The Difference Between a ‘Public Option’ and ‘Medicare for All’? Let’s Define Our Terms
A glossary for the emerging Democratic health care debate.
Democrats, the many running for president as well as energized members of Congress, are talking big about health care again. Among other things, that means brace yourself for some jargon.
Here’s your neighborhood health care nerd to help define some terms.
Various proposals are floating around, each of which would change the health care system in distinct ways. Some, like one from Senator Bernie Sanders, would do away with all private health insurance. Some would make small expansions in existing public programs. Some would try to cover all Americans through a mix of different insurance types.
It can be mystifying when people call all of these ideas “Medicare for all,” as some in the debate have been doing.
A glossary of terms could make the debate less confusing. Let’s start with the basics.
What is Medicare?
Medicare is a 54-year-old program that provides health insurance for Americans 65 and older, and for a few other groups of people with particular diseases or disabilities.
Traditional Medicare pays doctors and hospitals according to set prices determined by the government, and most medical providers in the United States accept it. It’s also possible to enroll in private Medicare plans that can offer additional benefits, though with a more limited set of health providers.
Private plans handle Medicare drug coverage, and you can choose among options. You pay premiums each year, and you pay deductibles and co-payments when you use medical services.
Because the program’s out-of-pocket spending has no limits, most Medicare beneficiaries also buy private supplemental insurance to limit those costs. That insurance doesn’t cover medical services outside the Medicare system, but it helps pay the patient’s share of the bill when a person goes to the doctor or hospital.
What is Medicare for all?
This increasingly popular term was coined to describe a system in which all Americans, not just older ones, get health insurance through the government’s Medicare system.
Mr. Sanders, who prominently featured such a plan in his 2016 presidential platform and just announced he has joined the 2020 race, uses this term a lot. His plan would both expand traditional Medicare to cover all Americans, and change the structure of the program, to cover more services and eliminate most deductibles and co-payments. So the Medicare everyone would be getting would differ in crucial ways from the Medicare older people get now.
There would effectively be no private health insurance, because the new system would cover everyone and everything; duplicative coverage would be banned. That’s why Senator Kamala Harris of California, a co-sponsor of the Sanders bill and a presidential candidate, told CNN recently that she would endorse abolishing all private insurance — doing so is a key feature of the plan.
But there are many other possible flavors of Medicare for all. Though no prominent politicians are currently proposing it, an expansion of the current Medicare benefits, with its current co-payments, deductibles and premiums, could also be thought of as “Medicare for all.”
The idea of Medicare for all is suggestive of the health care system in Canada. There, doctors and hospitals remain private, but everyone gets insurance from the government. No one there is asked to pay any money when seeing a doctor. The Canadian health care system is even called Medicare.
Listen to ‘The Daily’: How ‘Medicare for All’ Would Work (or Not Work)
Hosted by Michael Barbaro, produced by Rachel Quester, Andy Mills, Clare Toeniskoetter and Jessica Cheung, and edited by Paige Cowett
As the idea gains traction in mainstream circles, we look at its roots in progressive American politics.
- michael barbaro
From The New York Times, I’m Michael Barbaro. This is “The Daily.”
Today:
- archived recording 1
I think “Medicare for all” is the right solution.
- archived recording 2
I support “Medicare for all.”
- archived recording 3
Oh, I believe that we need Medicare for all.
- archived recording 4
We need to make sure that every American is able to get health care.
- archived recording 5
We need to have “Medicare for all.”
- archived recording 6
I believe we should have “Medicare for all.”
- archived recording 7
This country will pass a “Medicare for all” single-payer health care system. [CROWD CHEERING]
- michael barbaro
“Medicare for all.”
It’s Wednesday, March 13.
Margot, the 2020 Democratic primary, which is now officially underway, is very much starting to feel like the “Medicare for all” primary. Where does this idea, “Medicare for all,” come from?
- margot sanger-katz
Well, I think it actually makes sense to go all the way back and think about the origin of Medicare. [MUSIC] This is actually an idea that has been kicking around in progressive politics for a very long time. It had a brief moment in the Progressive Era in 1910.
- michael barbaro
Margot Sanger-Katz covers health care policy for The Times.
- margot sanger-katz
Then, I think the next serious moment was actually in the New Deal.
- archived recording (franklin d. roosevelt)
Two months ago, as you know, we were facing serious problems. The country was dying by inches.
- margot sanger-katz
And if you think about what the F.D.R. administration was trying to do, they were trying to build a sort of basic public social safety net for people, to protect them and prevent them from falling through the cracks.
- archived recording (franklin d. roosevelt)
First, we are giving the opportunity of employment to a quarter of a million of the unemployed.
- margot sanger-katz
And health care was something that they considered including in the package of reforms at that time when they made social security and a lot of these other programs, but it was too controversial, and it actually dropped out of that proposal.
- michael barbaro
And why would it be controversial in the New Deal period, when it seems like the idea of government taking care of people is very much in vogue?
- margot sanger-katz
I think the main reason why health care at that time was so controversial is because doctors were really against it. Doctors were these small business owners, people paid them directly for medical care, and they really didn’t want the government getting involved in their business and, perhaps, making it harder for them to make a living.
