PHOENIX—“Medicare for all” has become a rallying cry among Democrats who support single-payer healthcare.
But “Medicaid for all” might be a more feasible and effective single-payer system, said American University law professor Lindsay Wiley at the Public Health Law Conference on Saturday.
For Medicare-for-all to become a reality, a majority of the House and a supermajority of the Senate would need to support it, as would the president. With partisanship running high, that’s not likely to happen. Trump's top health officials have preemptively criticized the movement, arguing that such a policy would lead to the program's demise.
Medicaid-for-all, on the other hand, could be achieved at the state level via ballot initiative or a simple majority in the legislature. It would need the federal government’s blessing, but not necessarily federal legislation.
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"The idea that we would have national-level single payer would be pretty radical,” Wiley said, given that Medicare currently covers “about as many people as any single-payer healthcare system in the world."
Medicaid-for-all, though more feasible, is just as laudable, he argued. Not only would it improve access to care, coordination of care and health equity—it would also be cost-effective compared to the current system.
These public health and healthcare goals are inextricably linked.
The current system doesn't require private insurers to have "enough skin in the game," Wiley added. Patients frequently switch providers and insurers lack incentives to prevent churn.
But if payers control safety net investment and care about housing market regulation, it could have broader public health benefits, she said.
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Of course, that type of proposal is only viable in liberal states like Hawaii, Vermont or California. Although some of the worst health outcomes and disparities exist in red states, it’s “hard to grapple with” the future of Medicaid in those locations right now, Wiley said.
Under the Trump administration, CMS has sought to impose work requirements and reduce the number of people in the Medicaid program. It's unlikely that officials would look favorably on a Medicaid-for-all proposals.
“You’re kind of counting on the providers to make expansion happen because they have money to gain from it,” Wiley said. “Can you then flip that around and say, ‘let’s repurpose a bunch of that money that’s coming in so it’s … going through the hospitals to social determinants?’ I think that’s tricky.”