"Medicare for all who want it" raises the kludge question

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Given the "triple veto" imposed on legislators by the U.S. Constitution, U.S. policy is doomed to kludge. Policy design that's logical and internally coherent often can't survive the legislative process.

On the healthcare front, it's been evident since the early aughts that the logical, feasible, appropriately incremental way to improve access and control costs without throwing multiple healthcare industries into chaos and swiftly transitioning 150 million people out of employer-sponsored insurance is to offer a public plan on affordable terms to both employers and employees -- leaving employer insurance to either compete effectively or die on the vine.

Early iterations of such a "public option" included Helen Halpin's CHOICE program (2003), Rep Peter Stark's Americare bill (2006),and Jacob Hacker's Health Care for America plan (2007). All of these enabled any individual to buy in on an income-adjusted basis regardless of whether her employer offered insurance, and gave employers the option of paying into the public plan (e.g., via a payroll tax) rather than offering their own plans.  Instead we got the ACA -- with subsidy eligibility limited to those without access to employer insurance deemed "affordable" (by dubious standards), inadequate subsidies, and dependence on the whims, pricing, negotiated provider payment rates and plan designs of private insurers.

Now we're back to the future with the Medicare for America Act, introduced in late 2018 by Reps Rosa DeLauro and Jan Schakowsky and reintroduced last month. Medicare for America offers a revamped "Medicare" on affordable terms to any citizen or legally present noncitizen who opts in.

The kludge question: Does offering a truly comprehensive and affordable plan on affordable terms to anyone who wants it necessarily entail ending our existing mammoth and Byzantine public health insurance programs, Medicaid and as-currently-structured Medicare? Medicare for America's creators answered "yes."

Medicare Extra creates an all-payer system -- via a bank shot for employers

Like many "Medicare for All" or "Medicare for Most" plans that preceded it, the Center for American Progress's Medicare Extra plan, released on Feb. 22, preserves employer-sponsored insurance. Employers can opt to continue to offer their own plans, with a minimum actuarial value of 80% (near the current employer average). They can sponsor their employees' entry into Medicare Extra. Or they can leave their employees to enter the system on their own and reimburse the government.

The plan spells out two reasons for maintaining employer-sponsored insurance: keep employer dollars in the system, and minimize disruption (if you and your employer like your plan, you can keep it):

U.S. employers currently provide coverage to 152 million Americans and contribute $485 billion toward premiums each year. Surveys indicate that the majority of employees are satisfied with their employer coverage. Medicare Extra would account for this satisfaction and preserve employer financing so that the federal government does not unnecessarily absorb this enormous cost.