- archived recording (harry truman)
We are rightly proud of the high standards of medical care we know how to provide in the United States.
- margot sanger-katz
So the next American president to really make a go at this was Harry Truman —
- archived recording (harry truman)
The fact is, however, that most of our people cannot afford to pay for the care they need.
- margot sanger-katz
— who wanted to create a universal health care program.
- archived recording (harry truman)
Our ultimate aim must be a comprehensive insurance system to protect all our people equally against insecurity and ill health.
- margot sanger-katz
And again, he really was stopped.
- archived recording (john f. kennedy)
I believe the epic in which we’re engaged is worth the time and effort of all of us.
- margot sanger-katz
Then, J.F.K. made a big move to try to expand government health insurance, at least for the elderly.
- archived recording (john f. kennedy)
This is a campaign to help people meet their responsibility.
- margot sanger-katz
There was a view that while health insurance was starting to become available as a way for working people to protect themselves, that once you got old and you didn’t have a job that came with insurance and you started to get sick — that no one wanted to sell you insurance. And so he proposed this idea of having a health care program that would be financed by payroll taxes like social security, but he couldn’t get it through.
- archived recording (lyndon johnson)
No longer will older Americans be denied the healing miracle of modern medicine.
- margot sanger-katz
It was only when Lyndon Johnson became president afterwards and after the Democrats took big majorities of Congress —
- archived recording (lyndon johnson)
No longer will illness crush and destroy the savings that they have so carefully put away over a lifetime.
- margot sanger-katz
— that they were finally able to pass legislation that established the program that we now call Medicare.
- archived recording (lyndon johnson)
And no longer will this nation refuse the hand of justice to those who have given a lifetime of service and wisdom and labor to the progress of this progressive country. [MUSIC]
- michael barbaro
And what was Medicare at this moment when President Johnson signs it into law?
- margot sanger-katz
The idea was that everyone, once they turned age 65, if they had worked and paid payroll taxes, would be able to have government health insurance. They would have access to insurance that would pay for their hospital care and further visits to doctors.
- michael barbaro
So it took four presidents to pass a version of government-run health care. And even then, it is afforded to a narrow group of Americans.
- margot sanger-katz
That’s right. Around the same time that Congress passed Medicare, they also created a program called Medicaid that served the very poor in America. But essentially, there was a huge group of Americans in the middle who were left out of both programs.
- michael barbaro
And why is that, Margot? Why is this idea during this period of nationalized medicine, government-run health care — why is it being limited to such small groups of Americans?
- margot sanger-katz
I think the idea has always been pretty politically controversial. There are a couple of different threads of it. One is that industry doesn’t like it. So doctors are the kind of most vocal group in this period. But over time, we also have hospitals, and drug companies, and other parts of the health care industry that are wary of the government getting involved and maybe taking their dollars away from them. I think also, especially in this period, there is a real resistance to socialism and this idea that it’s not American to have the government providing these basic benefits, that the free market should work to do it instead.
- michael barbaro
But what about the people who are being covered by government-run health care programs like Medicare? Do they like it? Is it working well for them in this period — the 1960s, the 1970s?
- margot sanger-katz
Medicare is a uniquely popular government program. People really love it. It provides them with a lot of financial security. People pay taxes into the program, so they feel like it’s an earned benefit. It’s something that they deserve. But meanwhile, everyone else is in a health insurance program that is getting a little bit more rickety. There are some people who get really great insurance through their work, but there are a lot of other people who are sort of falling through the cracks — if they’re between jobs, if they work for a company that doesn’t provide insurance. The system for people in Medicare is that everyone gets it and they all get the same thing. The system for the rest of us is, it really depends on who you are, and who you work for, and what your financial situation is.
- archived recording (ted kennedy)
I’ve been able to receive it for myself and for my family. Just like all of us who are on the tip of the iceberg, way up high in the health care services.
- margot sanger-katz
And because of that, there are a bunch of proposals over the years to try to reconsider a more national health care system.
- archived recording (ted kennedy)
But I want every delegate at this convention to understand that as long as I’m a vote —
- margot sanger-katz
Ted Kennedy has a proposal in 1970.
- archived recording (ted kennedy)
— and as long as I have a voice in the United States Senate, it’s going to be for that Democratic platform plank that provides decent quality health care. [CROWD CHEERING] North and south, east and west.
- margot sanger-katz
In the 1990s, the Clintons have an idea to try to achieve universal health care. But largely for the same reasons that we had trouble with this before — concerns about socialism, industry opposition — those proposals essentially get batted down.
- michael barbaro
And so what happens next?
- archived recording (barack obama)
Six months ago today, a big part of the Affordable Care Act kicked in.
- margot sanger-katz
So I would say the next big thing that happens in this timeline is that we get the Affordable Care Act in 2010.
- archived recording (barack obama)
And millions of Americans finally had the same chance to buy quality, affordable health care, and the peace of mind that comes with it, as everybody else.
- margot sanger-katz
There is a brief discussion among Democrats at that time of trying to do a single-payer system, a more universal system, where everyone gets something like Medicare, but that really, even at that time, is very much a fringe view among Democrats. The consensus idea that President Obama and the Democrats in Congress want to do is something that sort of expands on our current system, where you still have a lot of different private insurers. People have a lot of choice.
