Medicare for All has been a key discussion in healthcare policy in the United States. As a result, this brief conducts an in-depth analysis of the public perception of US healthcare policy, and legislative suggestions for Medicare for All, which have the potential to help US citizens. Accessibility  is a large question in the context of healthcare because it is currently too expensive for many Americans. As a result, one of the most important healthcare considerations in recent years is associated with increasing healthcare accessibility, in the form of Medicare for All policies. Thus, some policies are analyzed with their unique ability to help the United States and its citizens.

Executive Summary

This brief will cover the public perception of Medicare for All in the United States and current policy considerations and developments with federal elections on the horizon. Some key pieces of our analysis include analyzing the historical context of Medicare for All and an in-depth overview of the current actions the federal government is taking, public popularity, and criticism.

Overview

A. Historical Context

As we rapidly approach the 60th anniversary of Medicare, it becomes critical to analyze its history and subsequent impact on the healthcare system. The 1965 plan signed into law by President Lyndon B. Johnson created two federal programs: Medicare and Medicaid, providing financial assistance to the elderly and the economically disadvantaged respectively.¹ While both programs started as standard health insurance plans for those who could not afford or obtain existing healthcare plans, they have evolved into critical components of today’s broader healthcare system. 

Through 11 unique presidencies, Medicare has experienced a plethora of structural and administrative changes that have dramatically altered its scope and significance. Critical changes include President Nixon’s 1972 legislation, expanding Medicare to cover individuals under 65 experiencing long-term disabilities and specific chronic diseases. Furthermore, in 1988, Congress attempted to institute a cap on Medicare’s total out-of-pocket expenditure, but the law only lasted for one year and there still is no spending limit on the program.² However, the biggest changes were headlined by the Obama administration, whose Patient Protection and Affordable Care Act (PPACA, ACA, Obamacare) redesigned the funding system for Medicare by transferring payments toward growing MA. Even so, the primary focus of the ACA was to introduce a new federal healthcare plan that improved benefits for individuals who could not access Medicare and Medicaid.³

B. Contemporary Context

Now, Medicare is grouped into four distinct categories, Part A through Part D. Part A and B are considered “original Medicare,” and they provide hospital insurance (primarily inpatient care costs) and medical insurance (primarily outpatient care costs) respectively. Part D insurance is a separate plan to improve access to and affordability of pharmacy drugs. Part C, known as Medicare Advantage (MA), is a combination of parts A, B, and D.⁴ MA requires patients to use doctors and pharmacists that are within their specific MA network; there are over 8,600 highly specialized MA plans heading into 2024. Moreover, MA plans frequently incorporate additional coverage including dental and vision care, both of which are not included in original Medicare. These benefits have steadily increased in usage over the past years, and now account for a significant component of US healthcare expenditures. As of March, over 65.7 million Americans are enrolled in Medicare,⁶ accounting for over one-fifth of all national health spending in 2021.⁷  

Policy Problem

A. Stakeholders

While Medicare and Medicaid act as a safety net for the elderly and economically disadvantaged, several segments of the US population still are underinsured/uninsured. Because federal legislation permits states to build upon the Medicare/Medicaid framework, they have the freedom and ability to develop additional programs to improve coverage of their residents. This manifests in a multitude of ways, including subsidized premiums, expanded eligibility, and greater competition with the private healthcare industry through the creation of state-run health plans.⁸ There are numerous states that have enacted such measures. Massachusetts leads the country in coverage rates, having extended benefits to almost 98.5% of its population.⁹ Dating to 2006, a blockbuster state-led reformation of healthcare is credited with Massachusetts’ success. Among the modifications, notable changes include expanded access and improved transparency within the industry. Massachusetts established Commonwealth Care, subsidized coverage for adults above 19 living at or below 300% of the poverty line. Additionally, the state built Commonwealth Choice, a program that improves access for employees not offered healthcare coverage by their employers. To supplement this, Massachusetts founded the Healthcare Quality and Cost Council, a body responsible for promoting transparency regarding the costs and benefits of health plans in a consumer-friendly method. The ensuing enrollment in the programs greatly exceeded expectations, highlighting the opportunity for such state-driven action to improve coverage.¹⁰ Other notables include New York and Minnesota, both of whom enacted similar “Basic Health Plans” to extend state-regulated insurance to individuals who are just above the Medicaid income maximum but still struggle to afford private alternatives.¹¹ Finally, states similar to Colorado have insured undocumented immigrants; the Centennial State has provided access to 10,000 undocumented immigrants in 2023 with plans to expand in the future.¹² 

