How can we make high-quality, affordable health care available to everyone?

In the 2016 election, one idea came to the fore with the campaign of presidential candidate Bernie Sanders: Medicare for All. The term has become shorthand for universal health care, but it turns out that not everyone is working with the same definition. In fact, there are numerous proposals that would expand Medicare, and they have some very basic differences.

But first, what is Medicare?

Originally proposed by President Lyndon Johnson, Medicare is a government-supported health care program for older Americans. At the end of 2017, Medicare covered more than 59 million Americans, and funding for the program accounted for 15 percent of federal spending. Enrollment begins automatically at age 65 unless beneficiaries choose to opt out. Most Medicare beneficiaries have some form of supplemental coverage as well.

The program has been expanded in a few ways since it began. In 1972, for example, it began covering people with kidney failure, even those younger than 65. Now, several congressional leaders and non-profit organizations have put forward proposals that would expand Medicare even further, perhaps to cover all Americans. You can see a clear analysis and comparison of these proposals in Vox.

Authors of the Vox articles looked at eight different plans and broke them down into two basic categories. Three of the plans, including Bernie Sanders’ proposal, would eliminate private insurance and cover all Americans through government funded plans. The other five would allow all Americans to buy into government insurance (like Medicare or Medicaid) at their option, or continue to buy private insurance.

In public opinion polls, Medicare for All enjoys a high level of support – but again, voters have different ideas of what the phrase means. A poll by Axios found that 67 percent of people say they support a single-payer health care system, but of those, roughly half actually want something a bit different: a public option alongside private insurance.

There’s also basic disagreement about how much single payer coverage might cost. The Medicare buy-in bills may not require a tax increase since people would pay to join the program (unless, of course, the premiums do not cover the full cost.)

For the single-payer plans that would provide universal coverage, the bottom line is that we really don’t know the cost. The Congressional Budget Office has not scored any of these plans yet, and independent estimates vary wildly. One cost estimate by a libertarian policy center found that single payer coverage will increase government spending by $32.6 trillion over ten years.  Another group, apparently using data from the same report, argued that single payer coverage would decrease total health care spending (including consumer spending) by $2 trillion over the same period.

These results seem hard to reconcile. Cutting fees paid to providers – doctors and hospitals – to Medicare levels would save significant costs. But even with those cost reductions, shifting all health care spending onto the federal balance sheet would require major tax increases.

The trend for now, unfortunately, is to focus on what an expanded Medicare program will look like rather than what the different options might cost. Other key questions remain as well. How much will beneficiaries pay for coverage? Can they keep their supplemental plans? And what will happen to health care coverage currently provided by employers?  We’ll look into these questions in Part 2 of this series.