Medicare for All. Single-payer. Expanding Obamacare. What's the difference?

Many Democrats claim to support Medicare for All — but the devil is in the details

Published July 7, 2019 10:00AM (EDT)

Sen. Bernie Sanders, I-Vt., introduces the Medicare for All Act of 2019, on Capitol Hill in Washington, Wednesday, April 10, 2019. (AP/Manuel Balce Ceneta)
Sen. Bernie Sanders, I-Vt., introduces the Medicare for All Act of 2019, on Capitol Hill in Washington, Wednesday, April 10, 2019. (AP/Manuel Balce Ceneta)

In the Democratic presidential race, "Medicare for All" is one of the most talked-about ideas for overhauling and revamping the nation's health care system. The phrase is cheered on the campaign trail — even by some Republicans — and promoted by a host of presidential hopefuls.

Despite its prominence in campaign literature, the truth is that the phrase is wielded vaguely; indeed, what precisely "Medicare for All" means varies among the Democratic candidates who claim to support it — and the  candidates' muddled rhetoric on plans to reach universal health coverage has revealed a stark policy divide among the nearly two dozen Democrats vying to take on President Donald Trump in 2020.

The division among the candidates could be seen clearly last week at the first primary debate of the 2020 race, when Sen. Elizabeth Warren, D-Mass., and New York City Mayor Bill de Blasio offered full-throated support for Sen. Bernie Sanders', I-Vt., Medicare for All proposal that would abolish private health insurance in favor of a single-payer system — the core of Sanders' health care plan — while other candidates served up more moderate proposals that would build more gradually on the public-private model of coverage that is currently in place.

Meanwhile, Sen. Amy Klobuchar, D-Minn., said she backed a "public option" that would build on former President Barack Obama's signature legislation, the Affordable Care Act (ACA), or "Obamacare." The plan would allow Americans to voluntarily opt into a government-sponsored plan — like Medicare or Medicaid — alongside those offered by private insurers. It is something of a compromise between a single-payer model and the current system, in which only certain Americans qualify for government-sponsored programs, and is considered a more moderate alternative to a single-payer system.

Other Democratic presidential hopefuls, including Sen. Michael Bennet of Colorado, Reps. Eric Swalwell of California and Seth Moulton of Massachusetts, former Reps. Beto O'Rourke of Texas and John Delaney of Maryland, former Washington Gov. Jay Inslee, former Housing and Urban Development Secretary Julián Castro,  Montana Gov. Steve Bullock and self-help author Marianne Williamson, have also embraced a public option.

Yet a host of 2020 Democrats co-sponsored Sanders' Medicare for All legislation. While co-sponsors Sens. Cory Booker of New Jersey, Kirsten Gillibrand of New York and Kamala Harris of California have made the case for making a government plan available to all Americans, they believe private insurance should still play a role in providing coverage, though it's unclear what that role would entail.

Such a plan — Medicare for All alongside private health insurance — has received support from former Vice President Joe Biden, Reps. Tulsi Gabbard of Hawaii and Tim Ryan of Ohio, entrepreneur Andrew Yang and South Bend Mayor Pete Buttigieg, who dubbed the proposal "Medicare for All who want it."

The battle over Medicare for All that unfolded live on national television last week exposed major divisions among the Democratic candidates on how to reach universal coverage in America. It was a sign, too, of how some presidential hopefuls remain exceedingly cautious about the potential political liabilities of endorsing a single-payer system, even in a primary contest in which candidates are fighting for the "most progressive" crown.

It has also emerged at a time when voters across the aisle are deeply frustrated with the nation's current health care system.

"For a decade now, we've had a system that has relied on markets and private competition more than any of our peer nations — and that hasn't worked. The [Medicare for All] debate is a revisiting of the question: 'Are we going to rely on our government to ensure access to health care and what form is it going to take?'" Allison Hoffman, a professor at the University of Pennsylvania's Law School and a senior fellow at the Leonard Davis Institute of Health Economics, told Salon.

She explained that the national debate over health care has shifted dramatically to the left over the past ten years because "all else has failed."

