Medicare for All?

Independent Senator Bernie Sanders has introduced a "single-payer," Medicare-for-All bill in the Senate, and this time he has some 15 or so co-sponsors (all Democrats). No one seriously expects his bill to go anywhere in the current Congress. So it's most likely effect will be to add further to the disruption in the Democratic party (of which, it should never be forgotten, Sanders is still not a member). 

As long as I have thought at all about health-care politics, I have consistently favored Medicare-for-All, as the obvious and only really practical solution. That said, I remain profoundly skeptical regarding the likelihood of its getting enacted anytime soon. 

Paradoxically, what it has going for it - besides its inherent obviousness - is the Republicans' obstinate opposition to any serious alternative. The fear of "single-payer" health care for all was what motivated conservative thinkers to propose alternative ideas in the 1990s. Out of those ideas eventually developed Romneycare on the state level in Massachusetts and then Obamacare on the national level. Their fanatical hatred for President Obama prevented Republicans from supporting this conservative, market-oriented plan, an they continue to try to undermine it to this day, increasingly leaving the country to contemplate two stark alternatives - millions of people with no coverage at all or some sort of "single-payer" system.

That said, the obstacles to enacting any sane solution to this politically created problem remain many. For one thing, I wish partisans of Medicare-for-All would call it that - and only that - all the time. "Single-Payer" sounds frankly foreign, at best Canadian. Of course, there are some very good foreign models out there, but Americans are chronically allergic to foreign ideas. Medicare, on the other hand, is an established part of the American health-care landscape, one of its more successful components, and - most important - one that is very popular.

But the bigger problem - as Jonathan Chait recently pointed out - is the fact that  some 155 million Americans already have (and are largely pleased with) employer-provided health insurance coverage.. (See "Bernie Sanders’s Bill Gets America Zero Percent Closer to Single Payer," http://nymag.com/daily/intelligencer/2017/09/sanderss-bill-gets-u-s-zero-percent-closer-to-single-payer.html). Logistically, phasing out employer-based health-care coverage would be an enormous task. Politically, getting people already content with such coverage to support replacing it with higher taxes for Medicare-for-All (while likely in everyone's long-term best interest) would be challenging, to say the least. 

What Sanders, et al., should be proposing is a phased-in progressive lowering of the age of eligibility for Medicare, without immediately eliminating employer-based coverage. Programs that are available to all (e.g., Social Security, Medicare) are usually popular - unlike programs that are targeted to help the poor (e.g., Medicaid). So just keep expanding Medicare to increasingly lower age cohorts - on the same terms as at present for seniors (who remain free, if they are still working, to have employer-provided coverage as their primary plan, while still being eligible to avail themselves of medicare once they need it).

While I would personally prefer the more logical and more efficient step of eliminating private health insurance once and for all, I believe the only practical approach would be to evolve to that point by prioritizing a social commitment to Medicare-for-All and making it more and more easily available to more and more Americans.