Medicare for all is a pleasing combination of words. People who are on Medicare, the government-run health insurance program available to virtually every senior in America, are generally happier with their plan than Americans on employer-provided private insurance. Expanding that popular program is such an obvious idea that it attracts an enormous amount of support in polls, even among Republicans. Sixteen Democratic senators—including all of the declared 2020 presidential candidates in the Senate—cosponsored Bernie Sanders’s 2017 Medicare for All Act, which represented a major shift from 2009, when Sanders introduced a similar bill and got zero cosponsors. Once an impossible dream, the longtime left-wing goal of government-provided health insurance for every American is now improbably close to becoming reality, or at least the subject of real debate in Congress.
But as Medicare for all goes from being a slogan to a concrete policy proposal that could transform the country’s healthcare system, the specifics start mattering more and more. And as the 2020 Democratic nominating process has lurched into gear, it’s quickly become clear that while most candidates support “Medicare for all,” they don’t agree, at all, on what that means.
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In the case of Sanders, the 2020 contender most closely associated with Medicare for all, there’s no doubt what he’s after: He wants to expand Medicare’s services (the program currently doesn’t pay for prescription drugs and many other things unless you purchase additional coverage like Part D), then move everyone onto Medicare. That would represent a massive expansion of government spending, but Sanders and his allies argue that what Medicare for all would really just transfer private spending on healthcare onto the government’s ledger and the US as a whole would actually spend less on healthcare as a result. Everyone would be on Medicare—literally, Medicare for all. (The only exceptions, according to a New York Times breakdown of Sanders’s bill, would include veterans and Native Americans, who would be allowed to keep their government-provided coverage.)
Under that system, private insurance would effectively cease to exist, meaning insurance company employees and others would likely lose their jobs and everyone who has employer-provided insurance would have a new plan. Medicare for all backers say the private insurance system is parasitic and harms—or kills—people and that the new system would give more benefits to anyone, but the proposal is a radical one that would touch pretty much every American’s life in some way.
Maybe unsurprisingly, presidential candidates have been hesitant about embracing that kind of change—even the ones who have cosponsored Sanders’s bill. California Senator Kamala Harris, one of those cosponsors, said she supported wiping out private insurance in January before course-correcting with more careful statements from her camp about how she also backed more moderate plans. New Jersey Senator Cory Booker has said that he doesn’t want to eliminate private healthcare, a somewhat confusing statement because even under a Sanders-esque system, hospitals and doctors’ offices would technically be privately run. (It’s private insurance, not care, that is really at issue.) New York Senator Kirsten Gillibrand said this week that she envisions a system in which anyone can buy into Medicare, which would naturally lead to private insurance dying out because it won’t be able to compete with the government.
That position sounds awfully similar to Beto O’Rourke’s preferred plan—a.k.a. “Medicare for America“—only O’Rourke is not selling himself as a Medicare for all proponent the way Gillibrand is. Confused enough yet? Consider the fact that the Democratic candidates have cosponsored other bills allowing people to buy in to Medicare, and Sanders himself cosponsored a bill that would let people buy into their states’ Medicaid plans.
Since Republicans control the Senate and the White House, Democrats evidently feel no need to worry about the details, since nothing they endorse is in danger of becoming law. They can throw out an array of proposals and see what sticks, or they can emphasize, as Massachusetts Senator Elizabeth Warren did this week, that the goal is “100 percent coverage in this country at the lowest possible cost.” Any plan that gets there will likely have the support of most, if not all, of the Democrats running for president.
Even the least radical of the plans being tossed around would be considered major progressive victories if they became law, and are likely to be opposed by powerful health industry players, who will inevitably enter the debate. During the Affordable Care Act debate of 2009, moderate Democratic senators like Joe Lieberman (who received a boatload of donations from insurance companies) killed the “public option,” which would have allowed people to buy health insurance directly from the government. Many Medicare for all alternatives resemble this public option, and there are good-faith arguments for why that sort of plan would be preferable to a Full Bernie Medicare for All scheme. It would be less expensive, less disruptive in the short term, and perhaps more appealing to the centrist Senate Democrats who will have effective veto power over any healthcare legislation. (Winning the presidency on a Medicare for all platform might be easier than getting West Virginia’s Joe Manchin on board to vote it into law.)
But there is still a wide gulf between Democrats who regard America’s current private health insurance system as abhorrent and in need of eradication, and those who might prefer to reform the system more modestly. At the moment, the healthcare debate in the 2020 primary resembles several Democrats standing in a circle and singing Kumbaya, insisting that they all want more or less the same thing. But they don’t. The vague answers most candidates have given so far on healthcare—consistently one of the most important issues to voters—will eventually not be enough as they face pressure from the media and primary voters to stake out unique turf. At some point, “Medicare for all” will sound less like a slogan, and more like a way to dodge questions.
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