At the minimalist end of the Medicare for all spectrum is an approach known as “buy-in.” Under this plan, Medicare becomes a safety net for Americans who cannot otherwise get health insurance. One variant would allow 50-to-64-year-old Americans to pay premiums to buy into Medicare. Another flavor offers Medicare enrollment as a public option on insurance exchanges to fill the gaps in counties that don’t have enough private insurers. This type of buy-in is, frankly, a trivial plan. In a country of 325 million people, it addresses a problem of affordable health coverage for a small percentage of them. It doesn’t make health care more affordable for the 175 million Americans with private health insurance. A Medicare buy-in for all isn’t necessarily a bad idea, but it won’t energize voters, much less solve the nation’s most pressing health-care challenges.
Between Bernie Sanders and a buy-in are two more practical and politically appealing plans. One is Medicare for America, a proposal drafted by the Center for American Progress. (Full disclosure: I helped design it. I’ve also received speaking fees from groups representing insurers, hospitals, doctors, and employers.) Now before Congress in a bill by Democratic Representatives Rosa DeLauro of Connecticut and Jan Schakowsky of Illinois, this plan creates two systems—one driven by Medicare and another run by private insurance. Employers could keep offering private insurance as a fringe benefit. However, all other Americans—those with Medicaid, individual insurance, and the uninsured—would be automatically enrolled in an expanded version of Medicare. Workers who do not like their employer’s insurance could switch over to Medicare. The new Medicare would have more generous benefits, and co-pays would be on a sliding scale, with households earning under roughly $50,000 paying nothing.
Read: The missing pieces of Medicare for all
Similar to Medicare for America is a fourth approach, which could be called Medicare Advantage for all. This plan builds on the wildly popular Medicare Part C, also known as Medicare Advantage, in which people choose between a managed-care plan offered by private insurers and the traditional fee-for-service Medicare. Employers could either continue to offer private insurance or pay most of the premium of a Medicare Advantage plan chosen by their workers.
By allowing businesses to continue to offer private insurance and allowing insurers to compete in Medicare Part C, these proposals expand coverage—and the government’s role in health insurance—without threatening private insurance companies with extinction. In fact, a number of insurers might see an opportunity under Medicare Advantage for all to enroll new customers.
There are also good policy rationales to preserve a role for private insurers. While progressives often claim these companies do nothing for the health-care system but add paperwork and extract profits, this view is anything but universal. Medicare Advantage plans offered by private insurers currently enroll about a third of seniors and are the fastest-growing part of Medicare. The evidence—only 2 percent switch back to regular Medicare— suggests that seniors like these plans and, by implication, the private insurers that offer them. In addition, having multiple payers adds competition, which can improve performance and prevent the government’s health plan from ossifying. The health systems of the Netherlands, Germany, and Switzerland all include multiple competing private insurers and sickness funds.