By Drew Altman
Axios, November 2, 2017
It is generally assumed that the biggest obstacle to a national health plan like Medicare for All will be the large tax increase needed to pay for it. But new polling shows another challenge: Almost half of the American people don’t know that they would have to change their current health insurance arrangements if there was a single-payer plan.
Would switching to a single-payer system mean changing your health insurance?
Percent who think they could keep their current plan:
47% – Total
52% – Democrats
50% – Independents
44% – Republicans
44% – People with employer coverage
Why it matters: Current insurance plans leave a lot to be desired for many people, and it is entirely possible that some people would want to switch to a Medicare for All style plan. But the public has resisted being forced to change their health care in the past — don’t forget the uproar over the cancelled plans at the launch of the Affordable Care Act.
So requiring people to change could trigger blowback and would certainly provide a talking point to help opponents scare people about single payer.
The details: Overall, the general idea of a national health plan is pretty popular, with 53% of the American people favoring a national health plan — 30% strongly favoring it and 23% somewhat favoring it. On the other side, 31% strongly oppose it and 13% somewhat oppose it. Democrats and Republicans split on the idea, as expected.
But as the chart shows, somehow, 47% of the American people think they would be able to keep their current health insurance — even though a single payer Medicare for All style plan would do away with employer-based insurance.
Advocates of single payer consider it a virtue that employer-based health insurance would be eliminated. Health reformers on the right would also do away with employer-based insurance, but they would replace it with tax credits for private insurance, not a government plan.
There are also more targeted public insurance proposals for people who can’t get Medicaid or marketplace coverage — including a government-run public option, a Medicare buy-in for 50-64 year olds, or a Medicaid buy-in option on the ACA marketplaces. They wouldn’t threaten people’s current health care arrangements, but they are far from the rallying cry for some progressives Medicare for All may be, and they’re no slam dunks in the current political environment.
The bottom line: There is no sweeping health reform plan without tradeoffs, as we learned with both the ACA and the Republican repeal-and-replace plans. The fact that so many people don’t know that a national health plan would require them to change their insurance arrangements underscores the challenge of making the transition from a popular idea to a reality for a single-payer national health plan.
By Don McCanne, M.D.
A friend of mine from Switzerland explained to me the reason that the voters rejected single payer for their country. She said that most Swiss were quite satisfied with their current plans and did not want to risk replacing them with a single plan run by the government. Likewise, in the United States many are satisfied with their employer-sponsored plans and may be uncomfortable with the prospect of changing to a plan run by government bureaucrats.
It is not too difficult to explain why people would be better off with a well designed single payer program than they are under private health plans, whether individual or group. One of the more important considerations is the stability of a plan that provides coverage for life. Obviously employer-sponsored plans change every time there is a change in employment and whenever the employer decides to change the plan(s) offered. Choice of providers is limited by most plans today resulting in fragmentation of health care with changes in provider networks. Employer-sponsored plans have been declining in actuarial value primarily through increases in deductibles and other cost sharing. The PNHP single payer model eliminates cost sharing thus removing financial barriers to care and preventing financial hardship due to excessive out-of-pocket costs. Financing of single payer is more equitable since it is based on income rather than on a premium that may not be affordable for low- and moderate-income individuals and families. Portability of coverage is not a problem since everyone is covered everywhere at all times. The list goes on.
Some would be concerned about losing the employer contribution to the insurance premium if we were to switch to single payer. But most economists agree that the employers’ contribution is paid by forgone wage increases. The premium contribution would be replaced by equitable taxes, but it would depend on the tax policies put in place as to whether the employers’ contribution would be replaced with taxes on the employer, or would be advanced to the employees as salary or wage increases, or some of both. Also, the tax expenditures (deductibility) for employer-sponsored plans are regressive since higher income individuals receive a greater tax benefit than do those with lower incomes. Regardless, the funding of health care under single payer would be much more equitable than it is now.
Thus, objectively there is no contest. A single payer national health program – an improved Medicare for all – would be vastly superior to our current fragmented, dysfunctional financing system. But facts and objectivity may be inadequate for someone whose mind is made up, as anyone can attest to who has had a conversation with a passionate Trump supporter who refuses to concede on issues for which well documented facts refute their positions. People are like that, even people who do not support Trump.
This does demonstrate the importance of educating the public on single payer Medicare for all. But the principles have to be repeated so often that they become memes, and we will always have to contend with the opponent meme-sayers. Our advantage is that we do not waiver on the truth, and they do. Most people can eventually recognize the difference.
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