By: Todd Lu
Universal Health Care: A Once Bipartisan Initiative
President Theodore Roosevelt once said of universal health care in the United States: “The health and vitality of our people are at least as well worth conserving as their forests, waters, lands, and minerals, and in this great work the national government must bear a most important part.” The idea that a Republican president would speak so passionately in support of universal health care seems unfathomable in today’s politics, and demonstrates that guaranteeing health care as a right was at one time considered a realistic goal that both parties sought to achieve, transcending the partisan politics that usually plague Washington DC. With universal health care coverage not yet achieved here in the United States, health care remains a top tier issue for voters as well as many legislators of both the Democratic and Republican parties.
Health Care as a Right and My Experience with National Health Insurance
One proposal that has renewed calls for universal health and garnered much national attention lately is Medicare for all, a national single payer program popularized by Senator Bernie Sanders and his 2016 presidential campaign. His proposal, to provide quality, publicly funded health care in the form of a Medicare expansion to cover all Americans rather than just seniors over the age of 65, was once considered a radical and unrealistic idea by members of the media, politicians, as well as many non profit organizations. However, since the election of President Donald Trump, his proposal has moved to the mainstream particularly among Democratic politicians and voters. Having been born and raised in Taiwan, an island in East Asia that utilized Medicare in the United States as a model to create the single payer National Health Insurance program to guarantee health care coverage to all its citizens in 1995, I have a unique and personal understanding of the benefits, simplicity, and cost effectiveness of a single payer health care system, which I believe should be adopted here in the United States in the form of Medicare for all to provide universal health care coverage to all Americans in the most comprehensive way possible.
My support for Medicare for all and universal health care in the U.S. is not only affected by my belief in a person’s right to medical care, an internationally recognized human right enshrined in the United Nations Universal Declaration of Human Rights, but also by my personal experiences living under the single payer health care system in my childhood home. With my National Health Insurance card that is given to me by the Ministry of Health and Welfare in Taiwan, not only are my basic medical services covered and paid for by the government, but I also have the freedom to seek out service from 99% of health care providers on the island regardless of what city they are located in due to the lack of restrictions with “provider networks” that often limit Americans’ health care choices in the private insurance model. This level of freedom to choose my health care providers along with an administrative cost of less than 1% of total health care spending in Taiwan represent the kind of goals both Democratic and Republican politicians in the United States have strived to achieve through health care reform.
That being said, with 275 million Americans currently covered by private health insurance, I recognize that in achieving Medicare for all here in the United States, the process will neither be as easy, nor as rapid as Taiwan’s transition towards single payer to cover 23 million people in a year. In the path towards Medicare for all in the U.S., a clear plan is necessary in order to allow for a smooth transition which minimizes disruptions in the current health insurance market and provide security to all Americans during which the program is being implemented. After reviewing a series of proposals from Congress and think tanks addressing the issue of health care reform in the United States, I have gathered a series of steps that I believe could serve to provide a smooth and peaceful transition into a Medicare for all single payer system over a period of four to six years.
How to Transition into Medicare for All
The first step in the path towards achieving Medicare for all in the United States lies in stabilizing the current private health insurance market, particularly the insurance exchanges established through the passage of the Affordable Care Act (ACA) in 2010. By stabilizing and securing the private insurance market that currently covers a majority of Americans, we would be able to provide certainty to those currently enrolled in an employer-sponsored health care plan as well as those currently enrolled through the ACA exchanges, and with that, be able to ensure that no American will suddenly and unexpectedly lose the current health coverage they have or be left with unaffordable health care plans as insurance companies adapt to the four to six year transition process into Medicare for all. Some policy suggestions I have for lawmakers that would stabilize the private insurance market and insurance exchanges while ensuring affordable coverage during the transition process include:
- Integrating and merging the 12 state based ACA exchanges, the 5 federally supported exchanges, the 6 federal-state partnership exchanges, and the 28 federally facilitated exchanges to create one centralized federal health insurance exchange as originally proposed in the Affordable Health Care for America Act passed by the House of Representatives in 2009 to lower health care costs for those currently enrolled in an ACA plan during the transition by gathering and centralizing the pooling of insurance funds.
