Medicare for all, or for anyone who wants it?

Physicians can have an outsized influence on the debate around Medicare for All versus private insurance.

When Medicare became law 64 years ago this April, many expected that it soon would be expanded to include all Americans, beyond the elderly initially covered. Much to the disappointment of progressives, more than a half-century later, Medicare remains a program only for persons ages 65 years and older and persons with disabilities.

Robert M. Ball, who worked in the Johnson administration and helped draft the legislation that became Medicare, recalled in a 1995 article in Health Affairs on the 30th anniversary of its enactment that “We all saw insurance for the elderly as a fallback position, which we advocated solely because it seemed to have the best chance politically. Although the public record contains some explicit denials, we expected Medicare to be a first step toward universal national health insurance ….”

There is a growing political movement today for enacting a Medicare for All program to replace private insurance, or at least to give everyone the choice of enrolling in a version of Medicare with better benefits and lower out-of-pocket contributions. Most of the current candidates running to be the next Democratic nominee for president have coalesced around one option or the other, betting that this will be a winning issue among its primary and caucus voters. And in the House of Representatives, which is controlled by the Democrats, several bills have been introduced to either require or give people the choice of enrolling in a public program modeled on Medicare.

Yet support for Medicare for All, or Medicare for Anyone Who Wants It, isn't just limited to the Democratic Party and its base voters. The Kaiser Family Foundation, which has been tracking public opinion on different coverage options for decades, reported in January that “Overall, about six in 10 adults favor a national health plan or Medicare-for-all plan.”

Yet, in pollster parlance, support for Medicare for All is soft, amenable to arguments that might sway opinion against it. “Public support for Medicare-for-all shifts significantly when people hear arguments about potential tax increases or delays in medical tests and treatment,” Kaiser's pollsters said.

Physicians, because they have unique credibility with the public when it comes to matters affecting health, can have an outsized influence on this debate. Will physicians and their professional associations speak out in favor of allowing or requiring people to enroll in a public program like Medicare? Or oppose it?

The New York Times reported on Feb. 23 that a coalition of industry stakeholders, called the Partnership for America's Health Care Future, has been formed “to kill ‘Medicare for all,’ an idea that is mocked publicly but is being greeted privately with increasing seriousness. Doctors, hospitals, drug companies and insurers are intent on strangling Medicare for all before it advances from an aspirational slogan to a legislative agenda item.” The American Medical Association is a member of the coalition. The coalition opposes not only a single-payer, Medicare for All system, but according to a statement on the coalition's website, any public option, saying, “Medicare for All, Medicare buy-in, single-payer or a public option … moves us toward a one-size-fits-all health care system that is wrong for America.”

Robert Pear, the New York Times reporter who wrote the Feb. 23 story, contacted me to get ACP's perspective, and he accurately included the following in his story based on our conversation: “But the coalition does not speak for all health care providers. The American College of Physicians, the largest medical specialty organization in the country, has supported a Medicare buy-in for people 55 to 64. And ‘during the whole debate over the Affordable Care Act, we supported having a public option in the individual insurance market in every state,’ said Robert B. Doherty, senior vice president of the college, which represents 154,000 doctors who specialize in internal medicine.”

Indeed, at the direction of our Board of Regents, ACP is currently evaluating ways to cover everyone while reducing costs and administrative complexity. We have not concluded what approaches we will call for. Yet it is pretty evident that it would be hard if not impossible to provide all Americans with affordable coverage that is not dependent on place of employment, residence, or health status (universal coverage), without making publicly financed coverage at least available to everyone.

And, while we believe universal coverage is an essential goal, ACP will include in our recommendations ways to ensure that physicians are fairly compensated for their services, billing is made easier and administrative costs reduced, and patients are able to choose their physicians and have access to the care they need. We anticipate that ACP will be ready to release its recommendations before the end of the year.

It's not necessarily a bad thing for physician membership organizations to have different views on how best to ensure that Americans have access to affordable coverage, since physicians themselves are a diverse lot. Each physician membership society is obligated to advocate based on the policies established by its members. In ACP's case, our policies have long supported universal coverage, including options for people to enroll in publicly funded coverage; we are committed to building on those policies to issue proposals later this year to achieve truly universal coverage for everyone.

As we do this, we must counter the narrative that “doctors” as a whole oppose making public insurance available to everyone, because they don't. And, by making our views known, we hope to influence the debate so that the country commits to the next step toward universal national health insurance, as Medicare's architects intended more than half a century ago.