- archived recording (barack obama)
7.1 million Americans have now signed up for private insurance plans through these marketplaces. [CROWD CHEERING]
- margot sanger-katz
And on the socialism side, even though this was largely a private market program, it still was susceptible to those kinds of criticisms. And we heard Republicans talking about it as a government takeover, talking about as a socialist plot.
- archived recording
This has to be ripped out by its roots. This is government taking over the entire health insurance industry.
- margot sanger-katz
But what it tries to do is kind of patch up the holes in the existing system. And one of the ways that it does that is by vastly expanding Medicaid, that program we talked about for poor people. A lot more people get coverage through Medicaid, and then the government helps people who don’t get insurance through work with financial subsidies that allow them to buy their own insurance.
- michael barbaro
So with the Affordable Care Act, once again, the concept of government-run health care is proposed and ultimately tossed aside.
- margot sanger-katz
Yes and no. I think you have to see the Affordable Care Act as a sort of compromise. As a moderate proposal that expands some government health care, expands some private insurance, keeps a lot of what already exists and doesn’t take things away from people. But I also think that it did change Americans’ expectations about what the role for government was in health care, and also what kind of health care they were entitled to. So, you know, we’re moving closer to the idea that everyone should be able to have health insurance, even if they’re poor, even if they don’t get insurance through work. And there are certain guarantees in the Affordable Care Act, like the guarantee that people who have pre-existing health conditions should be able to buy insurance —
- michael barbaro
Right.
- margot sanger-katz
— that really didn’t exist before.
- michael barbaro
So even though with the Affordable Care Act we didn’t end up with government-run health care, we end up with more government in our health care, which it sounds like is beginning to change people’s perception of what the government’s role should be when it comes to medicine.
- margot sanger-katz
Exactly.
- archived recording 1
Who are you guys here to see?
- archived recording 2
Bernie!
- archived recording 1
Who feels the Bern? [CROWD CHEERING] [MUSIC]
- margot sanger-katz
And I think this lays the groundwork for Bernie Sanders when he comes forward with a proposal in 2016 that he calls Medicare for all.
- archived recording (bernie sanders)
We must fight to make sure that we pass a “Medicare for all” health care system. [CROWD CHEERING]
- margot sanger-katz
Medicare for all builds on the idea that everyone should have access to affordable health insurance, but it kind of turbo-charges that idea. “Medicare for all” says everyone gets the same health care.
- michael barbaro
Hm.
- archived recording (bernie sanders)
I happen to believe — and I know not everybody agrees with me — I believe that health care is a right of all people.
- archived recording
Excuse me, where did that right come from, in your mind?
- archived recording (bernie sanders)
Being a human being. Being a human being.
- margot sanger-katz
Senator Sanders’s idea is that everyone in America would have access to health insurance that’s provided by the government that covers a wide array of medical services, and for which they do not have to pay any money when they go to the doctor.
- michael barbaro
Wow. And what’s the reaction to Sanders’s proposal?
- margot sanger-katz
It has a really mixed perception. So I think that it really speaks to some people who respond to the moral case that he’s making and to people who have really felt left behind by our current system, who are struggling with high health care costs or fighting with their insurance companies. So I think it really galvanized his campaign. It’s a central theme. Obviously, he really outperforms everyone’s expectations in the Democratic primary.
- michael barbaro
Mm-hmm.
- margot sanger-katz
At the same time, I think that the kinds of people who were uncomfortable with the Affordable Care Act, who were uncomfortable with some of these more universal health care systems in the past think it’s sort of a laughable idea. It’s really, really far from where we are right now, it’s far from anything that’s really been debated in a serious way in the Congress, and it would be extremely expensive to implement. It would require huge tax increases. And that is the kind of political debate that doesn’t typically get very far when it’s outside the confines of a campaign.
- michael barbaro
So we know Sanders loses the primary, and so his campaign ends. What happens to “Medicare for all” after that?
- margot sanger-katz
It’s really interesting. “Medicare for all” gets more popular than ever. So, you know, it’s not just that Sanders loses the primary to Hillary Clinton, who wants to do something much more moderate on health care, but also Hillary Clinton loses the election to Donald Trump.
- archived recording (donald trump)
I’m going to repeal and replace your disastrous Obamacare. [CROWD CHEERING] Much cheaper, much better.
- margot sanger-katz
So you might think that this sort of really left-wing idea of doing a universal health care would just go away, but instead it starts to gain in popularity, and we see this in a couple of different ways. Public opinion surveys show steady and modest increases in the number of Americans who seem interested in this idea when they’re asked about it. And the other thing that happens is we start to see way more Democrats in Congress signing on to proposals like the Sanders proposal. So Sanders himself had a bill that he had brought forward in previous Congresses and, basically, no one wanted to co-sign it. And then he brought it again in 2017, and all of a sudden he had, I think, 16 co-sponsors, including lots of really ambitious Democratic senators that we expected to run for president, and we now see are running for president. And there’s a bill in the House that had been introduced year after year with very few co-sponsors, and all of a sudden, again, in 2017, we saw the majority of Democrats in the House were signing onto this bill.