B. Public Popularity

Now more than ever, Medicare has become compatible with healthcare access and security for  millions of people in America, specifically the elderly. One of the primal reasons the public perceives Medicare as, ‘not so bad,’ is its commitment to providing universal coverage. The program ensures continuity of coverage regardless of changes in employment, family status, income, state of residence, or age.¹³ This assurance is particularly relevant to individuals contemplating career shifts. This continuity stands in complete contrast to other healthcare systems where individuals may face complications or changes in coverage due to various life events. Furthermore, the single-payer plan introduces the elimination of premiums and out-of-pocket expenses. This significant change ensures that individuals who face serious health issues are relieved of the financial burden associated with out-of-pocket charges. Additionally, the plan addresses the issue of surprise billing from healthcare providers, providing a more predictable and transparent healthcare financial landscape for all beneficiaries. 

Medicare's commitment to providing the same coverage to all U.S. residents contributes to a sense of equity in healthcare. According to the Health Reform Monitoring Survey, “Young adults, nonwhite and Hispanic adults, those with low incomes, and those without private health insurance are more likely to support than oppose Medicare for All.”¹⁴ The insurance program ensures that reducing racial/ethnic and income-related differences is made possible in large part by the program. Medicare serves as a key resource for advancing healthcare equity since it guarantees that all individuals have access to the same set of benefits. Which leads to improved access to care for everyone. This is important for people with low income who may have trouble getting healthcare. Even for those with greater income, access is expanded by including benefits like dental, vision, and long-term services and support. 

The public also favors Medicare due to its reform which reduces the confusion of complex paperwork and moves towards the ease of interaction with the healthcare system. Medicare's administrative simplification can result in a healthcare system that is more effective, affordable, and user-friendly. It seeks to improve beneficiaries' experience overall, lessen the administrative load on healthcare professionals, and guarantee that resources are used efficiently to satisfy the population's health care demands.

In summary, Medicare's enduring appeal to Americans stems from its dedication to providing universal coverage, equity, affordability, better access to care, and efficient administration. The program is positioned as a crucial part of the American healthcare system because of its ability to resolve inequities, guarantee coverage continuity, and apply cost-containment measures. Understanding the elements that lead to Medicare's favorable reputation is crucial for creating beneficial and knowledgeable discussions about the future of healthcare in the US as discussions regarding healthcare reform continue.

C. Criticism

Since its introduction in 1965, Medicare has been a target of reform for many Americans due to its limited availability reserved majorly for senior citizens of ages 65 and older. The lack of accessibility for most classes of income and ages has led to a system of privatized medicare in the United States, which has since proven to be unaffordable in many cases.¹⁵ In the scope of Medicare for All, cosponsors and supporters of the bill stand on the basis of the limited accessibility of the current American healthcare system, calling for a state-provided, single-payer insurance program that aligns similarly with Canadian Medicare.¹⁶ The largest criticisms against a Medicare for All system, however, still remains to be the recurring controversy of funding as well as emerging questions on the medical effectiveness of a single-payer system compared to the current U.S. healthcare system.

