Medicare for all, well, um, sort of

I n what passes for moderation these days, Virginia Sen. Tim Kaine has joined with Colorado Sen. Michael Bennet to propose a slimmed-down, non-compulsory version of Medicare for all.

Sen. Bernie Sanders and many other prominent Democrats want to see expansive Medicare for all - a single payer health care system that would enroll every American and cost, by official Congressional Budget Office estimates, around nine hundred bajillion dollars.

Kaine and Bennet suggest something much more restrained. Their Medicare-X proposal would allow people to buy into Medicare (or more precisely, a close analog). In the initial phase, only those who live in areas with one or fewer insurance companies offering coverage through the Obamacare exchanges could enroll. Eventually, it would become available to everyone, with subsidies for low-income buyers.

In short, Kaine is proposing the so called public option: If you can't get coverage through the private sector, or you'd rather get your health coverage from the government, then come on in - the water's fine. (Barack Obama pitched this idea during his first term, but it was not included in the final version of the Affordable Care Act.)This might be an effort to pull the party back toward the center, but some progressives hope it will do more: "The Road to Single-Payer Is Being Paved by Two Centrist Democrats," exulted the liberal Think Progress website.

This fallback approach has several advantages to commend it - along with several pitfalls.

On the plus side of the ledger, it can function much like an assigned-risk pool. People with severe health problems could opt for Medicare-X, with the government picking up the cost of their care (or forcing providers to internalize the cost by setting reimbursement rates below the break-even point).This also has the potential to shore up Obamacare's insurance exchanges, by enticing insurance companies to re-enter markets they had considered too costly. And it might even reduce the need for onerous community rating and guaranteed-issue regulations that hamstring insurance companies.

But Medicare-X also could involve plenty of downside. The chief concern, not surprisingly, is financial. Medicare spending already has nearly doubled over the past decade, and is projected to keep rising in the next few years even without expanded eligibility. The Kaine-Bennet plan could saddle tax payers with huge costs, especially if it attracts a less healthy demographic. (Kaine's staff says the bill requires premiums to cover the cost of care. And to be fair, per-capital spending has grown even faster for private insurers.)

True, the federal government could hold down costs by setting rock-bottom reimbursement rates for doctors and hospitals. But then many providers would decline to participate, and consumers would not want to join a network that has few providers.

All of these considerations could mean little until Democrats gain a stronger hold on Congress. While there's no telling what President Trump will do on any given day, the GOP-dominated House seems unlikely to go along with any further federal incursion into what's left of the private sector health care system. Little wonder: Government already accounts for more than half of all health spending in the United States. Increasing that ratio seems an unlikely way to make things any better.