SENATORS Bernie Sanders, Elizabeth Warren and Cory Booker are all for it, as are Kama- la Harris and Kirsten Gillibrand. “Medicare for all” has also be-come a rallying cry for many Democratic activists as the mid-terms approach. Like “repeal and replace”, the Republican Party’s three-word proposal for improving on Obamacare, “Medicare for all” sounds good but is largely meaningless. Ask any five Democratic senators what they have in mind and you will get five different answers. The urge to reform American health care deserves support. America is the only rich country to lack universal coverage. Even in a booming economy, 12% of American adults remain uninsured. Though the best care they receive is world-beating, the system as a whole has high costs and disappointing results. America spends 17% of GDP on health care, the highest of any rich country (see chart), but in return achieves an average life expectancy no better than that of the formerly communist countries of eastern Europe. Even Americans with good insur-ance plans find dealing with their providers maddening. Hence the urge to tear up the whole system and start again. Mr Sanders has done the most to popularise Medicare for all. He proposes converting the government scheme for the elder-ly into a single-payer system funded from general taxation, as in many European countries. Private companies would still provide the care, unlike Britain’s NHS, but individuals would no longer buy health insurance through their employers. This plan appeals to Democrats scarred by their experience with Obamacare, an incremental reform that worked with the grain of America’s market-based system but which Republi-cans successfully targeted as unjust. To avoid repeating the same mistake, the thinking goes, Democrats need a big-bang reform that cannot be unpicked later. Its backers point to polls showing overwhelming support for Medicare for all.
In some alternate America imagined by Pixar the health-care system could simply be reinvented. In the real world it would be unworkable—and political suicide. Because Ameri-can health-care costs are so high, making the government as-sume them all would require a huge increase in taxation. Vot-ers in Colorado, California and Vermont, all relatively friendly territory for Democrats, rejected single-payer systems when they realised how much they cost. The rebellion that would follow an attempt to remove jobs-based health insurance from the 55% of Americans who have it, putting medical-insurance companies out of business in the process, would make the pol-itics of Obamacare look like a church picnic.
A better approach would be to continue changing the health-care system in small steps, frustrating though that might be. In states that expanded Medicaid, the health-care programme for low-income Americans, the proportion of people without health insurance halved. If Democrats can win power in states that rejected the federal government’s offer to pay for Medic-aid expansion, they will be able to bring down the number of uninsured further. The markets where individuals can buy in-surance should be shored up. Finally, individuals could be of-fered the option to buy Medicare, paying an annual premium to the government just as they would to any other provider of health insurance. Since Medicare has more pricing power than individual in-surers do, this option ought to bring costs down eventually. It would also provide choice for those living in the many rural ar-eas where there is currently no competition in insurance mar-kets. Senators Michael Bennett and Tun Kaine have a proposal along these lines. It is not perfect. If premiums were not set high enough, the government’s liabilities would increase. It would leave much of America’s frustrating health-care system unreformed. But unlike most other versions of Medicare for all, it might actually happen.