- Capping health insurance premiums at 8.5% for all Americans currently enrolled in a private health care plan to protect consumers in the private insurance market from potential price adjustments and ensuring access to affordable health care for all Americans even during the transition process toward a publicly funded health care system.
- Establishing a national reinsurance scheme to provide certainty for the individual market and stabilize the ACA exchange, preventing significant hikes in health insurance premiums during the transition process.
- Eliminating surprise medical/emergency room bills by limiting patient cost sharing for services received by out-of-network providers to the amount their insurer would require for services received by in-network providers, as well as by requiring hospitals and providers to notify patients if services will be out-of-network.
- Mandating that all ACA exchange plans cover at least 80% of out of pocket costs to guarantee that no American will be financially burdened by out of pocket health care costs during the transition process.
The second step in the path towards achieving Medicare for all in the United States lies in reforming the current Medicare program to modernize and expand benefits for current enrollees as well as to decrease costs of care for seniors and decrease some complexities of the public health care system today. The Medicare program in the United States, created by President Lyndon Johnson in 1965, represents the progress that has been made in the fight towards achieving universal health care for all Americans and has guaranteed comprehensive and universal health care coverage to seniors over the age of 65. However, there are many aspects of the program that are becoming outdated, which requires the institution of some reforms and changes by policy makers in Washington and around the country. In doing so, we would be able to ensure that the program is becoming more efficient and stable as it expands to cover all Americans. Some policy suggestions I have for lawmakers that would modernize the Medicare program include:
- Expanding benefits to include coverage for vision and dental services, as well as hearing aids and examinations in the first year of the transition process, followed by coverage for long term care services in the second year, and coverage for emergency services in the third year, which are all currently not covered by Medicare today to improve quality of care for current and future enrollees.
- Eliminating deductibles for Medicare parts A, B, and D as well as eliminating premiums for Medicare parts A and B to protect the retirement income of middle class and vulnerable seniors and to simplify the payment of services/coverage for current and future enrollees.
- Eliminating the two year waiting period to enroll in Medicare for Social Security Disability Insurance recipients, eliminating the discrimination on individuals with disabilities in the public health care system.
- Establishing a maximum on out of pocket cost sharing of $1,500 for enrollees of traditional Medicare to ensure affordability of health services in the public health program, ensuring financial protection for vulnerable citizens.
- Lowering prescription drug costs by allowing Medicare to negotiate drug prices, allowing seniors currently enrolled in Medicare to be financially protected from rising costs and to have full access to the kinds of life saving medications they need. The next step in the path towards achieving Medicare for all in the United States lies in reforming, expanding and eventually integrating the state based Medicaid program into the federal Medicare program. This would allow many low income Americans and Americans that fall inside the Medicaid gap to gain state-driven, high quality health insurance at a low cost during the transition process and provide more freedom of choice for lower income consumers in the insurance market. Some policy suggestions I have for lawmakers that would reform, expand, and eventually integrate the Medicaid program to Medicare include:
- Giving states the choice to expand their Medicaid program as a public option that every resident in the state would be able to buy into, providing immediate access to publichealth coverage for uninsured residents of each state in the first year of the Medicare for all transition process. The expansion would be 100% funded federally if established in the first two years of the Medicare for all transition process, and 80% funded federally if established after the third year, decreasing the financial burden of state governments looking into expanding Medicaid while incentivizing states to expand their program early.
- Giving current enrollees and future enrollees of Medicaid the option to opt out of the Medicaid program and enroll in the Medicare program for coverage, giving Medicaid enrollees the freedom to choose to be covered by a broader and more comprehensive federal health program.
- Giving states the flexibility to establish their own benefits package, set their own premiums, as well as deductibles and cost sharing standards should they choose to expand Medicaid to make coverage available to every state resident, so long as all essential health benefits outlined in the ACA are covered and premiums do not exceeds 8.5% of income.
