Elizabeth Warren has finally laid out a detailed plan for providing universal, government-funded health care to the entire country, a signature issue for her presidential campaign. That she has at last cleared up some of the questions of how she will pay for the program she’s been promising could help her in her quest for the Democratic nomination. Certainly the pledge to directly avoid tax hikes on the middle class while placing much of the $20.5 trillion cost on corporations and the ultra-wealthy will appeal to progressives.
But Warren’s plan may hurt her when it comes to competing with President Donald Trump if they face each other in 2020. Trump’s already running on a general election message on health care: rather than gamble on a pricey universal fix, expand a part of the system that many people like — especially older voters in swing states, a group crucial to any 2020 victory. Warren’s massive disruption of the health care industry might delight her base, but what swing voters will hear is: If you like your current doctor or health plan, you most likely will not be able to keep it.
Beyond the political pitfalls, talking about universal health coverage plans won’t result in any immediate change, whereas Trump’s strategy can be adopted quickly.
And beyond the political pitfalls, talking about universal health coverage plans won’t result in any immediate change, whereas Trump’s strategy can be adopted quickly and easily (in fact, many elements are already available in the current open enrollment period). As a public health and military doctor, health care isn’t just a political talking point for me and my colleagues; inaction in Washington has real impacts on the patients we care for. (Full disclosure: I am a lifelong Democrat and a voluntary, unpaid contributor to the health policy council of Warren’s chief rival, former Vice President Joe Biden; regardless, I will line up behind our eventual nominee.)
Warren and her fellow progressive Democratic candidate, Bernie Sanders, argue for a “Medicare for All” health system that provides comprehensive services free of monthly premiums and co-payments. At first blush, that sounds great to me — especially since so many of my patients are indigent and have to choose between medications and food to subsist.
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The problem is that nothing is ever truly free. In addition to the financing for the $20.5 trillion price tag on Warren’s plan, which has gotten the lion’s share of media attention, there are other — perhaps even more insidious — costs to patients under “Medicare for All”: Free may actually mean longer wait times for needed services, as it does for Canadians on their government-funded plan, and the closing of beloved community hospitals unable to subsist on government reimbursement rates (reducing both care and caregiver options).
Such shortcomings are why our friends in Australia and England, both of whom have government-run insurance plans for everyone, encourage purchasing private insurance as a supplement to access primary and subspecialty care more quickly (Canada, too).
Expanding affordable private insurance options is essentially what Trump is proposing. Long past the divisive debate over scrapping Obamacare in 2018, Trump has moved to playing offense on health care and now has an actual strategy. It’s cleverly focused on expanding and better supporting popular privately run Medicare plans, known as Medicare Advantage, that are administered through well-known insurance companies like Humana, United and Anthem.
Trump’s version of Medicare for All — privatized Medicare for those willing to pay for it — is like one-stop-shopping for all your health care needs rather than expanding a large government-run health system that’s far less agile: Prescription drugs, vision, dental, gym memberships and, in some cases, a heavily discounted Apple Watch are all included if an enrollee is willing to accept fewer options in the doctors they can see. Not a bad tradeoff, all things considered.
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These plans are considered a part of Medicare because the government pays authorized private health insurance companies to administer them to enrollees, instead of running the program itself (that’s traditional Medicare). Private companies then have the ability to be creative in ways that a large government bureaucracy cannot.
Most private plans offer all essential health services at one monthly premium, which means less administrative hassle. And Medicare Advantage plans tend to be cheaper than Medicare’s (the average monthly premium is estimated at $23). There is clear evidence that switching from traditional Medicare to Medicare Advantage is a wise financial move: Enrollees who made the switch in 2016 saved approximately $1200 on average compared to 2015. Taken together, it should not be surprising that one-third of Medicare enrollees currently have a Medicare Advantage plan and, by 2029, almost half of all Medicare enrollees are expected to.
The bit on creativity and innovation in Medicare Advantage is important, as developments like telemedicine are already revolutionizing global health. As a nod to this, Trump plans to increase the scope of telehealth services that will be reimbursed under the plans. As a pulmonologist, I’m particularly excited about the enormous potential of telehealth services to improve the care of remote rural communities affected by high rates of chronic respiratory diseases. Unfortunately, there is not one mention of telemedicine in Warren’s financing announcement Friday.
Further, Trump has sought to enhance financial and regulatory support for digital health innovations by supporting a more streamlined safety review process at the Food and Drug Administration. Not coincidentally, a start-up health insurer recently announced it will provide the first Medicare Advantage plan that covers the purchase of an Apple Watch.
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It just so happens that these private Medicare plans are incredibly popular with seniors, who are overrepresented in crucial states key to determining which candidate takes the Electoral College. Indeed, Medicare Advantage plans are viewed favorably among older Americans in battleground states like Florida, Wisconsin and Pennsylvania that boast the highest enrollment rates nationwide.
In contrast, current polling data indicates that 60 percent of those polled oppose Medicare for All because it disrupts the existing system and eliminates the private insurance plans that offer Medicare Advantage. This is particularly important since two-thirds of individuals aged 65 and older (the current Medicare demographic) voted in the 2018 midterms, while those 18 to 29 only voted at a rate of 36 percent. That young people are more likely to support Medicare for All is great if the goal is to drive up the national popular vote margin, not remove Trump from office.
To be sure, Medicare Advantage is far from perfect, and there’s a reason why the plan appeals to those who are primarily healthy. For all its convenience and focus on prevention and the digitization of health, tradeoffs include narrower provider networks than traditional Medicare, meaning you may be saddled with higher out-of-pocket expenses if you prefer to see an out-of-network provider.
He can argue that it’s the GOP that will protect timely access to the doctor you already have and the health plan you already enjoy.
The Trump strategy also does little to combat the epidemic of underinsurance nationally and casts a blind eye to the plight of younger Americans below the Medicare eligibility age without health care coverage. Finally, Medicare Advantage plans are associated with higher administrative costs, meaning at least in the short-term, health care costs nationwide are unlikely to meaningfully change and, in fact, may increase.
The above drawbacks are all to say that centering a health care platform around expansion of Medicare Advantage is not revolutionary, nor will it address systemic ills like inadequate health coverage or our cost crisis. But that’s also why my fellow Democrats should be worried.
While we have internecine conflicts focused on laudable big-picture goals that will take several more election cycles to achieve, many voters -- especially older ones -- are concerned about the present day. The raging debate on Medicare for All has ironically allowed Trump an opportunity to co-opt one of our strongest policy advantages from 2018, providing better health care. Now he can argue that it’s the GOP that will protect timely access to the doctor you already have and the health plan you already enjoy.