The Case for Medicare for All: Congress passes an inflation bill but is it enough?

For Briana Moss, a Type 1 diabetic, making sure she has the health coverage she needs to live is a delicate dance.

She and her partner are putting off marriage because even with his workplace-based insurance, the co-payments for her frequent doctor visits would be more than they could afford.

And while Moss says she’d like to work full time, she keeps her hours to a minimum so she can continue to qualify for Medicaid, the government program that helps her pay for the insulin she must take every day.

“I think health care should not be dependent on your job or how much money you make,’’ says Moss, 33, a Medicare for All activist who lives in Dubuque, Iowa. "It’s clear a single-payer health care system, universal health care, works in every other developed country in the world. And there’s no reason it can’t work here except we don’t have elected officials who are willing to put people over profit.’’

As a growing number of companies announce layoffs amid corporate concerns about a potential recession, the conundrum of American workers being largely dependent on their jobs for health benefits is once again in the spotlight.

The Inflation Reduction Act, passed by the House last Friday and signed into law Tuesday by President Joe Biden includes vital provisions that will enable Medicare to negotiate prescription drug prices and extend Affordable Care Act subsidies another three years.

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It builds on the ACA, passed in 2010, which enables people who don't have job-based coverage or qualify for government-backed programs like Medicare to buy insurance through federal or state exchanges.

But the ACA remains one imperfect piece of a health care patchwork that continues to leave millions of Americans without insurance, and millions more with coverage that can be confusing to navigate, and loaded with premiums, deductibles and co-payments that many struggle to pay.

A hostility toward government mandates, a lack of price transparency among health care providers, and a host of players, from hospitals to pharmaceutical companies, that profit from our complicated system are leaving many Americans sicker and poorer than they would be if we as a nation guaranteed affordable accessible health care for all.

“I think there’s a consensus people want to pay less for their health care,'' says Fredric Blavin, a principal research associate in the left-leaning Urban Institute's Health Policy Center. "They want to have high-quality health care and have a freedom of choice in enrolling in what kind of health care plans that they want... There's a lot of division in how to get there.''

Americans without health insurance hit record low

Our mash-up of health care programs and payers makes the U.S. relatively unique among high-income Western nations, many of which mandate coverage for all of their citizens.

Half of the U.S. population had workplace-based coverage in 2020, the most recent year available, according to the Kaiser Family Foundation.

Then there is Medicaid, paid for by the states and federal government, which provides health insurance to lower-income Americans and those with disabilities, and Medicare, which covers the health needs of the elderly and those with disabilities and is mostly federally funded.

In the first quarter of this year, just 8% of Americans did not have health insurance, a record low, according to an analysis by the U.S. Department of Health and Human Services. The decline was due in large part to increased ACA subsidies, as well as a larger number of people becoming eligible for that assistance during the pandemic. The health crisis also led additional states to accept federal assistance to expand Medicaid, a key provision of the ACA.

But millions still lack health care coverage.

The ACA "did close a lot of gaps,'' says Gerald Kominski, University of California, Los Angeles Fielding School of Public Health professor emeritus of health policy and management. "But we still have upward of roughly 30 million Americans without health insurance and no other industrial, high-income nation can say that such a large portion of the population remains outside'' the system.

Heading to the ER but checking the price first

Cass Evans, an aesthetician who is self-employed, says her $50,000 a year in gross income was deemed too high to qualify for The Oregon Health Plan, that state's Medicaid option. And she never looked into buying insurance under the ACA because it seemed complicated to navigate and also expensive.

"I don't even have an extra $100 to spend on insurance,'' says Evans, 47, adding that she hasn't had health care coverage for about four years.

So when Evans' gall bladder burst on Aug, 5, she first called an advice nurse at the hospital to ask how much she'd have to pay if she went to the emergency room.

“I didn’t want to come in unless I was dying basically because of the cost,'' says Evans. "She just told me to worry about it later and come in immediately.’’

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Now she's waiting on the bill. Based on her Google searches, she says a hospital stay could be as much as $11,000 a day, and that's not counting the cost of her surgery. Then, Evans made another visit to the ER a week later when she wasn't feeling well and got a CAT scan. "So I’m sure my bill is going to be insane,'' she says.

Evans has applied again for The Oregon Health Plan and "worst-case scenario, I'll work out a payment plan ... and I guess just pay (the hospital) forever,'' she says, adding that she's worked hard to not rack up debt and is trying to buy a home.

Evans tries not to worry. "I have had to let it go because it is so stressful for me having my own business and being a single mom and living paycheck to paycheck,'' she says. "It’s the American Dream, right? You own your own business, you buy your own house. And then something like this comes up and it’s over.''

