Senator Bernie Sanders wants to implement Medicare for all. This isn't a new idea. But it is the first time in a while that this idea has been advocated so explicitly by a serious presidential contender. So it's worth asking: would this plan be a good one if implemented?
"Should I support a plan that will do more to provide opportunity for everyone, or should I just worry about myself?"
This of course hinges on what we mean by good. If our goal is to ensure more people have access to health care, to provide health insurance for an even larger segment of the population, this plan would accomplish that. The Affordable Care Act (ACA) has already lowered the number of uninsured in the U.S. by about a third, from about 17% to about 11%. But it’s not clear that the ACA will lead to substantially more coverage, which means 1 in 10 people would still lack health insurance. And so, Senator Sanders plan would shift from a series of whac-a-mole market regulations, to a plan to cover everyone. Because health can have such a profound effect on everything from employability to well-being, I’m inclined to favor a plan that provides health care coverage for everyone. But, of course, it’s not so simple as just providing coverage for everyone.
When we consider Medicare for all, we are not considering it from the starting point where no one has any coverage. We are considering it from an existing healthcare system, an existing set of coverage practices and patterns. The question for us on the social level: does Medicare for all produce a better set of practices and patterns than we currently have. Of course, all changes in policy make some people better off and some people worse off. Just because I, or anyone else, is made worse off doesn’t make it a bad policy.
I do not have time in this short column to address all the broader social questions we might ask. Instead, I will look at the question of Medicare for all as you might. As simply a question of whether I should favor Medicare for all given what it will mean for me.
On the individual level, I have to say that the plan does not appeal to my self-interest, or at least not very strongly. Based on the details of Senator Sanders’ proposal and the current structure of Medicare, switching from my current plan to Medicare might actually cost me more money out of pocket. There are several reasons for this. First, Senator Sander’s plan pays for the Medicare expansion, in part, through a 2.2% increase in my income tax. This is very close to the percentage of my paycheck that goes to pay for my insurance premium right now. However, the increase in income tax also affects my wife’s income. Just based on the income tax increase, we will be paying the same or slightly more out of pocket. And then, there’s the fact that Medicare Part B has a premium, and that it requires supplemental insurance to cover prescriptions. I happen to have a family that has a number of medications that are taken on a routine basis, so on top of the income tax, I would by paying for premiums to cover our medications. Short of some drastic change to the current premium structure for Medicare, we would almost certainly be paying more in premiums than we are now.
And then there is the deductible. If deductibles stay at current levels, our outpatient deductible would drop precipitously from our current high-deductible plan. Our inpatient deductible would likely be higher. Which means that whether or not the deductible is economically advantageous for us will hinge on the the kind of medical year we have.
And then there’s the medications. I’ve already mentioned the premiums for the insurance to cover medication, but my responsibility for the costs of the medications themselves will hinge on the supplemental plan that I buy. These supplemental plans are purchased from private insurance companies, and so it will depend on the type of plan I’m able to purchase. Unless Medicare is able to set the prices for medications, something it is currently legally prohibited from doing, I’m dubious on the prospect that I’ll be paying less for my family’s medications.
On the whole, it appears that I will be economically worse off under Medicare for all, as proposed by Senator Sanders. Of course, this assumes that my wife and I will keep our jobs and our income will not decline. If our income does decline, or my employer begins paying less of our premium, or stops offering coverage for spouses, that would no longer be the case. The harder it would be for me to purchase healthcare, the more Senator Sanders’ plan would help. In short, Senator Sanders plan helps those in need the most.
And so we have a classic moral conundrum. On the one hand, Senator Sanders plan appears to work against my self-interest in my current position. On the other hand, Senator Sanders plan would provide healthcare coverage for everyone. Should I support a plan that will do more to provide opportunity for everyone, or should I just worry about myself?
Abraham Schwab is an associate professor of philosophy and a medical ethicist at IPFW.
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