Journal of Health Politics, Policy and Law
Journal of Health Politics, Policy and Law
Point-Counterpoint
The Affordable Care Act versus
Medicare for All
Laurence Seidman
University of Delaware
Many problems facing the Affordable Care Act would disappear if the
nation were instead implementing Medicare for All—the extension of Medicare to
every age-group. Every American would be automatically covered for life. Premiums
would be replaced with a set of Medicare taxes. There would be no patient cost sharing.
Individuals would have free choice of doctors. Medicare’s single-payer bargaining
power would slow price increases and reduce medical cost as a percentage of gross
domestic product (GDP). Taxes as a percentage of GDP would rise from below average to
average for economically advanced nations. Medicare for All would be phased in by age.
Keywords Medicare for All, Affordable Care Act, single payer
It is striking how many problems facing the Affordable Care Act (ACA)
would disappear if the nation were instead implementing Medicare for
All—the extension of Medicare to every age-group (Morone 2002;
Woolhandler et al. 2003; Seidman 2013a). Medicare has five decades of
experience solving numerous practical administrative problems. Most
Americans are familiar with how Medicare operates, either as covered
seniors or as children of seniors who sometimes accompany their parents
when they go to the doctor or hospital. They are familiar with the free
choice of doctor under Medicare. Medicare’s fee schedules for hospitals
and doctors, which have been in effect for three decades, have not gener-
ated excessive waiting times, and Medicare fees have been sufficient to
enable patients to obtain high-quality medical care. Given its performance,
familiarity, and popularity, it is surely sensible to ask whether Medicare
should be extended to all age-groups.
http://jhppl.dukejournals.org/content/early/2015/06/09/03616878-3150160.full.pdf
Point-Counterpoint
Medicare for All—If It Were Politically
Possible—Would Necessarily Replicate
the Defects of Our Current System
Harold Pollack
University of Chicago
Abstract Medicare for All, ideally implemented, could offer powerful advantages
over our current health care financial system. Unfortunately, the political obstacles to
such a system are formidable and are likely to remain so for decades. More to the point, a
politically viable single-payer system would not replace our currently dysfunctional
health care politics. It would be a product of that same legislative process and political
economy and thus be disfigured by the same interest group politics, path dependence,
and fragmentation that Laurence Seidman rightly laments.
Keywords single payer, Medicare for All
Laurence Seidman’s brief for single payer will be congenial to many
JHPPL readers, and for good reasons. As someone who has spent the past
seven years advocating for the Affordable Care Act (ACA), I must concede
that a well-conceived, well-implemented Medicare for All system would
offer powerful advantages over our current health care financing system.
Facing the imperative of an overall budget, armed with the pricing power
of public monopsony, Medicare for All is indeed more likely to control
costs than any market-based approach is that relies on fragmented private
payers. Although insurer competition is proving helpful to restrain prices
on the new marketplaces, there is little evidence that such completion can
fundamentally reduce costs. Perhaps the opposite is true when these many
payers bargain with concentrated groups of providers and prestigious
academic medical centers that command vastly greater public legitimacy.
Government price pressures are never painless or administered without atleast some toxic side effects. As we have seen in Medicaid, such policies
can push too hard. They remain valuable tools in the mix.
Medicare for All also offers one path to escape the pathologies and
regressive impact of employer-based health coverage. Employer-based
coverage imposes the singular defect that losing your job simultaneously
disrupts your health insurance coverage. The ACA provides a valuable
safety net through subsidized coverage on the new marketplaces, though
this remains personally and sometimes financially disruptive for many
individuals and families. As Seidman rightly notes, employer-sponsored
insurance forces firms to waste valuable managerial attention on the com-
plexities of health insurance coverage.
Across the political spectrum, policy experts hunger for alternatives. Tax
expenditures for employer-sponsored insurance now total roughly $250
billion annually (CBO 2013). These subsidies benefit only the employed
and actively insured. Because these subsidies are most generous to those
with high marginal tax rates who buy the most generous plans, they are
among the most regressive in the American tax code. The ACA’s “Cadillac
tax” provisions chip away at these tax expenditures. It would be better to
do more, though the broad popularity of current policies limits what can
be done.
http://jhppl.dukejournals.org/content/early/2015/06/09/03616878-3150172.full.pdf
Journal of Health Politics, Policy and Law
Journal of Health Politics, Policy and Law
Point-Counterpoint
The Affordable Care Act versus Medicare for All
Laurence Seidman
University of Delaware
Journal of Health Politics, Policy and Law
Point-Counterpoint
The Affordable Care Act versus Medicare for All
Laurence Seidman
University of Delaware
Many problems facing the Affordable Care Act would disappear if the
nation were instead implementing Medicare for All—the extension of Medicare to
every age-group. Every American would be automatically covered for life. Premiums
would be replaced with a set of Medicare taxes. There would be no patient cost sharing.
