How We Can (Eventually) Get to “Medicare for All”  

By Jill Zorn


While Bernie Sanders’ prospects for becoming the Democratic Party’s presidential nominee appear to be fading, Medicare for All, like many of his other progressive policy proposals, is continuing to receive a great deal of attention.

Two recent, thoughtful articles that ponder the political and practical hurdles faced by “Medicare for All”, the health policy proposal favored by Sanders, are a must-read for anyone who is thinking about the future of health care in the United States.

The two articles are:

The Virtues and Vices of Single-Payer Health Care, by Jonathan Oberlander, published in The New England Journal of Medicine.  Oberlander is a professor of Social Medicine and of Health Policy and Management at the University of North Carolina – Chapel Hill.

Where Bernie Sanders’ Health Care Crusade Might Go From Here, by Jonathan Cohn.  Cohn is a well-known health journalist who currently is Senior National Correspondent for the Huffington Post.

Both authors point out how poorly the U.S. health care system, even with the implementation of the Affordable Care Act (ACA), measures up against the single-payer systems, in their many varied forms, that operate in most other countries.  Cohn explains, “Overseas, single payer systems provide nearly everybody with relatively generous coverage, while allocating less money to health care than the U.S. does.”

Oberlander describes the “fragmented, inequitable, costly, profit-driven, and wasteful nonsystem that prevails in the United States.”  In contrast, “The substantive virtues of single-payer programs are compelling.”

But both authors then pivot to describing the obvious obstacles that enacting a Medicare for All system  in the U.S. faces .

Here is Oberlander on the political challenges:

Medicare for All, which aims to constrain health care spending, faces intense opposition from insurers, the medical care industry, and much of organized medicine. It would trigger fierce resistance from conservatives and the business community and anxiety in many insured Americans fearful about changing coverage and the specter of rationing.

 And here is Cohn on the practical challenges:

Dramatically reducing payments to doctors and hospitals would likely cause many to cut back on what they provide or to go out of business altogether, leading to some combination of economic disruption and shortages of appointments and hospital beds. In order to avoid this, a single-payer plan would almost certainly require either much higher taxes….or much less generous coverage.

Both Oberlander and Cohn agree that Medicare for All, while it remains the right goal, is certainly not about to be implemented in the U.S. any time soon.   Instead, they advise a different way forward.

Oberlander, in an accompanying audio interview promotes “incremental steps” rather than the “all or nothing” approach often taken by single-payer advocates.  His article concludes:

Preserving and strengthening the ACA, as well as Medicare, and addressing underinsurance and affordability of private coverage is a less utopian cause than single payer. I believe it’s also the best way forward now for U.S. medical care.

Cohn talks about “narrower initiatives” and encourages Sanders to play a constructive role to:

…keep pushing to fill in the holes of Obamacare, while creating the building blocks for the single-payer system he has advocated for his entire political career.

Bold incrementalism is another name for this approach, as detailed by Richard Kirsch in the policy brief he wrote for Universal Health Care Foundation, Beyond the ACA:  Moving Toward a Health Care System that Works for All of Us.  As Kirsch writes:

These proposals are bold – even audacious – but they are achievable over time because they meet an essential prerequisite for any health care reform in the United States: they build on the health care system we have today.

A focus on incremental steps, narrow initiatives and building blocks does not have the same cachet as Medicare for All.  But right now Cohn, Oberlander and Kirsch all agree that this strategy is by far the best way to make progress.

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