- michael barbaro
How do you explain that shift?
- margot sanger-katz
I definitely think that Sanders was part of it. And if you talk to him, he definitely thinks he was part of it — that he really brought this into the mainstream of our political conversation. But I think there are a couple of other factors. One is that after Trump became president, the first thing he tried to do in legislation was repeal the Affordable Care Act. And, you know, Republicans had a lot of indications that was going to be a good idea. Their voters had been telling them for years that they really didn’t like Obamacare and they wanted it to go away. But actually, that turned out to be kind of politically perilous for the Republicans.
- archived recording
And today, the president summoned G.O.P. lawmakers to the White House for the second time in less than a month, after two versions of a bill to repeal and replace Obamacare failed.
- margot sanger-katz
They failed multiple attempts to repeal the Affordable Care Act, and its popularity got higher than ever. And there was kind of this boost among Democratic activists over health care — that they started to really care about the issue, and get organized, and get angry.
- archived recording
Many of the Republican congressmen who held town halls during this recess have heard the wrath of many of their constituents.
- margot sanger-katz
And I think some of those people are bringing new energy to the single-payer moment.
- archived recording
In North Dakota, congressman Kevin Cramer heard from a woman with a disabled child. She asked him not to repeal Obamacare, with her family facing bankruptcy. This is what $3.5 million looks like, and she’s two years old.
- margot sanger-katz
And then the third thing that I think that happens is the Democrats are kind of on their heels. They’re not in control of Congress anymore. They’re not in control of the White House. They don’t actually have to govern. And so I think that makes them a little bit more open to something that’s more idealistic, that’s more aspirational.
- michael barbaro
Mm-hmm.
- margot sanger-katz
When they’re in the minority, I think they can say, we want to tell you what our values are. We want to tell you what our dreams are and what we care about — equity, and we care about fairness. And they don’t really have to worry about the dirty little details.
- archived recording
When our congressmen took a party-line vote that would have canceled health insurance for thousands of Virginians, I knew I had to run.
- margot sanger-katz
That’s exactly what we saw happen in the midterms.
- archived recording
Health care affects everyone. Making it into a partisan battle makes things worse.
- margot sanger-katz
We saw a lot of Democrats all across the country running with health care as their primary message.
- archived recording
I’m voting for Mikie Sherrill because I know she’ll like fight for me and my family, my daughter, and for the A.C.A.
- margot sanger-katz
And it was very effective. They took over a lot of seats in the House that had previously been held by Republicans. But I think the exact message that they drew from this is a little bit mixed. I think a lot of them felt, oh, people really just want me to protect what they already have — that we have a very good message in protecting the Affordable Care Act. But some of these Democrats who won running on health care felt like this is a reason to go forward, to push further than the Affordable Care Act because the electorate really responds to this issue. And I think you can really see this now as the 2020 presidential field is starting to heat up. Senator Sanders, obviously, continues to support it. Cory Booker, the senator from New Jersey, is in favor of the Sanders proposal. Elizabeth Warren was a co-sponsor of Senator Sanders’ bill in the last Congress. But it is not universal among Democratic candidates. We saw Amy Klobuchar, a Democratic senator from Minnesota, who said, this is too aspirational. It’s too pie in the sky. We need to focus on more incremental changes that are more politically possible. They all want to make some increase for the role of government — try to have there be more health care available for more people, to make it more affordable. But there is this range from little technocratic fixes to let’s do single-payer.
- michael barbaro
Well, let’s talk about that. What does it mean when a candidate for the Democratic presidential primary in this moment says “Medicare for all“? What are the actual proposals on the table?
- margot sanger-katz
Who knows? I mean, we are so vague right now. I think when Bernie Sanders says “Medicare for all,” we know what he means because he talked about it in 2016 and he has a legislative proposal. I think with a lot of these other candidates, they are kind of latching onto a brand name that seems to be pretty popular with the public, that reminds them of Medicare, which a lot of people like. But we’re not in the phase of the campaign yet where we have really specific proposals that tell us exactly what it is that they want to do.
- michael barbaro
To the degree that Medicare for all is an actual, credible proposal like what has been offered by Senator Bernie Sanders, how practical is it? How expensive would it be to create? How disruptive would it be to the current health care system?
- margot sanger-katz
I think it’s almost hard to underestimate how disruptive it would be. Just to give one example, right now we have private health insurance companies that cover most Americans. These are big corporations. They’re among the largest and most —
- michael barbaro
Aetna, Cigna, Blue Cross Blue Shield.
- margot sanger-katz
Yeah. These companies would essentially be wiped out by the Sanders proposal.
- michael barbaro
Wow.
- margot sanger-katz
There would be no private insurance. Everyone would get their insurance directly from the government.
- michael barbaro
And what about the cost?
