Health Policy$ense

Medicare for all? How about Medicare for me?

Mark Pauly for the Inquirer

[cross-posted from the Health Cents blog on

U.S. Sen. Kamala Harris, at a recent CNN Town Hall, said the solution for providing quality health care for everyone at an affordable price is this: "We need to have Medicare for all.”

To the follow-up “Obama gotcha” question — those who like their [private] insurance don’t get to keep it? — the California Democrat and presidential candidate had a ready reply.

“The idea is that everyone gets access to medical care, and you don’t have to go through the process of going through an insurance company, having them give you approval. … Let’s eliminate all of that; let’s move on.”

My first reaction, being the designated person in my household for dealing with our kindly insurance company, was prospective relief from paperwork. It was quickly followed by my usual economist’s skepticism about a free lunch. For one thing, I am due to join the current Medicare program (for old folks) when I retire during a prospective President Harris’ term of office. For another, as part of my role as an expert, I have had to learn a fair amount about how that program actually works.

So, I asked myself whether Kamala Harris could deliver what she promised.

(A personal note: Sen. Harris’ father, Don, was my colleague when we were both assistant professors at Northwestern University years ago. I do not remember Kamala, but she must have been one of the many children present at faculty social gatherings. I do remember that I considered giving the faculty children a brief but sobering lecture on Medicare’s expected tax burdens if they did not behave themselves.)

The problem is that the label “Medicare for All” has been attached to a variety of different proposals from various Democrats, and their relationship to today’s Medicare program is only slight. There are two important features of Medicare they all ignore:

  1. It sometimes requires approval before paying doctors for some services
  2. The approval of coverage and development of payment policies for benefits are actually done by private insurance companies under contract with Medicare, and their policies vary across states. (In Pennsylvania, the contractor is Novitas Services, a subsidiary of Guidewell Group associated with Florida Blue Cross.) In addition, more than 35 percent of beneficiaries have opted for Medicare Advantage, which is coverage under private managed care plans in lieu of traditional Medicare, and all outpatient drug coverage is administered by private plans.

Sen. Harris was forthright in saying that under her plan, eventually you would not be allowed to keep your current employment-based plan (like the one I am on now) or any private Medicare Advantage plan (some of which my contemporaries praise). But, she says, not to worry, you will like the single public plan much better.

I might like it, if it pays more for services that I like than for others I don’t (though not everyone may agree with me on which is which). Of course, we as beneficiaries would all wish that insurance paid well for every service, so doctors and hospitals would pay more attention to us, although as taxpayers and premium-payers, we would prefer that it paid less for everyone but us.

So, I remain a little nervous about Sen. Harris’ plan, and wish I had paid more attention to the leaders of tomorrow at my feet when I was in my first academic job. One may hope more realistic details will be forthcoming. There is no shortage of goodwill and good intentions among the emerging and impressive list of candidates and plans. However, realism, being the most valuable political commodity, is also the scarcest.