Indeed, the road to universal coverage in the U.S. has been long and complicated. Health care reform was a prominent issue in the 2008 election cycle, and the passage of Obamacare in 2010 brought sweeping changes to the nation's health system. The number of uninsured Americans fell dramatically since the law passed, dropping from 48.6 million people in 2010 to 29.7 million in 2018. Studies have found that the ACA caused fewer people to struggle with medical bills or avoid or delay treatment because of cost and that medical debt has declined.

Still, health insurance in the U.S. remains one of the most expensive in the world and coverage remains increasingly out of reach for millions of Americans. The health care system is still difficult to navigate, meaning many consumers to struggle to get the care they need in a timely fashion, make sense of medical bills, and understand insurance plans filled with abstruse cost calculations and bureaucratic jargonThe U.S. also remains an outlier among developed countries by not having universal health insurance.

Hoffman called Obamacare a "patchwork system" that "ended up being very complicated and ended up relying on private insurers to do too much. It ended up relying on people to navigate a complicated system, and it, unsurprisingly, hasn't filled in the gaps."

"Even in its fully implemented form, it wasn't intended to be universal because it was too difficult to create the kind of system that was politically feasible and also kind of scooped everybody into it," she added.

But if Obamacare failed, does Medicare for All stand a chance? It's bolder, more progressive and appears politically infeasible in the current Republican-led Senate, though polls suggest proposals to expand Medicare have become more popular as a general idea across the political spectrum.

If providing affordable, universal coverage is a goal of the American health system — and it's unclear if it is —  there is more than one path to it. The U.S. can look to universal health care models in countries like Canada, the United Kingdom, Germany, France, Switzerland, and the Netherlands as an example.

Canada and the U.K. come especially close to having a true single-payer system. In Canada, the federal government covers medical bills with money raised through taxes, but people often purchase additional private insurance to cover care that isn't publicly reimbursed, such as dental and eye care and prescription drugs. Almost all hospitals are publicly funded and provide care to all residents, regardless of the ability to pay. The government keeps hospitals on a fixed budget to control costs and reimburse doctors at a fee-for-service rate.

Britain's government-sponsored system, the National Health Service, provides health coverage for all, including ambulance rides, emergency room visits, complicated surgery and chemotherapy. Prescription drugs are either free or controlled by a price cap. Private health insurance also exists, but it caters mainly to wealthier residents seeking specialized care or shorter wait times for elective procedures.

Other countries, including Germany and France, have a universal multi-payer health care system that incorporates private and public health insurance.This hybrid model looks more similar to the U.S. health system under Obamacare, though Germany and France have managed to cut costs across the board by imposing strict limits on out-of-pocket costs on as copays and prescription drugs.

"Every country with universal health insurance has some role for private insurance — it's just not the core role that it is for some people in the U.S.," says Hoffman, who believes that policymakers should be focusing on the question: "What is the government's role in providing healthcare, and where will private insurance fit into this picture?"

The idea of Medicare for All has come under heavy scrutiny from Republicans and conservative policy makers who have cited objections over the proposal's estimated cost and reimbursement rates paid to healthcare providers, which they claim would cause a massive doctor shortage and force hospitals to close. Critics have also expressed concern that the large influx of patients into the health care system could lead to long wait times and decrease the quality of care. Others have argued that pharmaceutical price controls would stifle innovation.

"This is where it really depends a lot on exactly what this thing would be. What the cost would be and where it would be — either private or public — could differ greatly depending on exactly what form of Medicare for All gets adopted," Martin Gaynor, professor of economics and health policy at Carnegie Mellon University and former director of the Bureau of Economics at the U.S. Federal Trade Commission, told Salon.

"This is why it makes it so hard. What is this creature Medicare for All? You get very different visions of what it would be depending on who is talking about it," Gaynor added.

Michael Merrill, an economist and historian at the Rutgers School of Management and Labor Relations, said that, in addition to considering how to extend health care to millions of Americans, the U.S. health system needs to address the imbalance of power between medical providers and patients — an issue he argues is often completely left out of the broader health care debate.

"Universal insurance, private or public, extends access to health care to millions who would otherwise not have it and as such is a good thing. But it does nothing to redress the balance of power between the medical providers and their patient victims," Merrill told Salon.

"Imagine what the school system or the armed forces or the criminal justice system would be like if they were almost wholly privatized and profit-driven? In the case of all three, we increasingly know — and it is a disaster," he continued.

By Shira Tarlo

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