- margot sanger-katz
So this would be an enormously expensive proposal. It is not necessarily expensive compared to all the ways that Americans pay for health care now. So right now, your employer, if you get employer based insurance, they pay something towards your insurance premium, you pay something towards your insurance premium. When you go to the hospital, maybe you pay a deductible. There are kind of all of these different pots that your health care dollars come from. What the “Medicare for All” plan would do is it would say, no one’s going to pay into any of those streams — the federal government is going to pay for all the medical bills, but in order to pay that, they have to collect way more money in taxes. So various estimates say it would cost more than $30 trillion to administer something like the Sanders plan.
That is a lot of money. And that is so much money that you can’t just raise it by taxing the rich. You would really have to have very broad-based taxes that would reach across the income spectrum.
- michael barbaro
So what you have described is a pretty radical idea that would upend a huge segment of the U.S. economy. It would require major changes to the tax code. So I wonder if there’s any practical chance that this actually could get through our legislative and political process to become the U.S. health care system.
- margot sanger-katz
So I’m always wary of making political predictions, but it seems extremely unlikely to me right now for a couple of reasons. One is that Republicans are dead-set against this. So now we’re left with just Democrats who would have to vote for such a bill. And then you would have to imagine that they could all agree on a proposal this radical. And I don’t think that there is enough unanimity among Democrats right now on this issue. But I also think that this is a way for Democratic politicians to signal that they are signed onto a particular set of values about fairness, about affordability, about kind of all being in it together. And I think that they want to send those kind of values messages to voters, even if they’re not necessarily sending them a specific policy platform that they can deliver on. And so I think it’s a way to say, like, that’s the mountain-top goal. We’re going to get there eventually. But it’s not necessarily saying, you know, on day one, I’m going to get there right away.
- michael barbaro
Well, what exactly does that path look like, then, from where we are in the minds of these Democratic candidates to a someday-world where “Medicare for all,” as envisioned by someone like Bernie Sanders, could ever be a reality?
- margot sanger-katz
So I had this really interesting and instructive experience about a year ago. I went with Bernie Sanders to Toronto, and we went on a tour of the Canadian health care system. And I would say that Canada’s system is the closest analog to what a lot of these politicians are proposing. And one thing that just really struck me about Canada is that people are all in on the values piece. There is just a real sense of kind of social solidarity around the idea that health care is a right, and everyone should have it in the country, and there shouldn’t be any restrictions, and that it should be sort of radically fair. And that just struck me culturally as so different. And the thing that I couldn’t untangle when I was in Canada is, do they have those values because they have that system, or do they have that system because they already had those values? And I think, you know, part of what will be interesting if Democrats, you know, retake power, and if they start moving us on this path towards something more like single-payer is, how hard will it be to shift those values? We see them. There definitely are people in the Democratic base who believe them deeply in their hearts, but I don’t think that most Americans feel that health care is a fundamental right and that everyone should have it. And I don’t know if that will change.
- michael barbaro
Right. Which comes first, the values that say that health care is a right, or the national health care system that dictates that? And from everything you’ve described, something like 80 years of U.S. history suggests that there has not been an appetite for this kind of a system. So the only way it would work is if we believe, right, that the system could come first and the values would flow from it.
- margot sanger-katz
I don’t know. I almost think that the opposite thing is probably true — that it’s really hard to imagine it being possible to pass something that would be so earth-shattering, that would make so many changes to our health care system, to our tax code, to the way that health care is delivered if we don’t have buy-in. And so I think that a real challenge for politicians around this issue is really going to be winning hearts and minds and trying to convince people that this vision of how the health care system should work is worth the disruption. The people who really believe in it really believe in it, but there are a lot of people that they will have to persuade.
- michael barbaro
It’s interesting. So when candidates like Bernie Sanders say “Medicare for all,” potentially, he’s actually trying to change the American culture to the point where “Medicare for all” could actually work. In other words, when he or anyone says “Medicare for all,” they’re actually calling for the cultural change required for the U.S. to get excited and adopt “Medicare for all.”
- margot sanger-katz
Maybe. I mean, it could be that this is the only way that we’re going to get the kind of cultural change that would be required to make a policy change of this magnitude, but I also think that there are real risks here. It’s totally possible that America could engage with this idea, and we could have a big debate about it in a presidential election, and then could thoroughly reject it. And then we sort of end up with the kind of politics around health care that we’ve had for a long time, where these sort of universal health care proposals are put forward, it’s decided that they’re kind of too radical for where we are, and they get shelved again.
- michael barbaro
Hm.
- margot sanger-katz
Which would put us in kind of a familiar situation of having considered a big government-run health care system and saying, no, thanks.
- michael barbaro
Margot, thank you very much. We appreciate it.
- margot sanger-katz
I’m so happy to come on. [MUSIC]
- michael barbaro
In his new budget unveiled on Monday, President Trump called for $845 billion in cuts to Medicare over the next decade, setting up a 2020 presidential race in which he will seek to shrink the program, while many of his Democratic rivals propose expanding it.
What is single-payer health care?
This one is pretty simple if you understand Medicare for all. Single-payer is a more general term used to describe a government system, typically backed by taxes, in which everyone gets health care from one insurer, run by the government. Think of Medicare for all as a brand-name single-payer plan. Some advocates also like the term “national health insurance.” These terms all describe a system in which the government pays for everyone’s health care services.
What is socialized medicine?