'I went on with my life and then I get this bill'

In 1985, Congress passed the Consolidated Omnibus Budget Reconciliation Act, or COBRA. The legislation gave some workers who'd lost their jobs the option of continuing their employer-based coverage with one critical caveat – the employer would no longer pay part of the premium.

"Every economic downturn leads to more interest in ... Medicare For All type programs because suddenly millions of Americans learn something they really don’t want to know about, and that’s a program called Cobra,'' says Kominski. "You can continue to buy your health insurance from your former employer but at 100% of the cost. That’s usually difficult when you're laid off.''

When Bea Matthews was laid off from her job as a paralegal in September 2020, she was told COBRA was an option. But coming up with an additional $800 a month when she was now out of work made little sense.

"I went for a period of about a year and a half with absolutely no health insurance,'' says Matthews, 47, adding that she didn't qualify for Medicaid.

Then, she got sick. It was in the midst of the pandemic, and Matthews eventually made her way to an emergency room outside Houston where the medical staff recommended she get a CT scan. She left the hospital that same day and over time her symptoms disappeared.

“I went on with my life, and then I get this bill,’’ Matthews says of the statement the hospital sent her in January 2021 saying she owed $7,997 for the brain scan.

There were thousands of dollars in other charges including $314 for a pregnancy test though she told the staff she'd had a hysterectomy.

Ultimately, Matthews made a charity application to the hospital's billing department and $13,595.18 of her roughly $15,000 bill was written off. She is paying $70 a month to erase the remaining balance.

“It is inhumane,'' she said of the nation's health care system. "It's about a lack of empathy but it’s mostly about greed."

Even workplace deductibles may be too high

Presidential administrations from Franklin D.Roosevelt to Bill Clinton have tried and failed to create a national health insurance system in the U.S.

What we have is a private insurance system that took off during World War II when employers who couldn't give raises due to wage freezes offered workers health benefits instead, says Kominski.

Now, roughly 50% of the U.S. population has workplace-based coverage. But many Americans lack the savings to cover the typical deductible for employer-based plans.

According to a paper from the Peterson Center on Healthcare and the Kaiser Family Foundation, "45% of single person non-elderly households'' did not have enough liquid assets to cover the typical workplace plan deductible of $2,000 for an individual. Among that group, 62% couldn't afford an individual plan's "very high" deductible of $6,000.

And for households that include more than one person, 42% would be unable to cover the typical family plan deductible of $4,000, while roughly 6 in 10 could not handle a very high family plan deductible of $12,000.

The Urban Institute’s Debt in America project found that 13% of Americans with credit records had medical debt in collection. The median amount was $703 according to February credit bureau data, says Blavin of the Urban Institute's Health Policy Center.

In May, 15 U.S. Senators including Sen. Bernie Sanders, I-Vt., introduced the Medicare for all Act of 2022, which would create a federally backed national health coverage plan over four years that would enable all Americans to access care without having to personally cover co-payments, deductibles and premiums.

But there are pros and cons to many of the approaches suggested to revamp our health care system, Blavin says.

"Having a single-payer approach would be most beneficial in terms of improving equity and lowering out-of-pocket burdens at point of care,'' he says. "But I think there are real costs associated with that ... The implications on taxes, and it would be a pretty drastic change.''

Rand estimated in 2019 that a Medicare for All system would cost $3.89 trillion, a 1.8% uptick over current health care spending. But expenditures specifically by the federal government would skyrocket, rising 221% from $1.09 trillion to $3.50 trillion.

Blavin said a more pragmatic approach might be to strengthen the ACA which was weakened when several Republican-led states refused to expand Medicaid, and in 2017 when the Republican-led Congress erased the financial penalty for those who refused to buy coverage.

Medicare for All?

To be sure, the U.S. has made meaningful strides toward increasing health equity. In addition to the ACA and Inflation Reduction Act, which also caps out-of-pocket medication expenses to $2,000 a year for those on Medicare, Congress previously passed the No Surprises Act. Starting this year, that legislation will largely protect consumers who despite having insurance are still hit with unexpected bills when they are treated by out-of-network specialists or hospitals.

A person sick enough that they have to be in an emergency room shouldn't be asked first for their insurance card. A laid-off worker shouldn't be driven further into financial despair because they have the unlucky timing of becoming ill days after they have lost their job and likely, also the coverage for their health care.

A single-payer system would be optimal, but if that's too great a goal, too far off in the future, perhaps we could alternatively allow anyone to enroll in Medicare, with some private insurance plans available to those wanting and able to pay for them.

We are all mortal. Many of us at some point will get seriously ill. We should all be able to access the quality health care we need, whenever we need it.

"I do think ultimately we do need to get to a single-payer system in this country,'' Kominski says. "If we have to do it through incremental reforms, I’m not opposed to that. And it may be the only way that we can get there.’’

This article originally appeared on USA TODAY: Medicare for All? Layoffs, recession may threaten health care access