The final step in the path towards achieving Medicare for all in the United States lies in a gradual expansion of the Medicare program to provide immediate coverage for the uninsured, underinsured, and young Americans while giving the health care market a few years to adjust to the Medicare for all, single payer system that it will eventually become. By expanding Medicare through this process, we would be able to Some policy suggestions I have for lawmakers to establish a public option through an expansion of Medicare include:
- Expanding the Medicare program and offering it as a public option in the ACA federal exchange in the third year of the transition process and subsequently as public option for all Americans looking to switch or gain coverage to be able to buy into, providing security and freedom of choice to consumers who have been burdened by or are worried about underinsurance, high deductibles, or premium rate hikes in the health insurance marketplace.
- Lowering the Medicare eligibility age to cover those 55 and over in the second year, 50 and over in the third year, 40 in the fourth year, 35 in the fifth year, and 25 in the sixth year to guarantee Medicare entitlement for all American citizens and residents by around the seventh year of the transition process.
- Establish automatic enrollment for Americans ages 0-25 and those over the eligibility age, as well as those currently living without health coverage in the U.S. and dual eligibles of Medicare and Medicaid in the Medicare program starting the third year of the transition process to ensure continued increase in enrollment over the transition period.
- Mandating employers with over 500 employees to offer Medicare coverage as an insurance option for their business to ensure universal access to the public health program, though employers are welcome to offer additional coverage through the private insurance market during the transition process if they choose to.
Conclusion: Medicare for All is a Viable and Realistic Goal
Among the many proposals proposed by think tanks, economists, and lawmakers alike, I believe that Medicare for all offers the most comprehensive and most viable route towards achieving universal high quality health coverage for all Americans. By establishing Medicare for all, the United States would be able to join the rest of the developed world in guaranteeing health care as a right for all individuals, thereby lifting the health and living quality of all Americans, and finally providing all Americans with the freedom of choice they deserve in a health care system. The path to get there is not going to be easy, but as I have outlined, there are a variety of incremental steps that can be taken right now to ensure that the journey getting there is one that minimizes disruptions and maximizes freedom for everyone living in this country.
Existing Legislative Proposals
The proposed reforms I have outlined in this paper are a result of reviewing and synthesizing a variety of health care reform proposals and compiling various ideas from lawmakers in Congress, economists, as well as from think tanks that represent various ideological leanings. Some of the legislation that inspired the proposals outlined in this paper include:
- Affordable Health Care for America Act, introduced by Congressman John Dingell (D).
- Bipartisan Health Care Stabilization Act of 2017, introduced by Sen. Patty Murray (D) and Lamar Alexander (R).
- Choose Medicare Act, introduced by Sen. Chris Murphy (D) and Jeff Merkley (D).
- Consumer Health Insurance Protection Act, introduced by Sen. Elizabeth Warren (D).
- Healthy America, developed by the Urban Institute.
- Lower Premiums Through Reinsurance Act of 2017, introduced by Sen. Susan Collins (R) and Bill Nelson (D).
- Medicare at 55 Act, introduced by Sen. Debbie Stabenow (D).
- Medicare Buy-In and Health Care Stabilization Act of 2017, introduced by Congressman Brian Higgins (D).
- Medicare Extra for All, developed by the Center for American Progress.
- Medicare for All Act of 2017, introduced by Sen. Bernie Sanders (I).
- Medicare for America Act of 2018, introduced by Congresswoman Rosa DeLauro (D).
- Medicare X Choice Act of 2017, introduced by Sen. Mark Bennett (D) and Tim Kaine (D).
- No More Surprise Medical Bills Act of 2018, introduced by Sen. Maggie Hassan (D).
- Reducing Costs for Out-of-Network Services Act of 2018, introduced by Sen. Jeanne Shaheen (D).
- State Public Option Act, introduced by Sen. Brian Schatz (D).