Medicare (access) for all
As the Trump administration works to undermine Obamacare, a progressive consensus is emerging: next time there’s an opportunity for health-care reform, it should be bigger and bolder. One lesson of Obamacare is that there’s little political reward for moderating policy goals anymore; the 2009 law’s modest goals didn’t spare it from scorched-earth opposition. Nine years later, Senator Bernie Sanders’s sweeping “Medicare for all” bill has a long list of cosponsors.
Yet many who support Sanders’s goals are skeptical of his means. His path is quite disruptive: eliminate most private insurance altogether. But a second lesson, this one gleaned from earlier failed efforts, is that successful health-care reform includes building on whatever already works. Indeed, Obamacare’s less innovative provisions—the Medicaid expansion, the consumer protections in the group insurance market—are proving its most durable.
So how to apply both lessons? How can health reform go big while also limiting the mess it makes?
By distinguishing between goals and means. The goal is bold, bolder than Obamacare’s: universal access to affordable, comprehensive health insurance. A single-payer plan like Sanders’s is one way to get there, but others have been proposed. Most share the basic premise that, because good insurance tends to be either public or employer-based, the task is to increase access to the first while using competition from a public plan to sharpen the second. This might be done by expanding eligibility for existing programs—Medicaid for the middle class, Medicare for the middle-aged. Or public insurance could even be offered to all Americans as one option among others.
A new proposal from the Center for American Progress follows the latter approach. “Medicare Extra” would take existing Medicare coverage, with its efficiencies and cost controls, and add some new benefits. Then it would automatically enroll all newborns, people turning 65, and anyone who turns up at a hospital without insurance. Over time this new public program would absorb the main existing ones; those with private coverage could elect to switch as well. Participants with incomes over 150 percent of the poverty level would pay insurance premiums, but no more than 10 percent of their income. Medicare Extra offers a viable path toward a national health insurance system that welcomes everybody—but also lets them opt out in favor of good private coverage.
CAP embodies the center-left establishment. By releasing this plan, CAP is demonstrating that the push for bold reform has gone mainstream—and that it’s more than just a campaign slogan. “Access to something modeled on Medicare for all” may lack the punch of Sanders’s “Medicare for all.” But the goal is much the same, and the CAP plan shows a way to achieve it.
Obamacare’s goals were limited, but you wouldn’t know it from the right’s ire. CAP’s are far more ambitious; its pragmatism is in the means. In an era of both polarized politics and entrenched interests, this may be what transformative policy looks like.
A version of this article appears in the print edition under the title “Medicare for all?”