To understand the perception of Medicare for All, it is important to note the history of flaws in the current U.S. system. Among the 42,000 questions on Medicare received in 2022 by the nonprofit organization Medicare Rights Center, the widest concern in today’s system remains to be challenges to accessing and affording treatment and medication, which has been further intensified since the COVID-19 outbreak.¹⁷ Employment changes and mass layoffs following the pandemic, compounded with rising health concerns of contracting the virus, have fueled a call for including low-income citizens in the demographic group guaranteed medicare under the government-provided system. Without any such promises in place, however, most American households turn to private insurance plans that average $24,000 in yearly payments for standard family coverage.¹⁸ In comparison to the median yearly income of $74,580, private healthcare can often account for almost 32% of a working individual’s annual earnings.¹⁹ However, as the U.S. has a wide margin of middle-class income between $47,000 and $140,000, the ratio of healthcare coverage can be over 50% of income.²⁰ Along with this, if certain families require special accommodations or treatments or generally wish to seek a broader coverage of healthcare, programs become costly to a degree where lifestyle is unsustainable. Considering housing costs, market basket expenses, taxes, and other payments, public perception has shifted favorably towards an affordable Medicare for All system.²¹

Despite widespread public support of Medicare for All, the bill has faced major opposition in every congressional committee it was introduced to, questioned with criticism on effectiveness and, ironically, affordability. On the note of effectiveness, experts such as Dr. Patrice Harris of the American Medical Association reported that 90% of the American population already has access to healthcare, and that an effort to establish a single-payer system–in which the government will be providing all healthcare related services–to extend accessibility to the remaining 10% without access to treatment will cause immense socio-economic repercussions.²² Some estimates project that 2 million jobs will be lost in the process of essentially eliminating the private sector of healthcare, while guarantees of drug costs decreasing and treatment becoming more broadly accessible are unclear. The Heritage Foundation also notes that under a single-payer system like Medicare for All, over 70% of Americans would be “financially worse off” than in the current system.²³ The organization also warns of a significant tax increase should a Medicare for All bill be passed, with almost a projected 21.2% rise in taxes for all working class Americans. These financial possibilities have ultimately shifted enough politicians and American citizens’ viewpoints to retract support for Medicare for All. As taxes have long been a contentious topic, a significant raise on the working class parallels the existing concerns with affording privatized healthcare; many citizens hold viewpoints that their monetary outflow will be equals, only their payments will be headed to a more unstable, unproven and new governmental program. As many Americans–despite the concerns of affordability–are already enrolled in healthcare, public perception highlights the idea that a government-provided system will only benefit some unsupported citizens at the expense of many others who deem the program unnecessary.

Election Changes

Each presidential election represents a chance for monumental change. This upcoming election comes at a time when the nation is battling with rising costs, disparity of access to healthcare, and the general impact of ongoing healthcare emergencies. The goal of this brief is to analyze how different health care policies, from republicans and democrats, may influence the US healthcare system. 

The democratic agenda is centered around Medicaid and the Affordable Care Act (ACA). There are still 10 remaining states that have not expanded medicaid to all lower income individuals under the ACA.²⁴ Two of these states (WI and GA) are typically democratic; regardless the decision has led to 1.3 million uninsured people with incomes below the current federal poverty level ($14,580 for a single person).²⁵ These ten states have placed these people in a position where they are not eligible to receive benefits from medicaid or ACA premiums subsidies (coverage gap).

Republicans generally oppose the expansion of medicare for all. Previously debated congressional republican plans would result in 63 million medicare beneficiaries 89 million medicaid beneficiaries, and 65 million social security beneficiaries potentially losing their health insurance, retirement, and/or disability benefits at risk.²⁶  Similarly, and more recently, congressional republicans proposed cuts in medicare and social security and also increases in prescription drug prices and health care premiums.²⁷  

There are a multitude  of issues that future presidential candidates will have to regulate regarding healthcare (abortion, pandemic preparedness, drug prices, health care programs, etc.), and even if these are not the focus of some presidential candidates it is important to understand their stance on these topics; as the stances that candidates take on these issues often yield general proxies of the potential political ideology of the candidate.²⁸ Determining the most likely political ideology of potential presidential candidates and their logic and ethics surrounding important legislation is crucial to preparing for elections. 

Federal Government's Stance

The federal government has played a crucial role in the implementation of Medicare, ensuring that the program was rolled out effectively. Over the years, there have been several amendments and expansions to Medicare, broadening its scope and benefits: 

The Social Security Amendments of 1972 extend Medicare eligibility to people under age 65 with long-term disabilities and those with end-stage renal disease. The Tax Equity and Fiscal Responsibility Act 1982 added the Hospice Benefit and Offered Private healthcare plans. Most significantly, In 1983, the Social Security Amendments introduced the prospective payment system for inpatient hospital services. Under this system, Medicare provides hospitals with a predetermined, fixed fee for each case type. The fee is determined in advance and is based on the average relative cost of treating that specific case type across hospitals nationwide, rather than relying on individual hospital costs.

