“Medicare for All” will get a full committee hearing Tuesday, which means the idea of enrolling everybody in a single, government-run insurance plan is about to get more serious attention on Capitol Hill than it has in at least 50 years.
To be clear, Tuesday’s hearing won’t be in one of the committees that actually write health care legislation. Their leaders don’t want a serious discussion of Medicare for All right now and neither does House Speaker Nancy Pelosi (D-Calif.). She thinks Democrats should focus on defending and improving the Affordable Care Act, the program she was instrumental in passing and that Republicans continue to attack.
But Pelosi and her lieutenants can’t keep Medicare for All out of the spotlight entirely, because the idea has too much support within the caucus and with Democratic voters around the country.
That says a lot about how far the Medicare for All movement has come, even if it still has a very long way to go.
Only a few years ago, almost nobody with power in Washington was talking about junking private insurance and replacing it with a single, government-run plan. But Sen. Bernie Sanders (I-Vt.) made Medicare for All a centerpiece of his presidential campaign, and the idea has gotten much more visible support since then ― in no small part because so many people are still dealing with high premiums, high deductibles and seemingly arbitrary denials of coverage.
Few people can speak to these issues with the authority of Ady Barkan, a progressive activist with ALS (amyotrophic lateral sclerosis, or Lou Gehrig’s disease) who has struggled to get approval for treatments that help keep him alive.
Barkan will be among those testifying on Tuesday ― despite leadership efforts, first reported by HuffPost’s Matt Fuller, to keep the most committed Medicare for All proponents off the panel.
It was after that story appeared and reportedly following a personal text message from Barkan to Pelosi that leadership extended the invitation. Barkan, appearing in his wheelchair and speaking with the aid of a computer, is sure to make a poignant argument about the failings of American health care.
One thing to watch on Tuesday is whether the tension between Democratic leadership and progressives spills over into public view. Republicans, eager to exploit and magnify divisions within the Democratic Party, will do their best to make that happen.
But the substantive questions about Medicare for All matter, too.
The reality is that documenting the failings of the U.S. health care system has never been the biggest impediment to enacting Medicare for All. The hard part is convincing a substantial majority of Americans that a single, government-run program would be superior to what exists now, and then getting such a proposal through Congress, where conservatives hold so much power and the health care industry has so much influence.
The most serious Medicare for All advocates know this. It is why the legislation they crafted, including the House bill from Rep. Pramila Jayapal (D-Wash.), still leaves out major, politically controversial financial details like the taxes people would have to pay in lieu of private insurance premiums.
More clarity is not yet essential. No major effort to expand health insurance coverage is going to become law until President Donald Trump is gone from the White House and Republicans lose their grip on the Senate. That can’t happen until 2021, at the earliest, and advocates have already done a lot of work to flesh out their idea.
But if Tuesday’s hearing isn’t going to produce all of the key answers, it might not be a bad place to start raising the key questions ― starting with these:
What does Medicare for All actually mean?
The idea has become a buzzword on the left but not everybody uses it to mean the same thing. The most committed advocates, like Jayapal and Sanders, have a very specific idea in mind. They want to wipe out private insurance altogether. The new government program would cover everything, with essentially no out-of-pocket expenses.
But some people talking about Medicare for All have a broader definition: They mean any system in which everybody has insurance, the government plays a much larger role in controlling health care spending, and the profit motive doesn’t interfere with people’s ability to get care.
In principle, that can mean a substantial if greatly diminished role for well-regulated private insurance, as an alternative or supplement to the public plan. And it could leave people with some modest out-of-pocket costs, albeit a lot lower than what most Americans pay today.
Public-private hybrid systems are actually more the rule than the exception in the rest of the developed world — although, to be clear, they have a lot more in common with Medicare for All than what the U.S. has today. It might be time to start discussing what a U.S. version of such a system could look like and whether it would deserve the label “Medicare for All.”
How should government control health care spending?
Making sure everybody has health insurance ― and generous health insurance, at that ― would require the government to spend a lot more money than it does today. The hope is that, overall, that spending will be no more and maybe even less than Americans spend on health care today, through a combination of private insurance premiums, out-of-pocket costs and taxes.
But for that math to work, the government would have to get a lot more involved in controlling the price of health care, either by fixing prices or setting overall budgets. And that would affect every part of the health care industry ― not just drug companies and insurers, but also doctors and hospitals.
This isn’t as radical as it might sound. The rest of the world operates this way and, here in the U.S., Maryland runs a similar scheme. But conservatives say that government control of prices would stifle innovation or lead to shortages, and even some liberals worry that cutting industry revenue too deeply or quickly might compromise access or quality.
A discussion of how these cost control systems work abroad and the magnitude of cuts necessary to pay for a Medicare for All system will have to take place at some point. Now is a good time to start.
What are the consequences of doing nothing?
This is a hearing about Medicare for All, so it is likely to focus on what such a sweeping change would mean for the American people. But it might be worth laying out for members of Congress ― and voters ― what will happen if the current system stays on its present trajectory.
Even many people with insurance today struggle with premiums or out-of-pocket costs, threatening them with catastrophe if they get really sick. And the problem isn’t going to get better on its own.
Employers keep raising deductibles because they either can’t or don’t want to absorb more of the costs themselves. As private insurance gets more expensive, people who buy insurance on their own and aren’t eligible for the Affordable Care Act’s tax credits face premiums that are more and more unaffordable.
Even Democrats who aren’t promoting Medicare for All want the government to take some kind of action, like opening up the traditional Medicare to people who are older than 50. Republicans have their own alternatives, most of which involve making it easier for people to buy cheap, skimpy policies that would be available only to people in relatively good health.
It’s worth talking about what those would entail and what would happen if Congress instead does nothing. Medicare for All has its costs and downsides, but these options do, too.