Medicare for all received a shot of adrenaline the other day as Vermont Sen. Bernie Sanders, who wants to be president, reintroduced legislation intended to provide health coverage to all Americans and put private insurers out of business.
As usual, conservatives responded by mischaracterizing and outright lying about the proposal, and by framing the debate by asking the wrong question: How will you pay for it?
That?s an important consideration, to be sure. But it?s not where the conversation needs to begin.
A more appropriate question to start things off is: How many people will it cover?
The failure of U.S. policymakers to use this as the basic premise of health-care reform is why tens of millions of Americans remain uninsured, and why this country pays more for health care than any of its economic peers.
?A productive debate would focus on the pros and cons of any proposal versus the alternatives,? said Martin Gaynor, a healthcare economist at Carnegie Mellon University.
?Scare tactics and slogans, such as calling single-payer proposals ?a government takeover? or saying the current system is a ?moral outrage,? move us farther away from figuring out how to best reform our healthcare system,? he told me. ?There are tradeoffs and hard choices, and it does no good to pretend there are simple answers.?
Sanders? latest bill would establish universal coverage by opening the Medicare insurance system to all. It would expand current benefits, including long-term care at home. It also would prohibit private plans from competing with the government program.
There are a number of provisions in the legislation that, for me, make it a non-starter. The biggest is its total rejection of a role for private insurers.
While that might be satisfying on a karmic level ? payback for all the denied claims and acts of greed ? it discards the potential benefits of competition. We know from the example of some other developed countries that private insurers can bolster and supplement a state-run insurance program.
?The most successful international models take a hybrid approach,? said Dana Goldman, director of the USC Schaeffer Center for Health Policy and Economics.
?Singapore, for example, has excellent outcomes at reasonable cost,? he said. ?While the Ministry of Health has overall responsibility for total spending, care is delivered by the private sector.?
I?m partial to what?s known in healthcare circles as the single-payer Bismarck model (after Prussian Chancellor Otto von Bismarck, who originated the idea in 1883). This is the system used by Germany, France and Japan.
Under this approach, funds are pooled by the government, and heavily regulated private insurers compete by offering more affordable coverage to younger people, or additional benefits for those willing to pay more. This wouldn?t be that far from the Medicare Advantage plans that are now part of the U.S. system.
Agree or disagree with that proposal, the significant thing is that it starts with a goal of universal coverage and fills in the blanks from there. Anyone with an alternative approach would have to walk the same road.