More recently, in 2010, Barack Obama signed the Affordable Care Act (ACA), which strengthens Medicare coverage of preventive care, reduces beneficiary liability for prescription drug costs, institutes reforms of many payment and delivery systems, and creates the Center for Medicare and Medicaid Innovation.

The federal government's stance on Medicare has evolved over the years, from the passage of the landmark legislation in 1965 to ongoing efforts to adapt and refine the program to meet the changing healthcare needs of the American population.

‍

Acknowledgments

The Institute for Youth in Policy wishes to acknowledge Michelle Liou, Joy Park, Nolan Ezzet and other contributors for developing and maintaining the Policy Department within the Institute.

Works Cited:

"History," US Centers for Medicaid and Medicaid Services, last modified September 6, 2023, accessed November 29, 2023, https://www.cms.gov/about-cms/who-we-are/history#:~:text=for%2050%20years-,On%20July%2030%2C%201965%2C%20President%20Lyndon%20B. Health Insurance.Org, "A Brief History of Medicare in America," Medicare Resources Organization, accessed November 29, 2023, https://www.medicareresources.org/basic-medicare-information/brief-history-of-medicare/.
Lena Borrelli, "What Is The Affordable Care Act (Obamacare)?," ed. Jason Metz, Forbes, last modified November 15, 2023, accessed November 29, 2023, https://www.forbes.com/advisor/health-insurance/what-is-obamacare/#:~:text=Known%20colloquially%20as%20Obamacare%2C%20the,high%20premiums%20exceed%20their%20budgets. U.S. Centers for Medicare and Medicaid Services, "Parts of Medicare," Medicare.gov, accessed November 29, 2023, https://www.medicare.gov/basics/get-started-with-medicare/medicare-basics/parts-of-medicare.Tamrah Harris, "Best Medicare Advantage Plans for 2024," ed. Alena Hall and Jessica Lester, Forbes, last modified November 29, 2023, accessed November 29, 2023, https://www.forbes.com/health/medicare/best-medicare-advantage-providers/#:~:text=But%20picking%20the%20right%20plan,highly%20personalized%20to%20the%20individual. "Medicare Enrollment Numbers," Center for Medicare Advocacy, last modified June 29, 2023, accessed November 29, 2023, https://medicareadvocacy.org/medicare-enrollment-numbers/. Juliette Cubanski and Tricia Neuman, "What to Know about Medicare Spending and Financing," KFF, last modified January 19, 2023, accessed November 29, 2023, https://www.kff.org/medicare/issue-brief/what-to-know-about-medicare-spending-and-financing/#:~:text=Medicare%20plays%20a%20major%20role,drug%20sales%20(Figure%201). Dylan Scott, "The US Doesn't Have Universal Health Care — but These States (Almost) Do," Vox, last modified November 26, 2023, accessed November 29, 2023, https://www.vox.com/policy/23972827/us-aca-enrollment-universal-health-insurance.Dylan Scott, "The US Doesn't Have Universal Health Care — but These States (Almost) Do," Vox, last modified November 26, 2023, accessed November 29, 2023, https://www.vox.com/policy/23972827/us-aca-enrollment-universal-health-insurance."Massachusetts Health Care Reform--On Second Anniversary of Passage, What Progress Has Been Made?," The Commonwealth Fund, accessed November 29, 2023, https://www.commonwealthfund.org/publications/newsletter-article/massachusetts-health-care-reform-second-anniversary-passage-what."Massachusetts Health Care Reform--On Second Anniversary of Passage, What Progress Has Been Made?," The Commonwealth Fund, accessed November 29, 2023, https://www.commonwealthfund.org/publications/newsletter-article/massachusetts-health-care-reform-second-anniversary-passage-what.R. Vincent Pohl, Cara Orfield, and Kara Nester, "How Colorado Provided Health Insurance to Nearly 10,000 Immigrants with Undocumented Status," Mathematica, last modified July 25, 2023, accessed November 29, 2023, https://www.mathematica.org/blogs/how-colorado-provided-almost-10000-immigrants-with-undocumented-status-with-health-insurance.
