By David Orentlicher
Should the United States achieve universal access to health care by adopting a single-payer, Medicare-for-All kind of system? Or should we build on the Affordable Care Act (ACA) and not disrupt the health care coverage of the 160 million Americans who have private health insurance?
Both reforms rely on important arguments about affordability, feasibility, and consumer choice. But there is one key reason to favor a single-payer system over an expansion of our current system. Experience with public benefit programs in the United States tells us that such programs thrive only when they serve all Americans.
Expanding ACA means maintaining private, employer-based insurance for most people under the age of 65, with government subsidies for those who do not receive coverage through their job and are too poor to afford the costs of coverage on their own. Most of the subsidies will flow through the Medicaid program, while other dollars will help pay for health insurance purchased on the ACA insurance exchanges. But if the subsidies go primarily to the poor, they likely will not be adequate to meet the needs of their recipients.
When governmental programs in the United States serve only lower-income Americans, they generally do not generate sufficient political support to ensure appropriate funding. For the most part, people with political influence will not back adequate funding for programs when they pay for the programs but do not benefit directly from them. Thus, for example, programs like Social Security and Medicare that serve recipients at all income levels are far more successful than programs like Medicaid that are targeted to the indigent.
The inadequacy of public benefit programs serving the poor is a phenomenon not only with health care programs but also with other public benefit programs. The food stamps program is able to stave off malnutrition for the most part, but many poor families suffer from food “insecurity,” and the level of food stamp benefits is not sufficient to cover the costs of a healthy diet. Fresh fruits and vegetables, for example, can easily overwhelm the grocery budget of a food stamp recipient. Similarly, housing subsidies for the indigent have not been adequate to reach all those who need a home, and many Americans have to rely on families, friends, or homeless shelters for a place to reside.
Programs targeted at the poor face other challenges. Many qualified persons are unaware of their eligibility or find it difficult to navigate the application process. Targeted benefit programs have to screen applicants for eligibility, and the screening process can be daunting, especially for poorly educated persons. Universal programs do not need to screen applicants, and thus have much simpler application processes.
Each path to reform presents a mix of advantages and disadvantages. On the question of sustainability over time, single-payer offers the most promise. Indeed, we’ve already seen repeated efforts—some successful—to undo ACA’s provisions for ensuring access to coverage. On the other hand, after more than 50 years, Medicare continues to provide a reliable source of coverage for seniors.