In a study published late last year, the nonprofit Kaiser Family Foundation identified eight pieces of legislation aimed at making insurance more widely available, which the study groups into four categories:
- Two proposals for instituting single-payer coverage for all Americans—in effect, Medicare For All.
- Three plans for creating a Medicare-like “public option” that would be available to all individuals and some or all employers via the ACA insurance exchanges
- Two bills enabling Americans younger than 65 to buy into Medicare. One proposal would allow buy-ins starting at age 55, the other at age 50.
- One proposal allowing states to offer their residents a Medicaid buy-in option through the ACA marketplaces.
A ninth bill, the Medicare for America (MFA) Act of 2018, was introduced after the Kaiser study was published. It would cover the uninsured, those who buy insurance on the individual market, and individuals on Medicare and Medicaid. Employer-sponsored insurance would remain, but employees who have it would have the option of enrolling in MFA coverage instead.
While all the proposals would come with costs and tradeoffs, the most difficult to navigate would come under Medicare-For-All, or some other form of single-payer system. Some method would be needed to pay for coverage of people who get insurance through their employer, says Joseph White, Ph.D., a professor of public policy at Case Western Reserve University and author of False Alarm: Why the Greatest Threat to Social Security and Medicare is the Campaign to “Save” Them.
“The transition to what we’re really talking about, which is financing through the tax code the portion of healthcare which is currently collected through employers, is really hard,” White says. “There are likely to be a lot of losers, or at least people who think of themselves as losers in the short run, and that’s going to create a lot of political backlash.”
Moreover, White notes, none of the single-payer proposals address what to do about Medicare patients who get their benefits via Medicare Advantage programs, which are administered by commercial payers.
As for doctors, a single-payer system would have the benefit of eliminating much of the paperwork and administrative headaches that comes from dealing with multiple payers. But it would also likely mean a reduction in income, since Medicare traditionally has reimbursed at lower rates than commercial insurers.
White and other policy experts caution that with the presidency and Senate in Republican hands, the chances for any type of Medicare expansion occurring before 2021 are virtually nonexistent. Nevertheless, they say, just the fact that the idea is being discussed, and will likely be the subject of Congressional hearings, is significant.
“The advantage of hearings is that members of Congress, as well as the general public, will begin to sort of kick the tires and learn more about the mechanics of these proposals and the trade-offs they would involve,” says Tricia Neuman, Sc.D., MS, director of the Kaiser Foundation’s program on Medicare policy and a co-author of the study on Medicare expansion.