If you thought the Medicare for All approach to medical insurance died along with U.S. Senator Bernie Sanders’ presidential bid, you might need to rethink that. Today’s most influential Democrats, at least in terms of the party’s future direction, still want to see it pursued, even though the party’s presidential nominee, former Vice President Joe Biden, has so far resisted this approach.
Progressive Democrat and “Squad” member Rashida Tlaib, a Michigan congresswoman elevated to national prominence with the help of President Trump’s taunts, voted to oppose the Democratic Party platform because it did not endorse Medicare for All. The platform does call for expanding health care coverage, but the old guard seems to think Medicare for All is too heavy a political lift — at least for now.
The Democratic Party has revealed that 3,562 delegates voted to approve the party platform, while a total of 1,069 voted no, and 87 abstained. That would put the number of convention delegates who voted no at roughly the same number of convention delegates pledged to Sanders.
Since Medicare for All is an idea that’s not going away, especially because it is proposed in a bill authored by Sanders, we discussed the concept with Robert P. Palmer, vice president of government relations for WPS Health Solutions.
We want to start out by getting your impressions of Medicare for All as Sen. Bernie Sanders has proposed it. Would it eliminate all private medical insurance?
“The first thing that is really important to understand is that while the title is Medicare for All, there is absolutely nothing resembling Medicare aside from the name. It would replace the current Medicare system — Part A, Part B, Part D, and Medicare Advantage — with a single program. It would replace all private insurance, as well as TRICARE (the health plan for military members), Medicaid, and CHIP (the Children’s Health Insurance Program). It would retain the VA (Veteran’s Administration) and the Indian Health Service. It’s a pretty dramatic restructuring of the American health care system.”
Medicare Advantage is one of the things that would be eliminated under Sanders’ bill.
“Exactly. What Medicare for All would do, at least under the Sanders’ bill, would create 13 benefit categories — kind of like the essential health benefits that we have under the Affordable Care Act but much broader. It would include dental, hearing, vision, long-term care, comprehensive reproductive services, and even transportation health services for people with disabilities and low-income individuals. What is significant is the law specifically prohibits private health insurance from providing any insurance that covers a benefit covered by Medicare for All. It does allow supplemental care. If you think about how comprehensive Medicare for All is, there is not a lot of room for supplemental coverage.”
Can you think of any benefit area that private insurance would cover?
“The 13 benefit categories covered by Medicare For All are quite comprehensive, so the only thing I can think of would be procedures that are not medically necessary, such as cosmetic surgery. You might be able to sell supplemental policies for elective procedures that are excluded from the Medicare For All benefit, but quite frankly, that would look very much like the coverage you see for dental and vision now.”
We should talk next about the dramatic restructuring required when you take private insurance away from 150 to 180 million Americans, depending on whose estimate you believe. If a smooth transition is realistic, what would it look like?
“I’m measuring my remarks here. It obviously would be a huge transition. It’s really almost unimaginable what it would be like to provide this sort of disruption to one-fifth of the U.S. economy. It would have a tremendous impact. We saw how the transition to the Affordable Care Act encountered some bumps. There is no reason to believe the transition to Medicare for All would go any more smoothly than the transition to the Affordable Care Act.
“When people say they are skeptical that the Medicare for All could pass, I think the transition is one thing that gives them pause, as well as what happens to these huge health insurance companies employing tens of thousands of Americans. How could we transition? That’s an excellent question, but I don’t know that concerns about transition will stop its advocates from pursuing Medicare for All.
“Congress has not really gotten serious about looking at this bill. While there have been some hearings on the companion bill in the House, the Congressional Budget Office hasn’t provided a cost estimate and none of the committees with jurisdiction have marked it up. If the November elections provide a critical mass for proponents of Medicare For All, there would still be some legislative give and take that determines where the proposal ends up.
“The Sanders bill is really the starting point for the debate on Medicare for All. Using the Affordable Care Act as an analog, there was Congressional interest in a public option that ultimately was not included in the ACA. There is no reason to believe that Medicare for All would not go through some sort of similar metamorphosis as it winds through the legislative process.”
Would the various insurance stakeholders become almost utilities? They are talking about taking a big piece of business away from WPS and perhaps eliminating other health insurers entirely.