Individuals would have free choice of doctors. Medicare’s single-payer bargaining
power would slow price increases and reduce medical cost as a percentage of gross
domestic product (GDP). Taxes as a percentage of GDP would rise from below average to
average for economically advanced nations. Medicare for All would be phased in by age.
Keywords Medicare for All, Affordable Care Act, single payer
It is striking how many problems facing the Affordable Care Act (ACA) would disappear if the nation were instead implementing Medicare for All—the extension of Medicare to every age-group (Morone 2002; Woolhandler et al. 2003; Seidman 2013a). Medicare has five decades of experience solving numerous practical administrative problems. Most Americans are familiar with how Medicare operates, either as covered seniors or as children of seniors who sometimes accompany their parents when they go to the doctor or hospital. They are familiar with the free choice of doctor under Medicare. Medicare’s fee schedules for hospitals and doctors, which have been in effect for three decades, have not gener- ated excessive waiting times, and Medicare fees have been sufficient to enable patients to obtain high-quality medical care. Given its performance,
should be extended to all age-groups.
http://jhppl.dukejournals.org/content/early/2015/06/09/03616878-3150160.full.pdf
University of Chicago
Facing the imperative of an overall budget, armed with the pricing power
of public monopsony, Medicare for All is indeed more likely to control
costs than any market-based approach is that relies on fragmented private
payers. Although insurer competition is proving helpful to restrain prices
on the new marketplaces, there is little evidence that such completion can
fundamentally reduce costs. Perhaps the opposite is true when these many
payers bargain with concentrated groups of providers and prestigious
academic medical centers that command vastly greater public legitimacy.
Government price pressures are never painless or administered without atleast some toxic side effects. As we have seen in Medicaid, such policies
can push too hard. They remain valuable tools in the mix.
Across the political spectrum, policy experts hunger for alternatives. Tax
expenditures for employer-sponsored insurance now total roughly $250
billion annually (CBO 2013). These subsidies benefit only the employed
and actively insured. Because these subsidies are most generous to those
with high marginal tax rates who buy the most generous plans, they are
among the most regressive in the American tax code. The ACA’s “Cadillac
tax” provisions chip away at these tax expenditures. It would be better to
do more, though the broad popularity of current policies limits what can
be done.
http://jhppl.dukejournals.org/content/early/2015/06/09/03616878-3150172.full.pdf
Keywords Medicare for All, Affordable Care Act, single payer
It is striking how many problems facing the Affordable Care Act (ACA) would disappear if the nation were instead implementing Medicare for All—the extension of Medicare to every age-group (Morone 2002; Woolhandler et al. 2003; Seidman 2013a). Medicare has five decades of experience solving numerous practical administrative problems. Most Americans are familiar with how Medicare operates, either as covered seniors or as children of seniors who sometimes accompany their parents when they go to the doctor or hospital. They are familiar with the free choice of doctor under Medicare. Medicare’s fee schedules for hospitals and doctors, which have been in effect for three decades, have not gener- ated excessive waiting times, and Medicare fees have been sufficient to enable patients to obtain high-quality medical care. Given its performance,
familiarity, and popularity, it is surely sensible to ask whether Medicare
http://jhppl.dukejournals.org/content/early/2015/06/09/03616878-3150160.full.pdf
Point-Counterpoint
Medicare for All—If It Were Politically Possible—Would Necessarily Replicate the Defects of Our Current System
Harold Pollack
Medicare for All—If It Were Politically Possible—Would Necessarily Replicate the Defects of Our Current System
Harold Pollack
Abstract Medicare for All, ideally implemented, could offer powerful advantages
over our current health care financial system. Unfortunately, the political obstacles to
such a system are formidable and are likely to remain so for decades. More to the point, a
politically viable single-payer system would not replace our currently dysfunctional
health care politics. It would be a product of that same legislative process and political
economy and thus be disfigured by the same interest group politics, path dependence,
and fragmentation that Laurence Seidman rightly laments.
Keywords single payer, Medicare for All
Laurence Seidman’s brief for single payer will be congenial to many JHPPL readers, and for good reasons. As someone who has spent the past seven years advocating for the Affordable Care Act (ACA), I must concede that a well-conceived, well-implemented Medicare for All system would offer powerful advantages over our current health care financing system.
Keywords single payer, Medicare for All
Laurence Seidman’s brief for single payer will be congenial to many JHPPL readers, and for good reasons. As someone who has spent the past seven years advocating for the Affordable Care Act (ACA), I must concede that a well-conceived, well-implemented Medicare for All system would offer powerful advantages over our current health care financing system.
