It’s a solid bet that our health care future won’t look quite like the present. Whether the outcome would be good or bad for the average working stiff will depend a great deal on who is president after the 2020 election.
If Donald Trump is re-elected, we know where health coverage for millions of Americans is probably going. It’s going away. For two years, a Republican president, House and Senate all tried to sink the Affordable Care Act. They did manage to punch holes in it, but the thing keeps floating. A re-energized Trump with no voters to face again would undoubtedly redouble his efforts to torpedo the whole law. Per his custom, he’s offered zip to replace it.
Democrats vying to replace him tend to support either “Medicare for All” or “Medicare for more.” The insurers like neither, but their bigger threat is the latter. Being less radical, Medicare for more is far likelier to become reality. Democratic primary voters should appreciate that the nominee backing Medicare for more has greater odds to become president.
A Medicare-for-All plan, such as Bernie Sanders’, would force Americans to give up employer-sponsored coverage they like and require raising taxes. True, Medicare for All would save money by lowering health care costs, but that wouldn’t register in a political rumble fueled by monied interests. The ACA is now more popular than ever, but recall the struggle passing it in the din of debate drenched in misinformation.
All this makes the Sanders approach perilous for Democrats—so much so that Republican Senate Majority Leader Mitch McConnell talks of pushing a Senate vote on his bill. That would put Democrats in the uncomfortable position of voting for or against a plan that ardent liberals may love but gives many others pause.
The genius of Medicare for more is that it would be voluntary. That makes it more sellable to Americans happy with the coverage they have. “Medicare for more” could mean letting those just below the Medicare eligibility age of 65 buy into the program. Or, in another version backed by presidential candidate Pete Buttigieg, “Medicare for all who want it” would allow anyone to buy into Medicare.
Medicare for more can coexist with the ACA, which has provided insurance for 25 million Americans and better coverage for millions more. And it could go hand in hand with efforts to strengthen the ACA. Medicare for All, on the other hand, would replace it.
In any case, Medicare for more would not close the door on Medicare for All. If large numbers of younger Americans choose Medicare over private coverage, then we’re on our way to Medicare for All.
As for the insurers, they have a lot to lose in any major expansion of Medicare. They also have a lot of money to stop it. The Partnership for America’s Health Care Future—a group combining insurance and pharmaceutical giants—spent $143 million on lobbying last year, even when not faced with an immediate crisis.
No doubt the American public would like to quit playing the world’s suckers, paying twice per capita for health care than people in other rich countries do.
Only by offering a choice between Medicare and private coverage will we know what Americans really prefer. Private insurers, we strongly suspect, don’t want to find that out. But let’s keep an open mind.