Critics of single-payer are particularly fond of this term, which describes a system in which the government runs not just the financing of health care — by running an insurance company like Medicare — but also manages hospitals and employs medical providers directly. Britain’s National Health Service is an example of a socialized system. Doctors there work for the government.
The United States has its own socialized system, for military veterans. Veterans get their insurance through the Department of Veterans Affairs, which owns hospitals; employs doctors, nurses and other medical professionals; and negotiates directly with pharmaceutical companies for drugs. In general a veteran couldn’t get coverage for routine care from a doctor who didn’t work directly for the V.A., but recent policy changes have started to privatize more health care for veterans.
There are currently no mainstream proposals to fully socialize the United States health care system.
What’s a public option?
When lawmakers were writing the Affordable Care Act, there was an extensive debate about whether it should include a public option. The idea didn’t prevail in the end, but many Democrats now want to bring it back.
You can think of a public option as something of a compromise between a single-payer system and our current system, in which only certain Americans now qualify for government-run programs. More people — maybe many more — could get government insurance. But only if they wanted it.
Public-option plans would allow middle-income, working-age adults to choose a public insurance plan — like Medicare or Medicaid — instead of a private insurance plan. There are various ways this could work. Some proposals would allow individuals to pay a premium to buy a Medicare or Medicaid plan that would be the same as the insurance now available to older people, the disabled or the poor. Others would set up a new public plan, run by the government, that Americans could buy. Under most proposals, people who get federal help buying Obamacare coverage could use their government subsidies to help them buy either a private or public option.
Most of the current proposals would limit access to the public option to certain groups of Americans. A bill from Senator Debbie Stabenow of Michigan and colleagues would allow only those older than 50 to buy a Medicare plan, for example. Some plans would allow only people who buy their own health insurance to choose Medicare or Medicaid as an option alongside those offered in the Obamacare exchanges.
Others would also let employers choose Medicare, instead of a private health insurance company, when offering benefits to their workers. A plan from a liberal think tank, the Center for American Progress, would make the public Medicare option available to anyone who wanted to sign up.
An advantage of a public option, at least politically, is it would preserve more choice for individuals, who could stick with a private plan if they prefer. That would make it less disruptive than a single-payer plan. A downside is that keeping lots of different insurance options could undermine one of the goals of a single-payer system, a simpler approach that would involve less money tied up in paperwork and insurance company profits.
What is universal coverage?
All of the earlier entries describe ways of organizing the health insurance system. Universal coverage is a broader goal. When people push for universal coverage, they mean that everyone should have access to the health care system. You’ll sometimes hear politicians say that health care should be a “right.” That statement is an endorsement of universal coverage.
Most other developed countries embrace this idea, that health care should not be only for those who can afford it. But those countries have not all embraced single-payer approaches.
There are ways to achieve universal coverage that don’t look like a single-payer system at all. Most European countries, for example, have systems with competing private health insurance plans, along with tight regulation and government subsidies that make the premiums affordable for everyone. This article from my Upshot colleagues Aaron Carroll and Austin Frakt, in which experts voted on the world’s best health system, does a nice job of showing the different ways that countries have achieved universal coverage. This sort of European-style coverage is not prominent in our current policy debate.
Patients, advocates clash with hospitals over bill to restrict facility fees in medical bills
The fees are often included to cover operating costs and pay for uncompensated services, hospital officials say, but they can leave patients on the hook for hundreds or thousands of dollars.
by Joe Lawlor - Portland Press Herald - May 12, 2023
AUGUSTA — Frustrated patients joined consumer advocates and health insurers on Thursday to support legislation to strictly limit – and in some cases ban – so-called “facility fees” that can add hundreds or thousands of dollars to medical bills.
But a representative for the state’s hospitals warned that the fees are critical to the facilities and make it possible for them to provide the care that patients expect.
Facility fees are often included in medical bills to cover hospital operating costs and pay for uncompensated services they provide, hospital officials say. But the fees can add hundreds or thousands of dollars to a medical bill and often confuse and surprise patients, especially when they are tacked onto bills for routine visits such as urgent care or diagnostic tests. Insurance companies sometimes refuse to pay the facility fees. Other times patients end up paying them because they have high-deductible plans.
Senate President Troy Jackson, D-Allagash, sponsored the bill and criticized the practice of sticking patients with unexpected fees for routine care.
“I don’t think it’s right that people are getting these extremely high bills and they don’t know that it’s coming,” Jackson said.
Jackson drafted the bill after a Press Herald investigation revealed that health care providers routinely add surcharges called facility fees that can be hidden in patients’ bills, often charging hundreds of dollars simply because an outpatient procedure or test was performed in a hospital. The newspaper’s investigation, published last August, reported that even patients who research prices and compare costs ahead of time are surprised, confused and frustrated by the charges.
Jeff Austin, vice president of government affairs for the Maine Hospital Association, told the Health Care, Insurance and Financial Services Committee that the bill would be “financially devastating to hospitals” because the fees are the only way hospitals can cover costs for some uncompensated services they provide.
“This bill essentially attempts to install rate regulation on hospitals for the benefit of (insurance) carriers,” Austin said. “The problem is that it sets the reimbursement rate for many hospital services at zero. This will close numerous services all across the state.”