Medicare for All also offers one path to escape the pathologies and
regressive impact of employer-based health coverage. Employer-based
coverage imposes the singular defect that losing your job simultaneously
disrupts your health insurance coverage. The ACA provides a valuable
safety net through subsidized coverage on the new marketplaces, though
this remains personally and sometimes financially disruptive for many
individuals and families. As Seidman rightly notes, employer-sponsored
insurance forces firms to waste valuable managerial attention on the com-
plexities of health insurance coverage.
http://jhppl.dukejournals.org/content/early/2015/06/09/03616878-3150172.full.pdf
High health spending is more persistent than you might think
You get hit with a major health condition and your health care needs and spending spikes. A lot. Welcome to the 10% club, whose members spend at least $30,000 on health care in a year. Yeah, most of it is covered by insurance, but selecting the plan with the $2,500 deductible you blew through (not to mention the thousands more in copayments) looks like a bad idea in hindsight.
It could be worse. It could happen to you next year, and the year after, and the year after that, and so on. Will it?
This is a question of health spending persistence. And, as surprising as it may sound, we don’t know a lot about it, at least for the working age population. The basic problem is that researchers rarely have access to many years of health care spending data for the same set of individuals. Those data are proprietary. Some are available, but expensive to purchase.
So, most of what we know about health care spending persistence is from Medicare—clearly not representative of the working age population.
A study by Alan Garber and colleagues examined Medicare beneficiaries in the top 5% of the spending distribution in a single year. They found that 15% remained in this high cost group one year later, and 9% did so two years later. Their analysis is now quite dated, extending only through 1995. A somewhat more recent analysis by Gerald Riley found greater persistence; among top 5% spending Medicare beneficiaries in 2001, 24% were in that group one year later, 16% two years later, and 12% three years later.
Most work focused on the working age population is only able to track people for two years. For example, an analysis using the Medical Expenditure Panel Survey by Steven Cohen found that 34% of high-cost individuals in 2009 were so in 2010. But another study, by Pauly and Zeng, examined a longer time period. From a sample of insured workers and adult dependents, it found that almost half of those in the top quintile of health care spending in 1994 were in the top quintile four years later. Again, these findings are now quite dated.
Richard Hirth and colleagues recently were able to take an analysis of persistence for workers and their dependents a lot further, and using recent data. They looked at six years of health spending data (2003-2008) for a sample of millions of individuals with coverage from over 100 medium and large employers. One of their findings is that at least one in every three high spenders in a given year will be a high spender in any of the next five years. (Here, high spender is defined as in the top 10% of the annual spending distribution.) I don’t know what your prior is, but this is a much higher level of persistence than I expected. Their chart below has the details.
Obamacare Flexes Muscles With New Medicare Payment Plans
You get hit with a major health condition and your health care needs and spending spikes. A lot. Welcome to the 10% club, whose members spend at least $30,000 on health care in a year. Yeah, most of it is covered by insurance, but selecting the plan with the $2,500 deductible you blew through (not to mention the thousands more in copayments) looks like a bad idea in hindsight.
It could be worse. It could happen to you next year, and the year after, and the year after that, and so on. Will it?
This is a question of health spending persistence. And, as surprising as it may sound, we don’t know a lot about it, at least for the working age population. The basic problem is that researchers rarely have access to many years of health care spending data for the same set of individuals. Those data are proprietary. Some are available, but expensive to purchase.
So, most of what we know about health care spending persistence is from Medicare—clearly not representative of the working age population.
A study by Alan Garber and colleagues examined Medicare beneficiaries in the top 5% of the spending distribution in a single year. They found that 15% remained in this high cost group one year later, and 9% did so two years later. Their analysis is now quite dated, extending only through 1995. A somewhat more recent analysis by Gerald Riley found greater persistence; among top 5% spending Medicare beneficiaries in 2001, 24% were in that group one year later, 16% two years later, and 12% three years later.
Most work focused on the working age population is only able to track people for two years. For example, an analysis using the Medical Expenditure Panel Survey by Steven Cohen found that 34% of high-cost individuals in 2009 were so in 2010. But another study, by Pauly and Zeng, examined a longer time period. From a sample of insured workers and adult dependents, it found that almost half of those in the top quintile of health care spending in 1994 were in the top quintile four years later. Again, these findings are now quite dated.
Richard Hirth and colleagues recently were able to take an analysis of persistence for workers and their dependents a lot further, and using recent data. They looked at six years of health spending data (2003-2008) for a sample of millions of individuals with coverage from over 100 medium and large employers. One of their findings is that at least one in every three high spenders in a given year will be a high spender in any of the next five years. (Here, high spender is defined as in the top 10% of the annual spending distribution.) I don’t know what your prior is, but this is a much higher level of persistence than I expected. Their chart below has the details.
by Margot Sanger-Katz
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