Blumberg, L. J., & Holahan, J. (2019, March). The Pros and cons of single-payer health plans - Urban Institute. Health Policy Center. https://www.urban.org/sites/default/files/publication/99918/pros_and_cons_of_a_single-payer_plan.pdf. Khazan, O. (2019, November 21). The stunning rise of single-payer health care. The Atlantic. https://www.theatlantic.com/health/archive/2019/11/why-people-support-medicare-all/602413/. “Why Are Americans Paying More for Healthcare?” Peter G. Peterson Foundation, 14 July 2023, https://www.pgpf.org/blog/2023/07/why-are-americans-paying-more-for-healthcare.“US vs. Canadian Healthcare: What is The Difference?” Ross University School of Medicine, 11 May 2021, https://medical.rossu.edu/about/blog/us-vs-canadian-healthcare. Copeland, Lindsey. “Medicare Rights Annual Trends Report Outlines Key Challenges Facing People with Medicare.” Medicare Rights Center, 26 May 2022, https://www.medicarerights.org/medicare-watch/2022/05/26/medicare-rights-annual-trends-report-outlines-key-challenges-facing-people-with-medicare. “Section 1: Cost of Health Insurance - 10240.” KFF, 18 October 2023, https://www.kff.org/report-section/ehbs-2023-section-1-cost-of-health-insurance/. Guzman, Gloria, and Melissa Kollar. “Income in the United States: 2022.” Census Bureau, 12 September 2023, https://www.census.gov/library/publications/2023/demo/p60-279.html. Cortes, Gabriel. “Middle class income in major U.S. cities.” CNBC, 2 January 2023, https://www.cnbc.com/2023/01/02/middle-class-income-in-major-us-cities.html. Jones, Bradley. “More Americans now favor single payer health coverage than in 2019.” Pew Research Center, 29 September 2020, https://www.pewresearch.org/short-reads/2020/09/29/increasing-share-of-americans-favor-a-single-government-program-to-provide-health-care-coverage/. Johnson, Akilah. “Medicare-for-All Is Not Medicare, and Not Really for All. So What Does It Actually Mean?” ProPublica, 6 September 2019, https://www.propublica.org/article/medicare-for-all-is-not-medicare-and-not-really-for-all-so-what-does-it-actually-mean. “How “Medicare for All” Harms Working Americans.” The Heritage Foundation, 19 November 2019, https://www.heritage.org/health-care-reform/report/how-medicare-all-harms-working-americans. “Status of State Medicaid Expansion Decisions: Interactive Map.” KFF, 1 December 2023, https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/. “Health Care Issues in the Early Stages of the Presidential 2024 Election.” JAMA Health Forum, 18 July 2023, https://jamanetwork.com/journals/jama-health-forum/fullarticle/2807689. “FACT SHEET: By The Numbers: Millions of Americans Would Lose Health Care Coverage, Benefits, and Protections Under Congressional Republicans’ Plans.” The White House, 1 November 2022, https://www.whitehouse.gov/briefing-room/statements-releases/2022/11/01/fact-sheet-by-the-numbers-millions-of-americans-would-lose-health-care-coverage-benefits-and-protections-under-congressional-republicans-plans/. “FACT SHEET: Congressional Republicans’ Many Proposals to Cut Social Security and Medicare, and Increase Prescription Drug Prices and Health Care Premiums.” The White House, 9 February 2023, https://www.whitehouse.gov/briefing-room/statements-releases/2023/02/09/fact-sheet-congressional-republicans-many-proposals-to-cut-social-security-and-medicare-and-increase-prescription-drug-prices-and-health-care-premiums/. “Health Care Issues in the Early Stages of the Presidential 2024 Election.” JAMA Health Forum, 18 July 2023, https://jamanetwork.com/journals/jama-health-forum/fullarticle/2807689.