Since Bernie Sanders made “Medicare-for-all” a central plank of his wildfire presidential campaign, support for a once-fringe idea has exploded. Democratic senators with eyes on the 2020 presidential contest – including Cory Booker, Kirsten Gillibrand and Kamala Harris – have conspicuously lined up as co-sponsors of the “Medicare-for-all” legislation that Sanders introduced last year; a similar proposal in the House has 123 co-sponsors. All of those politicians are Democrats, but among voters, support appears to cross the aisle: A recent Reuters/Ipsos poll showed that “Medicare-for-all” was supported by 70 percent of American adults, including a slight majority of Republicans.

It’s easy to understand the political appeal of a phrase that invokes the broadly popular Medicare program and promises new benefits for everyone. But scratch beyond the slogan, and “Medicare-for-all” starts to raise more questions than it answers. The American health care system is a vastly complicated $3 trillion slice of the economy, and although there’s plenty about it that needs fixing—it’s the most expensive in the world and still leaves nearly 30 million Americans uninsured—any seismic change will put reformers directly in conflict with some of the most powerful lobbies and voter blocs in U.S. politics. And that’s if the “Medicare-for-all” proponents can reach any kind of consensus on what they want.

Here’s a field guide to just what we don’t know about “Medicare-for-all.”



1. What does it even mean?

Some Democrats use “Medicare-for-all” as shorthand for a single-payer health care system, like the British National Health Service. But if you look at the actual plans forwarded by Democrats and progressive groups supporting universal coverage, you’ll find a range of ideas—from quickly replacing private health care with a government-run health system to slowly moving toward a hybrid scenario in which universal government insurance coexists with a private market. The House bill envisions implementing a system within two years that would offer all residents government-funded coverage for almost every conceivable type of care with no out-of-pocket costs for beneficiaries. Less quixotic blueprints have been drafted by policy analysts at the Center for American Progress (“Medicare Extra for All”) and the Urban Institute (“The Healthy America Program”).

Part of the confusing variety stems from the complexity of just what Medicare itself is. It’s not a single-payer system in the sense that most people think of that term; it’s better understood as a massive public-private hybrid coverage scheme, funded mostly by taxes. About a third of all Medicare beneficiaries, more than 20 million seniors, are in Medicare Advantage plans sold by private insurance companies. That number keeps growing, and today about half of new enrollees opt for private plans. Even seniors who stick with the traditional Medicare program can pay for private “Medigap” insurance to help cover out-of-pocket costs and services that aren’t covered by traditional Medicare. And Medicare’s coverage for prescription drugs—a huge part of many seniors’ health care bills—is also managed by insurance companies, which offer dozens of plans, almost all with a monthly premium.

Democratic presidential candidate Sen. Bernie Sanders helped promote the idea of “Medicare for All” during his 2016 campaign, including at this health care event in San Francisco. | Justin Sullivan/Getty Images

The bottom line is that Medicare is nothing like the big single-payer programs typically envisioned by supporters. Rather, it’s a lot like the rest of American health care: bewilderingly complex, stitched together financially with premiums and other out-of-pocket costs, and heavily dependent on the existing landscape of private insurance companies. Extending it to “all” could mean expanding the current patchwork quilt into an even bigger hybrid, or jettisoning it for an entirely government-run system, or something in the middle. None of those are really explained by the simple three-word slogan.



2. How would we pay for it?

The whole point of Medicare is that it’s not “for all”—it’s a system that pays health care bills for seniors by taxing the paychecks of America’s working-age people. Paying for everyone’s health care that way would be a radically different proposition, and far more expensive.

An analysis released last month by health care economist Charles Blahous at George Mason University’s Mercatus Center estimated that implementing Sanders’ “Medicare-for-all” proposal would add $33 trillion to Americans’ tax bills over a decade. Those findings mirrored an earlier analysis by the Urban Institute. Although supporters argue that those new bills will be more than outweighed by trillions of dollars in reduced insurance payments over that time—along with even more savings from reduced administrative costs—passing such a drastic tax increase is, to say the least, a tall order in U.S. politics.

