The debate around health-care reform in Washington has for years been dogged by a single question: Everyone deserves health care, but how do we pay for it? But as public frustration reaches a boiling point, and millions struggle with a lack of insurance coverage or exploitative medical costs, the question is being reframed around a different set of questions: Instead of asking how to pay for it, we’re asking why the wealthiest country in the world shouldn’t have the best universal health=care system for all?
Representative Pramila Jayapal’s Medicare For All bill starts the long-overdue attempt by lawmakers to answer that question in concrete terms: a massive single-payer health plan with no out-of-pocket costs, covering everyone living in the United States, and effectively abolishing the current health-insurance industry.
Expanding upon an earlier bill introduced by Senator Bernie Sanders, the 2019 Medicare for All plan envisions an expansive, multiyear program for rolling federal health plans and private insurance plans into a comprehensive single-payer system. To ensure fully equal access, the system would distribute “risks and benefits across all of society…eliminating eligibility, enrollment, and coverage gaps,” with the tremendously ambitious goal of lowering costs at the same time. The plan is designed to ensure not just “coverage” but real care whenever needed, including primary care to neonatal care, treatments ranging from chemotherapy to insulin, and everything in between. Reproductive care, including abortion, would be free (and free of the current ideological restrictions). It also includes civil rights–based benchmarks for equity, and protections against discrimination by race, ethnicity, gender, sexual orientation, disability, immigration status, or economic background. The proposal aims for a total transition to the new system within two years, and is in stark contrast to market-based universal-coverage plans that preserve the insurance market. It aims higher than even Canada and the United Kingdom, which impose some cost-sharing for beneficiaries.
The bill is a leap into the political unknown as far as Washington goes, but resonates with the pulse of the general public: Surveys show that most Americans generally support the idea that health care should be run by the government and provided for free, as a human right.
A granular analysis by National Economic & Social Rights Initiative (NESRI) assesses how the bill measures up on several human-rights principles, based on several core principles: universality; equity, which guards against discriminatory or structural barriers to care; transparency and accountability for both government as well as private providers; and the provision of clients’ “meaningful public participation.” The assessment extends beyond public health goals to place single payer within a broad constellation of human rights, parallel to other social entitlements and political rights.
NESRI gives the bill full marks for comprehensive, inclusive coverage, providing equal care to all residents regardless of immigration status, income, or past health record. And all providers would offer a uniform array of mandatory services, in a seamless infrastructure that would allow people to navigate across services with transparent, uniform access without the arbitrary cost differentials or coverage gaps.
To close the social and geographic disparities to access, the location and distribution of facilities and providers would be managed by a national Office of Primary Healthcare, channeling resources into isolated areas, including rural and underserved communities. Within facilities, staffing levels, wait times, and other standards of care would be centrally managed. The plan also dismantles discriminatory barriers baked into current health-care policies, including multiyear waiting periods for public coverage for immigrants and people with disabilities.
From a labor standpoint, the bill charts a course for balancing the needs of workers and patients during the transition. It offers economic readjustment protections for displaced workers to maintain jobs. But NESRI also underscores a need for a broader workforce overhaul, which focuses on uplifting historically disadvantaged and underpaid job sectors like home and personal care. Beyond just providing job security, whatever new jobs emerge in the new system would have to broadly improve minimum wages and offer “reliable scheduling, better safety standards, and protections of workers’ right to unionize without obstruction by employers.”
Yet the legislation still leaves some gaps. NESRI points out that in the pharmaceuticals industry, fair access and funding for prescription drugs should spur “public action in instances where drug companies fail to meet needs.” That opens the challenge of wrangling Big Pharma to follow the national health-care agenda, while preventing medicine shortages by “steering public research dollars toward treatments for medical conditions receiving inadequate attention” and breaking drug monopolies by mandating generic-medicine production.
Of course, the hard part will be figuring out how to finance the system sustainably, delivering excellent care without pricing anyone out of decent health care. Several plans have been rolled out by think tanks and lawmakers, including a steep tax hike, up to 80 percent, on the top income earners, a direct wealth tax, and a more progressive payroll-tax structure.
NESRI’s report does not have an exact answer to that question. But NESRI Manager Ben Palmquist argues that “at the end of the day, financing health care is a question of what we value as a country and whom Congress is accountable to. Do we keep low tax rates on corporations and the wealthy, and allow drug and hospital companies to charge employers, patients, and the public whatever they want? Or do we treat health care as a human right…and take concerted political action to challenge wealthy interests and win redistributive taxes and policies?”
While there are still many open questions surrounding the Medicare for All plan and its implementation, NESRI suggests that the conversation can be an opportunity to refine our conception of what qualifies as a human right. Giving communities, workers, and providers a voice in developing the system would be a monumental project, but it may be the only way to provide the fairest and most sustainable program. NESRI recommends, for instance, that the process incorporate innovative approaches to governance, such as “participatory budgeting practices”—a citizen-led assembly-based deliberation structure—or incorporating supportive programs to construct a holistic network of social as well as medical care.
But the bill itself, of course, is a reflection of a growing cry for radical change in the way this country takes care of itself. And whatever the congressional arithmetic tells us about how politicians will vote on this particular proposal today, the public’s health won’t wait, and the people, accordingly, have decided they’re ready for a new system.