49

    @Baud: True. Technically these bills would not be Bernie.

  50. 50
    jl says:

    @Baud: Where’s the Baud 2020 buzzword? How does ‘Let’s play Doctor!” sound?

  51. 51
    Cacti says:

    Given the level of detail Bernie has previously put forth for his policy proposals, I’m guessing his Medicare for all bill will be something like:

    1. Expand Medicare coverage to everyone
    3. Victory

  52. 52
    Miss Bianca says:

    @gorram:so much to love in this article, but I particularly enjoyed this paragraph:

    So let’s be clear: getting fired because you hate women is not an equivalent hardship to getting fired because you happen to be one. People who have been disowned by their parents for being gay or transgender aren’t going to have sympathy when your mum and dad find your stash of homophobic murder fantasies and change the locks. Getting attacked for being a racist is not the same as getting attacked because you are black. The definition of oppression is not “failure to see your disgusting opinions about the relative human value of other living breathing people reflected in society at large.” Being shamed, including in public, for holding intolerant, bigoted opinions is not an infringement of your free speech. You are not fighting oppression. You are, at best, fighting criticism. If that’s the hill you really want to die on, fine, but don’t kid yourself it’s the moral high ground. I repeat: You cannot be a rebel for the status quo. It would be physically easier to go and fuck yourself, and I suggest you try.

  53. 53
    Insane Clown POTUS says:

    We can call the free prenatal care bill the “Pro-Life Act” or “American Mothers and Babies Act”. The ads would say – “Why did Ted Cruz vote against the Pro-Life Act? What does he have against babies?” I can do this all day.

  54. 54
    cthulhu says:

    I think as David as mentioned before, moving to a single payer is not really as much of a deal unless it is paired with heavy amounts of pressure to push down what we spend on healthcare in the US vs other countries – that’s what will take a lot of time without major disruptions to the economy/taxes etc. Any shift downward from the top means more costs to try to control compared to upward from the bottom.

    I wonder about an option where you cover all people under 25 and each year simply keep paying for that increasing cohort: year 0 0-25, year +1 0-26, year+2 0-27, etc. Sure it takes 40 years to get to universal coverage but seems likely that cost controls can more easily be implemented. With 65+ already done, you’ve got a starting point of around 45% population in the universal system and a lot of opportunity for prevention/early, less costly treatment. Sure, I and probably many readers of this blog are left to the vagaries of the current patchwork system during working adulthood but I certainly be willing to continue to do that knowing my kids and (future) grandkids won’t have to deal with it. It might also not take the full 40 years as perhaps by year 25 or 30, we have gotten better on cost such that adding in that last 10 to 15 age cohort gap is no longer much of a lift.

    One potential downside for employment ageism is that it would certainly make younger people even cheaper to employ which, then again, as they may be facing more competition from automation, might not be such a bad thing after all.

  55. 55
    Fair Economist says:

    This is the way we’ll get single payer, if we ever do; adding underserved groups to Medicare or Medicaid, one at a time.

    I think, though, that just for the practical reasons of not wanting to upend health insurance for 80% of employed adults, we’ll eventually end up with something more like the Swiss system.

  56. 56
    Uncle Ebeneezer says:

    @Cacti: 5. Blame Hillary when it doesn’t pass.

  57. 57

    @jl: If you give me three beers and a dare, I’ll argue that Medicare and Medicaid SSI mandatory eligibility groups effectively act as a partial high risk pool. Medicare in this case as it pays for the old is a far more effective high cost risk pool than Medicaid which has all sorts of eligibility knock-outs to people who are sick but not poor enough. But they both serve to pull out a lot of high cost people and pay for their care at administratively set rates. The care is funded mostly through general taxation.

    Now moving Medicare to age 55 or age 50 or whatever you want, chops out from the ESI, individual market and not covered at all groups the cohort that is most likely to be sick and expensive so average costs for the rest of the group that remains crashes.

    Tom is proposing salami slicing tactics to delink coverage from work and move more people to coverage that pays providers near Medicare rates. The rest is details in my opinion.

  58. 58
    Percysowner says:


    I wonder about an option where you cover all people under 25 and each year simply keep paying for that increasing cohort: year 0 0-25, year +1 0-26, year+2 0-27, etc. Sure it takes 40 years to get to universal coverage but seems likely that cost controls can more easily be implemented.

    You can get it down to 20 years if you add covering 65+ year becomes 64+ year 2, 63+ year three etc. Step it in on both sides. Now at some point the people in the middle, or their employers will want in, so it could take a few years less, but attacking it from both ends is an idea.

  59. 59
    Raoul says:


    It’s the new donut hole. I think it makes a decent presentation: covered for the first 25 years of life, covered for the last 25+, you’re responsible for the 30 years in the middle by getting a job.

    I mean, it makes a decent proposal to those who think people need to ‘earn’ health care. I’d rather everyone was covered prenatal through their passing without regard to station or employment.

    I agree. And, like the prescription drug donut hole, as more people end up in the middle of it, more pressure to make the hole smaller. So it may create the conditions of eventual lifetime cover. I’m OK with incrementalism — it sure beats failure.

  60. 60
    Regime Touchon says:

    Sounds like you’re on to something. The CHIP program? How do the horrible deplorables try to take it away?

  61. 61
    cthulhu says:


    You can get it down to 20 years if you add covering 65+ year becomes 64+ year 2, 63+ year three etc. Step it in on both sides. Now at some point the people in the middle, or their employers will want in, so it could take a few years less, but attacking it from both ends is an idea.

    Yes, I think adding age cohorts at the older side too quickly would be more difficult to economically absorb but 1 year at a time should be doable. We basically need to cut our healthcare expenditures by half more or less (while of course, maintaining or improving outcomes) and doing so in anything less than 20 years doesn’t seem feasible.

  62. 62
    way2blue says:

    My first step would be implementing the ‘public option’ to accompany all the current flavors of Obamacare.

  63. 63
    Tom Levenson says:

    @David Anderson: What David says.

  64. 64
    Caravelle says:

    Another good thing about Medicare For All Kids up to 25 is that as the years go by, you’ll get a population of 26, 27, 30 year-olds who have experienced universal coverage and lost it, and will thus be much more open to expanding it to 26-to-55 year-olds than the same age cohorts are now.

  65. 65
    thalarctosMaritimus says:

    @Alain the site fixer: Toyota.

  66. 66
    Elie says:

    Late to the thread Tom, but I like your idea of the phase in. We have to call it something to wrestle “single payer” from the only democratic approach. Bernie is all center stage and it’s hard to make a full argument in the face of the Medicare for all fantasy.

  67. 67
    JK says:

    I think that it would be a better choice to expand Medicaid to all children. Medicaid provides more comprehensive coverage than Medicare – see:

    Medicaid is also less complicated – no prescription plans, no Medicare Advantage.

  68. 68
    CynthiaK says:

    I often read this blog but rarely comment. However, I wanted to add this to the conversation.

    In 1989 Vermont created Dr. Dynasaur, a public healthcare program for children under 18. It should be a model for the entire country, as Massachusetts was for the ACA.

    One day Medicare for all

  69. 69
    Pittsburgh Mike says:

    I’m going to add my support to the idea of allowing Medicare buy-in from the start. Medicare buy-in takes some of the more *expensive* people out of the private insurance market, which will lower premiums for everyone else. IOW, this *stabilizes* the private insurance market.

    And doing this gradually, by starting off with 55 year olds being eligible, and then dropping the eligibility age by 5 years every 2 calendar years, provides an easy transition to either a full public option or full single payer, depending upon the details.

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