Austin said the way the bill is currently worded would prohibit hospitals from recouping costs in other ways, ending many outpatient services. He did not give a list of services that would be shuttered, but gave one example of cardiac stress test services closing because of the billing restrictions.
The bill would ban facility fees from outpatient clinics and other non-hospital locations. For certain procedures, hospitals also would be barred from charging facility fees.
The Maine Department of Health and Human Services would be required to create a list of services for which patients could not be charged facility fees. The list is not spelled out in the bill, but common screenings such as colonoscopies, blood tests, MRIs, mammograms and other routine care would likely be targeted. The legislation also would require DHHS to submit to the Legislature an annual report about facility fees.
‘ABSENCE OF TRANSPARENCY’
Mike Lauze of Portland submitted written testimony in which he recounted how he received outpatient eye surgery in Portland and was charged three separate facility fees for three distinct procedures during the surgery. The three fees totaled $7,800. Insurance covered most of the cost, but he was on the hook for $850 in facility fees.
“This was on top of the professional fees for those same procedures totaling over $6,200. Before paying multiple facilities fees, I requested the billing manager, his boss, and the CFO considering the multiple charges. They insisted it was right … and ultimately I paid all charges I owed.”
Lauze said he is a supporter of patients sharing in the cost of their medical care. “It just seems the absence of transparency and the whole process by which providers double charge (facilities fees), mark-up in anticipation of only receiving partial payment makes it impossible for patients to be responsible with overall medical care,” he said.
Sierra Kent of Bangor said in her testimony that she went to a hospital emergency room in February with symptoms that she thought could be appendicitis.
“Once I was at the ER, I spent all but a few minutes in the waiting room,” she said in written testimony supporting the bill. “I was given an IV with antibiotics and some Tylenol. … I wasn’t in the exam room for more than five minutes.
“When I got the bill for the ER visit, the total bill was over $9,000, $4,605 of which was a facility fee charge. The balance for me to pay after insurance was $2,507. I was confused by the facility fee charge, so I asked some of my doctor friends about the charge and was told that it was the charge for just walking into the ER.”
Kent said she is trying to set up a payment plan, but can’t afford to make minimum payments. “I’m having other health issues and I can’t work. This is so stressful.
“I know the medical bill is my responsibility because I received the services, but I would have liked to have had a heads up and some sort of estimate of how much my bill was going to be beforehand,” she said. “That may have altered my choice of going to the ER.”
The insurance industry supported Jackson’s bill, with representatives from Anthem Blue Cross Blue Shield, Community Health Options, and the Maine Association of Health Plans advocating for restrictions on facility fee charges.
“Defining and limiting the use of facility fees in Maine, especially concerning consumers covered by private insurance, will increase transparency and improve fairness,” said Dan Demeritt, executive director of the Maine Association of Health Plans, with represents the insurance industry in Maine before the Legislature.
IMPACTS QUESTIONED
Lawmakers peppered advocates with numerous questions about the impacts of passing the bill, and whether it would potentially cause unintended consequences by, for instance, limiting reimbursement rates for independent practices in rural areas.
“This seems more like cost-shifting than savings, to me,” said Rep. Gregory Lewis Swallow, R-Houlton.
Advocates agreed that some cost-shifting would occur, but that it would be more fair to patients to have transparency in billing rather than to be surprised by large facility fee charges.
“People don’t expect to receive facility fee charges for routine or outpatient care,” said Kate Ende, policy director for Consumers for Affordable Health Care, a patient advocacy group.
Advocates agreed that some cost-shifting would occur, but they said cost-shifting already happens, and that it would be fairer to patients to have transparency in billing rather than to be surprised by large facility fee charges.
Consumers for Affordable Health Care published a survey on Thursday that shows that despite almost all Maine people having health insurance, 68% of survey respondents said they are “one major medical event or illness” away from a “financial disaster.”
Ann Woloson, executive director of Maine Consumers for Affordable Health Care, said part of the reason people are worried about medical bills even if they have insurance is they have high-deductible plans. While facility fees are merely one component of the cost of health care, getting charged an unexpected facility fee that costs hundreds or thousands of dollars that either insurance won’t cover, or would go toward a high-deductible plan, would be a financial hardship for many, said.
Those in favor of the bill, including Kim Cook, representing Community Health Options, pointed out that Medicare already substantially restricts how hospitals charge facility fees, and that passing a law in Maine would make billing more consistent among Medicare patients and patients with private insurance.
But Austin, of the Maine Hospital Association, said that “facility fees” are merely a label for the true cost of providing the service.
“There is nothing hidden or inappropriate about hospitals charging for operational expenses such as the hospital, the nurses, the electricity, the supplies, all of the administrative costs related to billing, collections, regulatory compliance, medical malpractice, data collection and reporting, community relations, and so forth. Whether that is called a facility fee, hospital fee, nurse fee, or any other label, hospitals should be allowed to cover our operational costs,” Austin said.
A representative for the Mills administration said the Department of Health and Human Services is neither for nor against the bill, which could change MaineCare billing practices and require additional resources and staff to comply with the reporting requirements and oversight.