“I have absolutely no idea. That’s what makes this such a daunting prospect. It’s very hard to imagine how we would go from where we are now to Medicare for All in a relatively short period of time. Obviously, there is some political pressure to do that, but the political process is — even in our polarized environment — still one of compromise and tradeoffs.
“At this point, we really haven’t addressed the cost of Medicare for All, which is going to be enormous. Would there be some sort of Medicare for All premium? The current bill doesn’t allow for that. Would there be some sort of copay or cost sharing? The current bill doesn’t allow for that. Those would be two areas where you could see some compromise or trade off simply to make it more affordable. How would it be administered? And would there be a role for the private sector health insurers? I have no idea how Medicare For All would address that.”
What’s your assessment of its impact on physicians? There are a lot of reports about how Medicare already squeezes costs out of the system and doctors are negatively affected and don’t even take Medicare patients in some cases. We have a shortage of medical professionals already. What do you think is the potential impact on the provider side?
“This is one of the areas that needs greater public discussion. Certainly, opponents of Medicare for All have looked at it and said, ‘There is no way Medicare for All would work unless they did something to address the physician reimbursement rate and hospital reimbursement rates.’ In other words, what it pays. Medicare currently pays physicians and hospitals less than private insurance does. There are a lot of potential, long-term effects to that. The economic principles of supply and demand suggest that if you’re going to pay people less, fewer people will go into that line of work. If we lower physician and hospital payments, there will likely be fewer physicians and hospitals in the future. This is an issue that needs a lot more exploration and a lot more public discussion before we say, ‘Hey, that’s a great idea. Let’s go do it.’”
I want to address, to the extent possible, the financial impacts on employers. If you’re replacing premiums with taxes, what will the tax bite be? Has this ever been quantified in some way? Has anyone crunched the numbers?
I think it’s flawed to say, ‘Hey, this is going to cost the same. Instead of paying premiums, we’ll just be paying more in taxes.’ It appears that Medicare For All could cost a whole lot more, and so we’ll have to figure out how we’re going to pay for that. I feel like it is the triumph of hope over evidence.
“There is one economist affiliated with George Mason University [Charles Blahous] who had done some research on the cost of Medicare for All. According to him, a lot of his research has been taken out of context, but last year he estimated the cost of Medicare for All to be somewhere between $32 trillion and $38 trillion over 10 years. So, let’s assume that is between $3 and $4 trillion a year on average. It’s a number that’s been thrown around a lot, but I went back through some of his articles, and he said, ‘No, no, no, that’s the additional cost of it to the current system.’ He thinks the total cost would be between $54 trillion and $60 trillion over a 10-year period.”
Do you know of any study that would compare what we’re paying in monthly insurance premiums and this is what you would pay in taxes under Medicare for All?
“I haven’t seen anything like that. Not at all in terms of how we would pay for the taxes. There is still a great deal of debate over the cost, and until you know what the cost is, you can’t come up with the taxes. It’s either going to be paid by employers, employees, or a combination of both. That’s the way the current system is paid for. With current Medicare, you’ve got Part A, which is paid for by basically a working-life payroll deduction split between the employer and the employee. There is a modest premium for Part B and then Part D also has a premium. There are only so many ways you can pay for it.”
What would removing the medical insurance benefit from employers mean from a corporate culture or employee retention standpoint? Or is that a moot point because they would be paying it in one way, shape, or form?
“I would think it’s a moot point. I’m not really certain. Basically, you’re dismantling the current system and creating an entirely new system. Under Medicare for All, whether you’re a retiree or still in the working population, the benefit would be the same —13 covered benefit areas, and no copay or premium.”
Do you have any other observations about the potential impacts of Sen. Sanders’ proposal?
“Obviously, it would give the government control of the benefit design. As the political environment changes, what Medicare for All covers could change, which may be unfavorable for certain groups. Or, as the fiscal situation gets really tight, the government may cut back on what it will allow. Essentially, you’re putting all of the control over the medical care you would receive in the hands of Congress and the executive branch. Under the current system, and there are certainly flaws in the current system, you have some choice as to who insures you and what your benefit looks like. Medicare for All would standardize all of that.”
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