Nov. 01 2019

Let's Talk About Medicare For All

As the 2020 United States presidential election approaches, healthcare policy is at the forefront of the national conversation. It’s no question that access to doctors and hospital care improves health outcomes. But the number of uninsured Americans is on the upswing after years of decline, with non-Hispanic blacks, in particular, losing coverage. At last count, more than 27 million nonelderly Americans were uninsured. How to provide high-quality care—and pay for it—remains a critical public health debate. We asked three of the School’s experts to discuss the feasibility of expanding healthcare coverage.

Why is healthcare at the top of the political agenda and what are the proposals being considered?

Michael S. Sparer, JD, PhD, chair of the Department of Health Policy and Management: The fierce debate over our healthcare system is, in many respects, a proxy for a larger debate over the role of government in our lives and the relationship between the private and public sectors.

We’ve had this debate for a couple hundred years, but it’s particularly focused right now. On the left, Medicare for All, in which the government would be a “single-payer,” has been proposed to eliminate private insurance, remove the employer from the healthcare arena, and significantly expand Medicare coverage. Moving toward the middle, a large group of Democrats acknowledges that 90 percent of Americans are insured, and propose shoring up the Affordable Care Act (ACA) and expanding Medicare and Medicaid, possibly with an option to buy into these programs. The Trump administration says the problem is not that government isn’t engaged enough; the problem is that government is engaged too much. The administration proposes either repealing the ACA or, if that’s not politically possible, imposing work requirements on Medicaid beneficiaries, offering slimmer benefit plans, and scaling back the federal role. Generally speaking, the public health community is not in favor of any program that would further restrict access to care. Getting care to as many people as possible, as early as possible, saves lives and money in the long term.

What should be the goals of any healthcare reform?

Jamie Daw, PhD, assistant professor of health policy and management: One goal is to ensure that everyone has access to healthcare, which should be based on need for care and not ability to pay. Another big goal is cost-effectiveness. The U.S. spends around 18 percent of GDP on healthcare, and costs need to be reduced, both on the individual and the societal level. Finally, we don’t want to sacrifice quality.

Ashwin Vasan, MD, PhD, assistant professor of population and family health: I think the goals should be, number one: Cover every person. Number two: Provide care in a very effective manner, where people are treated for their illnesses in a timely fashion close to where they live. And number three: Do that in a cost-effective manner, both at the level of the individual and at the level of the system.

What’s your take on the various reforms being proposed?

Vasan: The research is pretty clear that a single-payer healthcare system would reduce costs over time. We currently pay the highest healthcare administrative costs of any country. If we were building a system from scratch, there is no persuasive argument for anything other than single-payer. But in transitioning from our current system, we should understand that there must be a rational glidepath to get to single-payer. We can make Medicare, via a public option and/or reducing the age inclusion criteria, an easier option for people to choose. Private plans will either be forced to compete on costs and quality, or lose market share until we get at or near a true single-payer public system.

Sparer: What’s needed is a central government that effectively regulates the health insurance market, shores up the ACA, and expands programs like Medicare and Medicaid. I don’t think it’s politically plausible to eliminate the private health insurance system. Nor do I 

think it’s wise. A single-payer system can be quite good, but you don’t need
a single-payer system to have affordable universal coverage.

What healthcare models could serve as examples for the U.S.?

Daw: Lots of advocates recommend that we look to Canada: Get rid of private insurance, or very much limit its role, and have one government program. But we ought to think about models that would more naturally build on the current system. Many other countries, such as Germany, provide healthcare through a social insurance system, which uses private insurance, plus tax revenues, to offer affordable universal health insurance.

Sparer: States can serve as laboratories. The ACA itself was significantly modeled on the 2006 Massachusetts health reform. More recently, Washington state became the first state to impose a cost cap on a health plan sold in a commercial insurance market (a so-called “public option”). This is an innovative approach expected to significantly lower premiums for prospective buyers. But you can’t simply pick up something that works in one state (or country) and drop it in another and expect it to work perfectly. You really have to consider what works where, how it works, and why it works.

How might expanding access to coverage change the patient experience?

Vasan: Constant uncertainty about coverage creates more instability in the lives of the poor, whose lives can already be quite unstable. And when uninsured people delay care, they end up in emergency rooms, which cannot manage chronic illness. They struggle to coordinate care and it costs more. We don’t have the ability—because of lack of universal coverage, either through single-payer or otherwise—to redirect those folks into more frequent, higher-quality, lower-cost primary care.

Daw: I think about women in the period around pregnancy. Pregnant women often experience changes in employment, income, marital status—and all of those changes affect health insurance and the ability to access care. Since the late 1980s, Medicaid has paid for nearly half of all births in the U.S. However pregnancy care under Medicaid only offers coverage from conception to 60 days after their delivery. 

18% of the GDP is spent on healthcare. | Nearly half of all births have been paid for by Medicaid since the late 1980s.

That’s a huge issue because women experience all kinds of pregnancy-related health conditions that can extend long after delivery. Medical problems such as postpartum depression, anxiety, substance abuse, urinary incontinence, pelvic floor dysfunction, and breastfeeding infections affect not only women’s health but also children’s health. The ACA introduced Medicaid expansion, and in the 37 states that did expand coverage to low-income adults, many more women can now maintain Medicaid after pregnancy. Universal coverage would get rid of the complexity and provide stability.

Vasan: Another population I’d call attention to is incarcerated people. When my patient is incarcerated, I have no idea what care they receive inside. The “inmate exception” rule prevents federal dollars from being used to pay for inmates’ healthcare—so there’s no continuity nor standard quality of care. The correctional system is one of the largest
if not the largest provider of mental health and substance abuse treatment in every state. But medical care in this setting is mainly focused on basic triage and not managing chronic conditions. Universal coverage and the elimination of the “inmate exception” could begin to tackle these problems.

In the presidential debates, the idea of “Medicare-for-all-who-want-it” came up. How would that work—and can it work?

Sparer: The Democrats seem divided between those who want “Medicare-for-all” and those who want “Medicare-for-more.” Bernie Sanders, for example, wants to eliminate employer-sponsored insurance and the private insurance industry, replacing it with Medicare for all Americans. The Medicare-for-more folks are proposing that the current private insurance system would survive, but that some (or all) would be offered the option of “buying into” a 

Medicare-like program. This is the more politically viable proposal, though it too would be opposed by providers (worried about lower reimbursement) and private insurers (worried about losing subscribers). Would it work? Yes, it could, though the devil is in the very complicated details.

What’s the role of academia in the political discourse?

Vasan: Schools of public health are working to build the next generation of researchers who want to dive into the details around these grand policy visions. A huge amount of analysis, forecasting, and modeling is needed, and these are all things our School has led in the past, such as with research that helped inform Obamacare.

Daw: We bring evidence to the discussion. Research can tell us which options will lead to improved access, reductions in cost, and better quality. I think another major role we play is to remind people that we’re not the first country to consider expanding health insurance. By teaching students about health systems around the world, we can expand the options being considered and provide guidance on how other nations made the leap to covering all citizens. Indeed, maybe being late in the game could benefit the U.S. in that we can learn from other countries’ mistakes and successes.


Alison Fromme is a science writer in Ithaca, New York. Since 2013, she has reported on climate and public health, global health justice, and implementation science for Columbia Public Health.