Paul Starr was the keynote speaker at the Medicare for All and Beyond Conference that filled the Penn Law School’s Fitts Auditorium.

Last week LDI hosted a day-long conference on Medicare for All and Beyond. Our goal was to participate in one of today’s most pressing conversations in health care—how to expand health insurance to the 28 million people in the United States who are currently uninsured. We welcomed close to 300 people from across the spectrum to participate in this conversation, to consider the critical questions underlying today’s debate, and to look in depth at the challenges we face in expanding insurance coverage in our country. The conference gave us all plenty to mull over. 

Rachel M. Werner, MD, PhD, is Executive Director of the Leonard Davis Institute of Health Economics.

If there was a thread that ran through the panels and presentations, it was that the challenges in expanding health insurance access are interconnected. Reforming one part of the health care system will have potentially major impacts on other parts, some intended, and some unforeseen. The U.S. has ensnared itself in a “policy trap”, devising an increasingly complicated health care system that makes change extraordinarily difficult. We must be wary of falling into this trap. And yet, most of the public (and people in the room) have a sense that our current system of coverage is failing to provide access to care to all and financial protection against large costs when we become sick. Here are some of my takeways:

Paul Starr

We heard first from Paul Starr, who reminded us of the lessons we’ve learned from three major health care reforms: Medicare, Medicaid, and the ACA, as well as from the many failed reform efforts of the 20th century. But he also challenged us to consider how to move forward. In particular, he highlighted ideas that to date have not been part of the campaign debates.

He advocated for more incremental change than replacing our current health insurance system. In particular, he thought lowering Medicare eligibility age in a step-wise fashion would be popular and politically feasible. It would target an older group that is facing major affordability concerns, while not overwhelming the federal budget. He estimated that 10 million people would be eligible for Medicare at a lower age, although just 3 million would likely enroll, because most would have employer-based insurance. 

Affordability standards

We talked about affordability standards—what does it mean to make health insurance affordable for American consumers? Everyone agrees that health care needs to be affordable, but no one really knows how to define it. Connecticut’s experience shows us that while it is very hard to define affordability, it can be done.

Importantly, while we often talk about affordability in purely economic terms, we were reminded that defining affordability requires a value judgement.

That judgement forces us to ask, affordable for whom? The panel pointed out that while average out-of-pocket (OOP) costs have not increased greatly in the past few years, the range of costs is large.  Large variations in OOP costs bring up serious equity issues—falling particularly hard on sicker and poorer people. Affordability is now top-of-mind for an American public concerned that they will not have the funds needed to obtain health care when they are sick.

Payment and pricing

We were reminded that it is hard to address affordability without simultaneously thinking about prices. In our panel on payment and pricing, we heard about the enormous variation in payment, specifically in the gap between commercial and Medicare prices. That gap varies by state and also across communities within state. While the reasons for this variability are not entirely clear, it is driven in part by affluence and market concentration.

What can we do to address prices? Interest-group politics are difficult to overcome when we consider changing the way we pay people today. In this decision, it is important to consider the tradeoffs. What would we be losing if we cut prices? And whatever we do, we need to do it slowly so we don’t inadvertently worsen access by forcing hospitals and other providers to shut their doors.

The value of choice

When considering the value of choosing health care providers and health plans, our panel brought up a number of paradoxes about how we value choice in the health care system. It is common wisdom that people say they want choice, but often resist choosing, as experience shows with Medicare Part D, the ACA, and Medicaid. Is it that people like the illusion of choice rather than choice itself?

In addition, people often don’t make good choices when confronted with complicated options. The process of exercising choice often doesn’t deliver much value; many consumers make choices that leave them worse off than they would have been if they had chosen differently. Changes in choice architecture, such as standardizing plan options and grouping plans by level, can help people make more optimal decisions.

Some options for expanding health insurance options result in limiting choices. But if we limit choice, who will make the choice for us? Many people get squeamish at the idea that we might get rid of all choices and put full faith in any one entity – whether the government or the private market.


The live recording of the Tradeoffs podcast was both entertaining and thought-provoking. We were asked to re-examine the assumption that a plan-for-all must be based on the existing Medicare fee-for-service system, which does not consider cost-effectiveness in its coverage decisions.

Unlike an open-ended Medicare benefit, a universal plan that provides cost-effective care to all Americans would not crowd out funding other important investments in education, housing and the like. In this scenario, people could then “top up” to use their own funds to extend benefits. The panelists noted that the public thinks it’s entirely fair to get more coverage by paying more for it.

Political feasibility

Our concluding panel tackled the elephant in the room in this presidential election season: what is possible politically? It is hard to predict when any reform will happen, but sometimes what feels impossible can quickly become possible. One big question the panel raised was whether this will be a “change” election, heralding sweeping shifts in Congress. That is the most important factor in determining the appetite in Washington to move something big. Our ability to move something big may be changing if the filibuster goes the way of the dinosaur. And if it does, we might rethink what is possible and what is not.

Polls tell us that Americans across the political spectrum support changes to the current health care system. There has been a slow and steady increase in support for Medicare-for-all specifically and for health care reform in general, although that support can be swayed by how you ask the question and the details you provide about any one proposal.

Public opinion says that whatever happens, we need to address the primary concern – affordability. And that led us full circle back to the first panel.