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Is Medicare-for-all an idea whose time has come?

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Healthcare reform has been a major issue on the political battlefield in the United States since the election of Obama, rising to a crescendo with the election of Trump. But the battlefield has shifted substantially in the past nine months.

Bernie SandersThe failure of Republicans to repeal and replace Obamacare has highlighted growing public support for this law and seen political and public sentiment move further left than could ever have been predicted, so that the idea of a single payer system is now openly canvassed.

Former presidential candidate Senator Bernie Sanders will take credit for this, but in fact many champions have pushed for the United States, the only developed country without universal health care and always the outlier in terms of healthcare costs, to adopt a single payer system.

Seventy-two years ago, at the end of World War 2, and as the United Kingdom was implementing National Health Insurance, President Harry Truman sent a message to Congress proposing a new national healthcare program. But compulsory health insurance became entangled in the issues of the Cold War, and its opponents were able to make 'socialised medicine' a symbolic issue in the growing crusade against communist influences in the United States.

For conservatives, socialised medicine is still a bogey man, but with a majority of Americans now having health insurance provided with government assistance, one that is much less potent. After the introduction of Obamacare and the realisation of its benefits, modest and limited though these might be, there can be no return to the status quo that existed prior to 2010. Indeed, Obamacare can be seen as the first step on the road towards a single payer system.

Last week saw the extremes of conservative and progressive views on healthcare reform on display. Republican Senators Lindsey Graham and Bill Cassidy released their legislation to repeal and replace Obamacare, in what they described as a last-ditch effort to enact the Republicans' commitment.

Almost simultaneously Bernie Sanders released yet another version of his Medicare-for-all plan. The last time he did this, in 2013, his bill had not a single co-sponsor. This year Sanders (despite not really being a Democrat) was surrounded by his 16 Democrat co-sponsors, including Senators Kamala Harris, Al Franken, Cory Booker, Kirsten Gillibrand, Tammy Baldwin and Elizabeth Warren. Several of these are possible presidential candidates for 2020.


"Americans increasingly see healthcare as a universal right and a majority of Americans now believe it is the responsibility of federal government to ensure health coverage for all Americans. But this does not necessarily mean support for a single payer system."


Trump, who has been on all sides of the healthcare reform issue, took to Twitter in response to Sanders' bill, saying, 'I told Republicans to approve healthcare fast or this would happen.' Despite his seeming support at several points over the years for universal healthcare, and his expressed admiration for both the Australian and Canadian systems, Trump now calls the Sanders proposal 'a curse on the US and its people'.

The Sanders Medicare-for-All bill is not a new idea, it has been mooted ever since Medicare was first introduced in 1965. Hillary Clinton canvassed the idea that people aged 50 and over could buy into Medicare during her presidential election campaign, and back in February this year John Conyers from Michigan introduced a similar bill in the House of Representatives, without accompanying fanfare.

Sanders' utopian proposal is to transition the United States to a single payer system where one government plan would provide insurance coverage for all. The benefits (to cover hospital, primary care, medical devices, pathology services, maternity care, prescription drugs, vision and dental services) are incredibly generous, with no co-payments except for those on pharmaceuticals to encourage the use of generics.

Employers would be barred from offering separate plans and Medicare and Medicaid would sunset but the Veterans' Affairs health system and the Indian Health Service would continue to operate as they do currently. Patients could use private health insurance to cover services not deemed medically necessary, such as plastic surgery. There would be a four-year transition to the new universal plan; in the interim, there would be the option to buy into Medicare or some other publicly-run option.

Current Medicare rates would be used as the new standard for medical services (presumably these would be updated regularly as currently). These rates are typically lower than those paid by private insurance plans but higher than those paid by Medicaid.

Cost is a real problem for Sanders' legislation and not one that has been addressed. There is currently little information about how such a generous system would be funded (presumably by increased taxes — the bill mentions changes to the Internal Revenue Code), what the economic offsets would be, and where the winners and losers are. An earlier version of this approach was estimated to cost $1.38 trillion annually over the first decade (interestingly, a figure that approximates what the federal government currently spends on healthcare). However there is considerable disagreement about this estimate; other estimates are as high as $2.8 trillion/year.

Medicare-for-all is best seen as aspirational — it is a slogan that is shorthand for policy ideals and that papers over policy disagreements and political realities. With Republicans in control of Congress, there is obviously no immediate chance of Sanders's bill becoming law any time soon. But with Republicans and the President viewed as ineffectual in implementing their healthcare commitments and uncaring about voters' concerns, it is advantageous for Democrats to be seen to have solutions to the problems that confront their constituents.

Public sentiment is growing towards the Democrats' approach. Americans increasingly see healthcare as a universal right and a majority of Americans now believe it is the responsibility of federal government to ensure health coverage for all Americans. This does not necessarily mean support for a single payer system (this is supported by 33 per cent of those who see a government role in the provision of health coverage, but such support declines when people are told their taxes will increase).

There is plenty of evidence from both international and states efforts to build a single payer system about how difficult this can be. In 2014 Sanders' home state of Vermont tried to do this, but despite public support, the effort collapsed when legislators figured out how much it would cost and how much taxes would need to rise to cover this. There is much difficult policy work to be done to tease out the extent to which this promise can be delivered nationally, in ways that are both acceptable to all stakeholders and economically sustainable. And — a lesson from Obamacare — some very astute communication initiatives will be needed to sell these approaches.



Lesley Russell

Dr Lesley Russell is an Adjunct Associate Professor at the Menzies Centre for Health Policy at the University of Sydney. From 2009-12 she worked in Washington DC on the enactment and implementation of Obamacare.

Topic tags: Lesley Russell, Obamacare, Trump, Republicans, Bernie Sanders, US politics



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Existing comments

Australia's publicly funded health care system is streets ahead of the US but it's far from perfect and never beyond threat of being wound back by Coalition governments. The lack of coverage for dental health care Is a glaring anomaly reflecting the reluctance of both sides of politics to confront the dental profession. The rapidly increasing costs of private insurance reflects the greed of the private for-profit providers. But despite that, every attempt to further socialise health care in this country will be met by spurious warnings about waste and inefficiency. As if there were no examples of over- servicing and price-gouging in our private sector already!

Ginger Meggs | 19 September 2017  

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