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50 is the New 65: the Perennial Debate on Medicare Expansion Meets the 2020 Candidates

“Everybody who allows that phrase to escape their lips has a responsibility to explain how you’re actually supposed to get from here to there,” pointedly remarked Mayor Peter Buttigieg as applause broke out from the audience. It was a striking reply—one of many made-for-TV soundbites from June’s Democratic presidential candidate debates. Others on stage soon followed suit, joining Buttigieg in berating sitting U.S. Senators in front of millions of Americans. 

What was “that phrase,” and why was Buttigieg upset over its mere mention? What could be so divisive that amiable senators on stage reduced themselves to a shouting match over it?

It was “Medicare for All.” 

Health insurance, as it turned out, sparked several spirited exchanges throughout the night. From the very first question of the night, fielded by Senator Bernie Sanders (I-VT), to the concluding remarks from the candidates, several markedly different views surfaced on expanding health coverage to more Americans—a key tenet of the party’s current platform.  

Medicare for All is a relatively new moniker for a familiar concept: a free, nationalized health system that extrudes coverage to all Americans, not just those over 65.  

Since its inception over 50 years ago, Medicare has expanded into one of the largest state-run health insurance programs in the world. At its heart, it provides the same basic benefits as it has since 1967, covering costs for hospital stays, outpatient medical tests, skilled nursing care, and more. Medicare is subsidized by U.S. taxpayers, but its enrollees still face some out-of-pocket costs in the form of deductibles and certain premiums; this means coverage only kicks in after medical costs exceed a certain level. The complexities of Medicare administration resulted in the creation of a dedicated government agency, the Centers for Medicare and Medicaid Services (CMS), to oversee it. 

Though routinely challenged and criticized in political spheres, Medicare remains deeply popular with Americans, and recent reforms have enjoyed stable bipartisan support. For millions of elderly Americans, it is still the only option for receiving any kind of health insurance. 

But Medicare for All represents a completely different program from Medicare, and those two extra words make all the difference. Medicare for All exists in the form of various different proposals which share a common goal: insuring all Americans regardless of age, income, and pre-existing condition. 

Again, nationalized health insurance is hardly a new concept. Proposals have come and gone, as several Western countries have moved to nationalize their own health systems. But to this day, the U.S. relies heavily on the private insurance industry; 67.2% of insured Americans have private plans as determined by the U.S. Census Bureau. Since the passage of the Affordable Care Act (ACA), and its subsequent repeal attempts, the debate on health care has resurfaced. 

Leaving aside a conversation on the benefits and drawbacks of nationalized health care for another day, the next big question is one of timing: why do candidates who support Medicare for All think they have a better shot of enacting such a momentous program now more than ever? 

For one, their revitalized efforts coincide with a broader leftward shift of the Democratic Party. After Sanders brought them to the fore in his 2016 candidacy, several progressive positions, including a long-standing call for nationalized health care, have been adopted by a number of candidates. Even his push to end the entire private insurance industry, potentially one of the most radically transformative changes to American health care, finds mainstream supporters in Senator Elizabeth Warren (D-MA) and Senator Kamala Harris (D-CA).  

At the same time, moderate Democrats have increased their appetite for health care expansion. Repeated challenges to the ACA, the last major effort to expand coverage to uninsured Americans, failed to substantially affect the law; along with its gradually buoying popularity, the ACA’s durability is a promising sign for Democrats keen on further reform. 

Touting new stepping stone plans, moderate Senate Democrats have been testing the waters with various Medicare expansion proposals. Among those gaining the most traction are proposals to create Medicare Buy-In programs.

Medicare Buy-Ins blur the line between public and private insurance. Essentially, a Buy-In allows a person to purchase a Medicare plan from the government and pay for it out of pocket. Though functionally the same as private insurance, Buy-Ins have several unique advantages. For one, insurance is provided through Medicare, so enrollees would benefit from existing subsidies and tax credits. Proponents also argue that the CMS does not face the same pressure to generate profit as the private insurance industry inherently does. 

Affordable, accessible, and competitive, Medicare Buy-In proposals are attractive to the general public, with over three quarters of respondents supporting the idea in a January poll. Citing this, a Buy-In bill called “Medicare at 50” proposed by Senator Debbie Stabenow (D-MI) is generating increased media attention as it wades through Congress. 

Medicare at 50 lowers the program’s qualifying age by 15 years. This would pave the way for millions of Americans to buy affordable coverage at a time when early retirements and age-related ailments are pressing concerns. Older Americans, particularly those from low-income families, could benefit from the option of having competitively priced health insurance.                                

If Medicare Buy-Ins change the healthcare landscape, Medicare for All envisions a new landscape altogether. A range of options promotes constructive debate, but it is less than convenient for those vying for the White House. 

On the debate stage, some Democratic candidates appeared wary of the cost in public support that comes with backing Medicare for All. Of the nine other Democrats on stage with her, Harris was joined only by Sanders when the debate moderators asked which candidates supported abolishing private insurance. Later the next day, Harris retreated, indicating her support for private insurance. 

Buttigieg, who so emphatically criticized Medicare for All that same night, stated his support for Medicare Buy-Ins. But the mayor seemed apprehensive about shutting the door entirely on basic coverage, pining for a “natural glide into the single payer environment.” Others appear content camping in both parties; Senator Cory Booker (D-NJ) supports Medicare at 50 and Medicare for All, denying the dichotomy between the two proposals that share purpose but differ starkly in their mechanics. 

For now, it seems the candidates seeking the Democratic nomination are tangled in a delicate dance of supporting assertive liberal proposals while staying mindful of the realities of partisan politics. As the field of candidates will winnow with time, the ones remaining must pin down their vision for Medicare or risk sinking their campaign without it.