By Adam Gaffney, M.D.
The Guardian, Feb. 25, 2018
On Thursday, the Center for American Progress (CAP), a Democratic party-affiliated think tank, launched a proposal confusingly called “Medicare Extra for All.” For proponents of a Bernie Sanders-style single-payer “Medicare for All,” this might seem like a positive development. Well, yes and no.
On the one hand, “Medicare Extra” is a step to the left for CAP, suggesting that the Democratic establishment is following the lead of its galvanized base. On the other hand, this new proposal would exact sacrifices from patients to placate the insurance industry, and could serve to divert the single-payer movement, which has been rapidly gaining steam.
A debate over the next step on health reform has roiled the Democratic party. Some, like Hillary Clinton, have advocated incremental changes to Obamacare, such as a “public option.” Others, led by Bernie Sanders, seek to replace the hodgepodge of private and public health plans with “Medicare for All” – a single-payer program covering everyone without copays or deductibles.
Though Trump’s victory might have dampened support for the more radical road, it did just the opposite. The president swore to repeal the Affordable Care Act, and try he did – but apart from felling the individual mandate, the effort flopped in Congress. He did, however, rouse millions of Americans behind the cause of healthcare justice. Single-payer bills in both houses of Congress accrued record support in 2017, including a majority of House Democrats and more than a third of Democratic senators.
The political winds had shifted: progressives were out of power, but they were coalescing around a post-Trump plan – improved “Medicare for All” – overwhelmingly popular with the party’s base: about 69% of Democrats supported it, according to a September survey.
Enter Medicare Extra. CAP’s proposal is a response to these shifting winds. The new Medicare Extra program would automatically enroll anyone without other insurance. Premiums and out-of-pocket payments (eg copays and deductibles) would continue, with limits based on income.
Employers could choose to offer private coverage, or switch their employees into Medicare Extra. Notably, private insurers would get a big slice of the Medicare Extra market, enrolling millions in “Medicare Choice” coverage modeled on today’s wasteful, privatized Medicare Advantage plans, which in effect cost taxpayers “104% of per capita traditional Medicare spending” per enrollee, as noted in the Journal of the American Medical Association.
What’s not to like?
First, there’s the proposal’s voodoo economics. The US healthcare system hemorrhages cash through useless billing and bureaucracy, the inevitable consequence of battles between our jumble of profit-seeking insurers and the country’s providers. Transitioning to single-payer could end this waste, saving about $500bn annually; multi-payer systems such as Medicare Extra that add yet another plan to the existing slew of private insurers cannot. And without these efficiencies, expanding to fully universal coverage could prove unaffordable.
Second, because the economics don’t work, the coverage is insufficient. Although Medicare Extra would be more generous than most Obamacare plans, it would still leave millions encumbered with copayments and deductibles, which force people to choose between healthcare and other necessities. Keep in mind that one survey found that almost half of Americans couldn’t afford an unanticipated $400 expense, per the Washington Post.
Indeed, under the CAP program, some might see their coverage worsen if their employer elected to transition them to Medicare Extra. Consider that large employers’ plans cover, on average, 85.4% of healthcare costs. But Medicare Extra would cover only 80% of costs, for at least some families (depending on income). Republicans would have a field day scaremongering about the government taking away your healthcare plan. While CAP touts the political advantages of their plan, it may well be a juicier target for such scaremongering than “Medicare for All”, which would cover 100% of healthcare costs.
Medicare Extra offers an inferior policy option, when a better one is on the table. Improved “Medicare for all” can affordably provide healthcare to everyone. It’s widely supported by the progressive base – and indeed by the majority of the nation in most polls. And it can serve as a powerful political promise as we wade into the profoundly consequential 2018 and 2020 election season. Democrats would be wise to unite behind it, rather than be sidetracked by CAP’s second-rate scheme.