The vision of universal access to health care that lies behind Medicare for All has wide appeal. However, as David Brooks noted in a recent column for the New York Times, the problem is less the vision than the transition. Medicare for All, in both its Senate (Sanders) and House (Jayapal) versions seems designed without a thought to the problem of transition. If we can’t get there from here, what is the use of a glittering vision of health care reform?
Fortunately, Medicare for All is not the only path to affordable access to health care for all Americans. Our team at the Niskanen Center has been working on an alternative health care reform known as universal catastrophic coverage (UCC). UCC would cover the needs of the very poor and the very sick in full, as does Medicare for All. At the same time, it would also require those who can afford to do so to pay a fair share of their routine medical expenses through income-based deductibles, coinsurance, and copays. That gives UCC a greater flexibility that would ease many of the transition problems that Brooks lists.
Sticker Shock
The sheer cost of Medicare for All is one of the biggest obstacles to its adoption. As measured by the Kaiser Family Foundation, Public support for comprehensive national health care drops from 56 percent to 37 percent when people are told that it would require higher taxes.
Backers of Medicare for All point out, correctly, that most people would get those taxes back through lower premiums and out-of-pocket costs. But taxation is a leaky bucket. Taxes distort financial decisions made by families and businesses. There are administrative costs of collecting taxes and disbursing benefits. As a result, it takes more than one dollar in tax burden to support each dollar of benefits.
Because of the leaky bucket effect, it makes no sense to impose heavy new taxes on upper-income households and then give that money right back as health care benefits. That is all the more true since the benefit in Medicare for All are more generous than in other countries. Highly regarded health care systems, such as those in Australia, Singapore, and France, require at least modest deductibles or copayments. What is more, they do not cover as wide a range of services as Medicare for All would do.
By comparison, universal catastrophic coverage would cost at least 30 percent less than Medicare for All. Based on reasonable assumptions, the government could finance UCC entirely from funds it now spends directly on health care, plus funds that now go to mandated and tax-advantaged employer plans. The lower cost of UCC would greatly reduce the problem of sticker shock.
What Role for the Insurance Industry?
Observers like Brooks rightly worry about the impact of health care reform on the half-million-odd people who work in health insurance. The fragmented and adversarial nature of our health care payment system is a big part of the reason for its high costs relative to those our high-income peers. Any serious reform will, and should, have a big impact on the insurance industry.
Still, it would be possible to implement UCC in a way that would be less disruptive to the insurance sector and its employees than Medicare for All, under which the entire industry would effectively disappear.
Under UCC, many higher-income households would have deductibles and coinsurance of thousands or even tens of thousands of dollars. Many of them would probably choose to buy some form of supplemental insurance. Private companies would serve that market, much as they serve today’s market for Medigap coverage.
UCC could also create a role for private insurers as payment agents for the federal catastrophic program. For example, they could offer a private option, similar to Medicare Advantage, even if the Centers for Medicare and Medicaid Services administered the basic UCC program.
Instead, UCC could contract out all coverage to competing private insurers, as the highly-rated Dutch and Swiss systems do. Those countries regulate insurance companies much more tightly than the U.S. system currently does. The regulations ensure that companies compete by offering lower costs and better customer service, rather than boosting profits by denying as many claims as possible. But even with its much tighter regulation, the transition to a Dutch or Swiss model would be far less disruptive for insurance companies and their employees than Medicare for All.
If You Like Your Plan . . .
The failure of the Affordable Care Act to deliver on President Obama’s incautious promise, “If you like your health care plan, you can keep it,” helped spark a widespread backlash against that program. No such promise should ever have been made. There are too many health care plans in today’s system that make no sense even to try to keep.
Employer-sponsored health insurance (ESHI) is Exhibit A in that regard. ESHI, which covers about half of all households, came into being in the 1940s as a wartime accident. It has been nothing but trouble ever since. It is a source of job lock that ties millions of Americans, terrified of losing coverage, to unsuitable careers. What is more, it contributes to fragmentation and raises administrative costs.
Above all, ESHI is appallingly inequitable. Economists Robert Kaestner and Darren Lubotsky estimate that workers in the bottom fifth of the family income distribution get annual tax benefits of less than $500 from ESHI, while those in the top fifth get benefits averaging $4,500. What is more, their data show that inequity to have become worse over time.
Still, surveys have repeatedly shown that more than two-thirds of people on ESHI like their plans. Presumably, many of those are people who have little chance of getting other coverage. Others have no interest in changing jobs, or are on the favored end of the unequal distribution of tax benefits. Whatever the reason, Medicare for All’s determination to throw millions who like what they have into an unfamiliar new system is a major barrier to its adoption.
UCC, in contrast, could be phased in more gradually than Medicare for All, especially for employer-provided plans. One possibility would be to lift the employer mandate, phase out the tax deductibility of ESHI, and allow employees to opt into UCC if they chose. Most lower-paid workers would probably take that option. Employers who wanted to use health care benefits to retain higher-paid employees could offer them supplemental policies. That way many fewer people would have to make a change of plans against their will.
Cost Controls
Any successful health care reform will have to deal with the high prices charged by American doctors, hospitals, and pharmaceutical companies. Medicare for All takes a risky and simplistic approach to cost control through across the board cuts in of as much as 40 percent in reimbursement rates for doctors and hospitals. That could be very disruptive to the many communities where hospitals are among the biggest employers.
UCC, too, would need to put downward pressure on excessive prices, but it could do so in a more nuanced way. Like Medicare for All, UCC would empower government administrators to bargain for favorable prices with hospitals, doctors, and drug companies. However, direct bargaining would be only one of several cost-control mechanisms. Market-based cost controls would back up administrative actions for consumers who have not reached their oout-of-pocket limits. Measures to promote competition and transparency, and to reward those providers who offer the best value for money, would make it easier than it is today for such consumers to shop wisely for health care services.
Transition Will Never be Easy
No matter what the final design, comprehensive health care reform will encounter problems of transition. Our existing system is not a product of rational design. It performs so far from optimally that there will be no way to fix it without big changes, necessarily disruptive. Providers and consumers who exploit imperfections in the system to their own advantage will resist change.
Transition will never be easy, but there is no reason to make it harder than it needs to be. The versions of Medicare for All now on the table in the House and Senate face obstacles that are likely to prove insurmountable. The greater pragmatism and flexibility of universal catastrophic coverage offers a less hazardous path forward.
Based on a version previously published at NiskanenCenter.com
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