And it’s more than just the challenge of increasing taxes. Moving to a “Medicare-for-all” system, however it’s defined, would trigger a massive shift in the country’s economy. Health care currently accounts for a staggering 18 percent of the gross domestic product. The trillions of dollars that currently flow from employers to insurance companies to health care providers would instead need to be funneled to the federal government. In the most sweeping schemes, that would mean the end of the insurance industry and an expansion of government unprecedented since World War II.

While polling has shown a steady increase in support for a single-payer system over two decades, there’s also evidence that that support is fairly thin for many Americans. For example, if respondents are told that it might give government too much control over health care, opposition rises by 21 percentage points, according to the Kaiser Family Foundation. Similarly, opposition jumps by 19 points if they’re told that taxes would have to be raised on many Americans.

3. What happens to insurance?

Private insurance as we know it would be radically changed by almost any kind of Sanders-style proposal, but it’s not clear how. Even in a single-payer system, private insurance isn’t likely to go away. In Britain, for example, everyone is eligible for free treatment by the National Health Service, but about 10 percent of residents still opt for private coverage, which offers access to providers and procedures they can’t get through the government system.

Health insurers won’t make change easy: They’re a massive industry with millions of employees and tremendous lobbying muscle on Capitol Hill. Today, 160 million Americans get health insurance coverage through their jobs, and a sizable majority of them—about 70 percent, according to one poll—are satisfied with their plans, which gives the industry a great deal of clout to resist any change. And the industry isn’t afraid to play hardball, as it showed when it killed the Clinton-era health care overhaul with an aggressive national ad campaign.

Supporters of Medicare for All legislation at an event in Congress in September, 2017. | Alex Wong/Getty Images

Americans might vaguely agree that our health care system is dysfunctional and financially unsustainable, and might even think “Medicare-for-all” is an improvement, but that doesn’t necessarily mean they’ll be willing to give up their own heavily subsidized gold-plated coverage to bet that Congress can build a better replacement.



4. What happens to doctors?

There’s no question a more nationalized health system, no matter how it’s funded, would control costs by decreasing the amount of reimbursement to providers, which means doctors and hospitals would make less money. Medicare payment rates are already far below what private insurers pay – somewhere around 40 percent less – and hospitals and doctors would undoubtedly revolt over a cut anywhere approaching that magnitude for their patients who currently have private coverage.

Doctors and hospitals enjoy broad public support, and like insurers they have lobbying clout: They spent around $200 million on lobbying last year, according to the Center for Responsive Politics. Anyone who witnessed the annual lobbying blitz over the “doc fix” on Capitol Hill—an obscure-seeming, multibillion-dollar fight over how much Medicare reimbursed doctors—understands how unlikely it is that lawmakers will back any change adamantly opposed by medical providers. Year after year, spanning more than a decade, when members of Congress were faced with possible cuts to doctor payments resulting from Medicare’s “sustainable growth rate” formula, they voted to stave off those cuts—a rare example of bipartisan agreement on health policy.



5. What happens to Medicare itself?

Medicare is already on financially shaky ground: The most recent calculations show the Medicare trust fund will be able to cover the entire cost of hospital insurance coverage only through 2026. That means there’s pretty much no way the current system can remain in its current form. Just to keep Medicare in business, Congress needs to take some unpalatable steps—some combination of higher taxes, higher prices and reduced benefits. Reforming Medicare as part of a larger expansion package would require much the same.

The adage that change is scary when it comes to health care is exponentially more potent when it comes to grandma and grandpa. In addition, seniors are a notoriously powerful, engaged voting demographic that politicians are loath to antagonize. Witness the scare tactics that both parties have wielded in recent campaign cycles to woo Medicare beneficiaries. Democrats and their allies ran ads showing House Speaker Paul Ryan literally pushing an old lady off a cliff to emphasize the threat of Medicare privatization. Republicans pummeled Democrats for multiple cycles over $700 billion in reduced Medicare spending that helped pay for Obamacare, even though there were no significant reductions in benefits.

Fixing Medicare as it stands is difficult enough. Fixing Medicare by hitching it to a massive nationwide health care program and tax increase would be a fiscal and political challenge that makes Obamacare look trivial. Campaign strategists would undoubtedly be salivating at the prospect of warning seniors that their health care could be put at risk in order to provide free coverage to oil tycoons, hedge fund sharks and tech gazillionaires—and everyone else who’s suddenly part of the “all.”

Paul Demko is a health care reporter for POLITICO Pro.

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