One way to prevent gun violence? Treat it as a public health issue
by Rachel Treisman - NPR - May 12, 2023
Dr. Deborah Prothrow-Stith was working in an emergency room as a medical student more than four decades ago when she realized that victims of violence were getting treated and then released — unlike other patients — without any sort of preventative care.
"And one night, at 3:00 in the morning, a young man just very specifically said to me that he was going to go out and cut the guy who cut him," she says. "I thought, this is not adequate. My response is not adequate. My profession's response is not adequate."
Prothrow-Stith has played a key role in defining youth violence as a public health issue in the years since (her 1991 book Deadly Consequences is considered a classic in the field). That means focusing on prevention efforts — not only in emergency rooms, but in doctor's offices and schools, too.
And guns are increasingly a part of that conversation.
Prothrow-Stith, who is dean and professor of medicine at the Charles R. Drew University of Medicine and Science in Los Angeles, remembers that when she first started out, stabbings were "the number-one way that young men were killed" in Philadelphia. The picture of violence changed dramatically in a matter of years.
"Guns in America play a huge role, especially as we start looking at weapons of war being available and the mass shootings that are taking place," Prothrow-Stith tells Morning Edition's Michel Martin.
The Centers for Disease Control and Prevention recorded 48,830 U.S. firearm deaths in 2021, the last year for which complete data is available. Those include suicides — which have long accounted for the majority of U.S. gun deaths — as well as homicides.
Culturally, suicide is more common in white America and homicide more common in Black America, Prothrow-Stith notes. But she stresses that violence in general is a learned behavior.
"We don't come out of the womb ready to commit suicide or homicide," she adds. "And I think as a culture, [we need an] understanding that children who are hurt, hurt others or hurt themselves. And our job is not to give them a gun, but our job is to figure out how to help them heal."
The role of guns in America, as told by a doctor
Prothrow-Stith says it's clear that guns turn "an everyday emotional situation" into fatal encounters.
"We know that sometimes people act differently when they have a gun in a situation, feeling invincible or escalating a situation that they might otherwise de-escalate," she added.
And at least when it comes to teenagers, she says, there are some similarities in the contributing factors that can lead to homicide and suicide.
Most homicides are the result of arguments between people who know each other, whether family members, friends or romantic partners, she says.
"I remember some youth workers saying, 'Well, it doesn't surprise me that he killed somebody because he didn't care anything about himself, so why would he care anything about anybody else?'" Prothrow-Stith says. "If you think about that, not caring anything about yourself is a symptom of depression. It's a symptom of a clinical illness and should be explored that way."
What preventing gun violence could look like
How would prevention work from a public health perspective? Prothrow-Stith uses the analogy of cigarette smoking and lung cancer.
First, there's primary prevention, which involves informing the general public of the consequences of smoking. The second phase is helping smokers quit, and the third is treatment for those who have lung cancer.
When it comes to gun violence, Prothrow-Stith says the primary phase should be raising awareness and trying to increase safety.
The secondary phase is about understanding the risk factors. "How do we help children who are hurt, either because they're victims of violence or they're witnessing violence, especially domestic violence or gang violence, on a regular basis?" she asks. "How do we help them heal from the anger, the guilt, the pain, but also give them the strategies to move forward?"
Programs like "Big Brothers Big Sisters" are a great example of a secondary intervention because they give kids distractions, purpose and opportunities. Don't underestimate the power of staying busy, Prothrow-Stith adds.
She shares the story of a high school student who, when asked how he stayed out of trouble, said he played football even though he didn't especially like it. Sports gave him an excuse to stay late and bail out of late-night social events as needed.
"He had developed his own strategies for dealing with the peer pressure," she says. "Those are the things that are very, very important for kids 'in the thick', if you will."
Focus on what works: an assault weapons ban
Many people are used to thinking about guns as a political issue rather than a public health issue. But Prothrow-Stith says a more productive way to talk about it would be to start where the U.S. has seen success in the past: in banning assault weapons from 1994 to 2004.
Studies have shown a decrease in gun massacre deaths during the decade the federal ban was in place — and an increase after it expired, which Prothrow-Stith attributes to the gun industry strategically "flood[ing] the market" with assault weapons.
There are many more deaths in mass shootings when high-powered assault weapons are available, she adds.
"They are like the movies and the sequel where more people get killed in the sequel than in the first movie with these assault weapons, weapons of war," she says. "We are seeing more and more people killed with each episode."
Practically speaking, guns are here to stay in the U.S., Prothrow-Stith says.
"But we don't need assault weapons," she adds. "And I think we just zero in on that argument. And I think that's a matter of time."
Back to the cigarette analogy. Prothrow-Stith remembers that smoking was ubiquitous and glamorous when she was a kid, and that it took roughly half a century after the first report on its health effects for the public understanding to follow.
She is confident that the U.S. will have the same transformation with guns. "It is time again to treat this epidemic, reduce our rates and stay with it," she says. "We've done it before. We can do it again ... just make our children safer."
Ben Abrams produced and Olivia Hampton edited the audio version of this interview. contributed to this story
https://www.mainepublic.org/npr-news/npr-
