It should be easy for the Democrats to beat President Trump on healthcare. After all, he never followed through on his promise to “take care of everyone” or to unveil a “phenomenal” plan. Moreover, his sabotage of Obamacare, attacks on Planned Parenthood, and stress introduced by his tweets have caused additional damage.
However, leading Democrats including Bernie Sanders and Elizabeth Warren insist on shooting themselves in the foot by touting Medicare for All. The critics are right: it would be expensive, complex, disruptive and represent a government takeover of the healthcare system. A new Kaiser Family Foundation poll shows that most people don’t even believe their wages will rise if employers save a bundle on health care, as they would under Medicare for All.
Meanwhile, Trump has competent people in his administration in healthcare (unlike other areas) and they’ve worked hard on productive areas such as Medicare Advantage, kidney care, transparency, and vaping.
As a result, Trump can win on healthcare even without a signature TrumpCare program.
Democrats would be wise to nominate someone who espouses building on Obamacare, not replacing it with Medicare for All. Michael Bennet is my pick, but he isn’t getting traction. Joe Biden is the best of the current frontrunners and as Obama’s Vice President is best placed to cement the Obamacare legacy.
The term ‘Medicare for All’ is being bandied about as the campaign for the Democratic Presidential nomination gets underway. Declared and potential candidates are warming to the idea.
It’s easy to see why:
After years of trying to defend complex, compromised Obamacare from GOP rhetorical attacks and legislative and administrative undermining, Democrats are going with a program that is popular and well funded
Medicare especially appeals to the middle-aged and older population, who tend to vote. There’s no stigma attached to it
It could be funded and implemented as a sweeping program at the federal level, which is ideal for a Presidential candidate to talk about.
However, I’d much rather see attention turn to continued expansion of Medicaid, specifically by offering people the opportunity to “buy in” to Medicaid coverage. This has real advantages:
“It’s the prices stupid,” we have been told since 2003. Price, not utilization, is the main reason the US spends so much more than other countries. By design, Medicaid puts the squeeze on costs through lower reimbursement rates
Medicaid has provisions to squeeze drug prices, too, something Democrats and Republicans favor
Medicaid coverage is more holistic than Medicare. It includes programs to address social determinants of health, and is suitable for younger people including parents and children
Medicaid is a partnership between the states and federal government, enabling individual states to craft solutions that fit their specific populations
Several states are already looking at Medicaid expansion as a way to address their specific issues. For example, New Mexico (a purple state) is getting serious about further use of Medicaid. The state has some distinctive characteristics:
Medicaid is by far the largest player already, covering 40% of the population
The uninsurance rate remains stubbornly high at 9%
There are many undocumented and mixed status families who are shut out of the current coverage system
New Mexico is studying four approaches. (You can read the assessment here.)
Targeted Medicaid buy-in: Medicaid-style coverage to those ineligible for Medicaid, Medicare, or the Obamacare marketplace. The state would subsidize premium costs
Qualified health plan public option: A variant on the program originally proposed in Obamacare, with coverage on the marketplace in partnership with an insurer
Basic Health Program: An Obamacare option already
Medicaid buy-in for all: An off-marketplace program available to anyone except Medicare eligibles
The analysis leads me to the idea of starting with Option 1 as a trial run for Option 4. The advantage of Option 1 is that it doesn’t require federal approval, would bring uninsured people into the system who are currently discriminated against, and provide a test bed for further expansion. It would not disrupt the current market by drawing away healthy people, because it is only open to those currently outside the system.
Option 4 could come into force after the 2020 election, when the federal environment is more favorable and once New Mexico has learned from its initial experience.
Sometime down the road, an even more radical version would shift everyone into Medicaid. Private health plans would still have a role since everyone could be enrolled in Medicaid managed care. Providers and drugmakers won’t like the compressed reimbursement, but maybe it will encourage them to innovate on efficiency.
All of these proposals can be combined with value based approaches, which enable the efficient, high quality providers to succeed while containing costs and potentially boosting the patient experience and outcomes.
For now, I’d like to see the debate start up as part of the presidential race. Candidates visiting early primary and caucus states should dig in. In Iowa, for example, Medicaid for all is being discussed by local Democrats.
I have long predicted (Goodbye Obamacare? More like hello single payer) that if the GOP succeeds in undermining the Affordable Care Act it could hasten the move toward single-payer. Well, the undermining has been reasonably successful. And I think 2019 will shape up as the year that formerly taboo proposals like single payer health insurance go mainstream.
Despite what opponents say now, the Affordable Care Act was a moderate bill that sought to work within the existing system and incorporate bipartisan elements, including 188 Republican amendments. Before the individual mandate was pilloried as a threat to freedom, it was upheld as a virtuous plan of personal responsibility by the Heritage Foundation and American Enterprise Institute. Democrats tried to get Republican votes for the ACA. It was a GOP strategy to refuse.
When Republicans tried Repeal and Replace, they didn’t even pretend to include Democrats in their solutions. And of course, Candidate Trump’s promise to replace Obamacare with “something great” was a lot of nonsense.
With all this history, mainstream Democrats are feeling freer to jump to more radical and comprehensive proposals. After all, the ACA was complicated, messy, and full of compromises largely because of its attempt to be bipartisan and incrementally change the existing system. Why not jump to something purer and simpler that doesn’t need GOP input?
As the race for President gets underway, Democrats will start to feel their way on healthcare. Defense of the ACA is a pretty modest, minimum requirement. You can expect to hear calls for Medicare for All, which is a way to offer a popular benefit to more people without creating a whole new system.
But I’m also on the lookout for more radical approaches and it looks like we won’t even need to wait for the Presidential campaign to heat up in order to hear about them. Newly installed California Governor Gavin Newsom is ready to take on Donald Trump directly, calling for a single-payer system, mandatory coverage, expanding access for undocumented immigrants, and regulating drug prices. California is holding an early primary this cycle, so the ideas Newsom is setting out now will influence the debate.
I’d like to see serious discussion of Medicaid for All (rather than Medicare for All). Medicaid pays providers and drugmakers less and is also more comprehensive than Medicaid and better suited for younger adults and children. It’s a more affordable way to provide coverage, provides discretion to the states, and would drive down overall costs by driving down reimbursement rates. Medicaid for All would be a mixed bag for providers and pharma, so would unleash a very passionate debate.
A likely compromise is to offer Medicaid to everyone as a fallback, while retaining commercial and Medicare coverage for those who are eligible and want it.