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How to Medicare for All

Thoughts about how to transition from the current system to something like Medicare for All.

The question of whether Medicare for All is the best way forward is being lost in the non-conversation about healthcare. The conservative viewpoint isn’t to do a fair evaluation of alternatives, but to deny problems exist, and so proposals like Medicare for All are attacked relentlessly as impossibilities while any sort of balanced approach is neglected. Sad.

But let’s say you want to Medicare for All, anyway. You have several different transitional problems to deal with.

Transitioning Jobs

Jobs are one of the problems. Lots of people working in for-profit roles in healthcare administration. They do things like formulate the most lucrative way to bill (basically reverse-accountants) insurers and the government. But they also do other things like process claims. Some of those jobs will vanish, while others will be reallocated through a government contracting system.

How many vanish depends on the flavor of the new system. If it keeps fee-for-service, it will be more expensive and retain more jobs. If it moves to billing by condition (instead of separate billing events for a cast, x-ray, etc., you bill for a “broken arm” treatment) or patient, that’s fewer jobs, but lower cost.

So you have a policy tradeoff of choosing cheap and dealing with more job loss and more retraining, or you choose more expensive and deal with higher taxes. Some of the expenses will be paid for by expanding other parts of the medical sphere to provide coverage to unserved and underserved communities and individuals. There will also be some increase in productivity as societal health improves and therefore workers are more productive (they are also more productive when they don’t have to expend a lot of time and effort understanding and navigating a mess of an insurance system). But it’s still a transitional choice to be made.

Transitioning Off Employer-Provided Insurance

This is a big one. The best way to handle it is to set aside a basic Medicare for All structure that will partially replace the employer’s insurance at the next renewal date. The employer can continue to provide a lower-cost supplement on top of that for some period of time (say a decade), which will allow the winding-down of both the firm’s employee-insurance responsibility and the private insurer’s market.

Think of it like any other natural transition. You have a car and drive everywhere. Then alternatives come up and you use them part of the time, where they make the most sense. As those alternatives improve in coverage and cost, you use your car less until you abandon it on the side of the freeway. . . .

The beauty of such a plan is that it lets insurers keep their most profitable business alive (bells and whistles) while they give up the most expensive part (core insurance, including catastrophic stuff). As long as such a plan’s guns are stuck to, it lets them wind down responsibly and with as little pain as possible.

Also, the fact that different employers will have different renewal periods means that the business should wind down in a fairly steady manner.

Age-Based Transitioning

There’s long been talk of expanding Medicare down to younger groups. Pre-retirees, usually. That can still be done in the transition, and it again should benefit private insurers during their twilight years, as older workers are more prone to health events.

The Tax-and-Cost Problem

How do you pay for it? Is there a pot of gold we can get and it’ll solve everything and we’ll eat our free lunch?

No. Good, old-fashioned taxes. Something like the existing work-credit system where you pay in will be part of it. General income taxes another part. A third part might be a periodic discounted credit-purchasing period. This would be equivalent of a sale. Everyone loves a sale, but the government never puts things on sale. If you let people buy up extra Medicare credits from time to time, they’ll help to top-off the trust fund. There are other things of this nature the government could do that make a lot of sense.


Point is, there are a lot of opportunities to do smart transitioning. It’s not that hard to see the path forward on something like Medicare for All. I’m not convinced it’s the only way forward, but I am convinced it is a way forward, and absent alternatives, none of which the Republicans have shown any desire to entertain anyway, we might as well take it.