4.1 Political Barriers and Opportunities for Enactment
Political barriers and opportunities for enactment are similar to the ones the ACA had experienced and can be seen for any implementation of a system-wide reform. Benefits
package, design, provider reimbursement rates, and scope of the services covered need to be determined (Liu and Brook 2017).
One major political barrier consists of the history of attempts to implement universal health care, which have constantly failed in the past. Reasons for failure include opposition from health care stakeholders, distrust in government, fear of ‘socialized medicine’, and fragmentation of the system. Over time, other systems have been implemented (Medicare, Medicaid, ACA) that now build a well-accustomed status quo and need to be considered when implementing a new system. It is necessary to build based on the complex and fragmented system or replace the system completely.
Moreover, the expansion of Medicare, which was the hidden goal when it was implemented, never was accomplished and further lead to a turn away from single-payer reform. The implementation of Medicare for All entails a huge amount of change as it disrupts financing, insurance coverage, and provider payment. This is especially difficult as past health care reforms followed the approach of incrementalism. Therefore, stakeholder opposition and public anxieties will be a lot higher than in prior health care reform approaches (Oberlander 2019).
The American political system regarding health reform is characterized by hyper-partisanship leading to issues for collaborative work in Congress and makes the passing of health care reform incredibly difficult (Obama 2016). A shift of the Democratic party to the left and a new willingness for federal initiatives emerging out of the failed efforts the Trump administration took to repeal and replace the ACA would make Medicare for All more likely. One opportunity to pass Medicare for All lies in a mass movement to break down barriers, but this is less likely. Another opportunity would be that the ACA would be declared unconstitutional and a president supporting Medicare for All has majorities in Congress (Oberlander 2019). Nevertheless, Medicare shows that a single-payer and government-funded health care reform can pass Congress, and can also be widely accepted in the population and political environment (Galvani et al. 2020).
4.2 Stakeholder Analysis and Public Opinion
Medicare for All is a disruptive health care reform approach and therefore receives strong opposition or support from different stakeholders. It is a partisan divided health care reform with 79% of the Democrats favor it and 71% of the Republicans oppose it (Henry J Kaiser Family Foundation 2020).
A study conducted among physicians in four states (New York, Texas, Colorado, Mississippi) found that 43.8% of physicians favored a single-payer system, and that geography may influence attitude towards health care financing options and political beliefs. Their primary concerns are centered around the reduction of provider payments and a rise in workload through the broader insurance pool (Khan, Spooner and Spotts 2018).
At first sight, employers could favor M4A as it reduces the amount of money paid for employees’ health insurance and strengthen the workforce through broader coverage (Galvani et al. 2020). However, they will more likely oppose the M4A Act because they fear higher payments due to tax increases that emerge out of the transfer from a private to a public financed system.
The American Hospital Association opposes Medicare for All and argues that the system relies on private patients to subsidize the care of patients covered by Medicare and
Medicaid, since reimbursement are not sufficient to cover expenses (Galvani et al.
2020).
The public is more likely to support a National Medicare for All Plan (54% in April 2020). Hereby, terminology is important as terms like ‘universal health coverage’ or
‘Medicare for All’ have greater support as they are associated with positive experiences, than the term ‘socialized medicine’. A major risk to this positive public opinion is the uncertainty of approaches of the M4A Act and support drops when understanding certain impacts. For instance, 60% would oppose the reform when it would require most Americans to pay higher taxes. As this is most likely due to the financing of the reform, deeper knowledge about it could change public opinion in an unfavorable way (Henry J Kaiser Family Foundation 2020).
Health insurance companies and pharmaceutical industries typically oppose the health care reform approach as it intends to eliminate private insurance and cut down drug costs (Galvani et al. 2020).
4.3 Costs of the Approach and Finance
Different approaches amount to different federal and national health care spending depending on the design of the health care reform (Blumberg et al. 2019). Galvani et al.
suggest that the M4A Act would cost $3,034 billion annually (Galvani et al. 2020). It is unclear whether the Medicare reimbursement rate is sufficient to cover health care costs.
Projections say that over 80% of hospitals will lose money by treating Medicare patients, which would increase as every patient is paid under these Medicare rates (Heffler et al.
2018). Losses from Medicare patients that are not fully reimbursed (89% in 2014) cannot be compensated through private insurance reimbursement rates (Blahous 2018). This would lead to a reduced supply of health care services due to higher demand. This could lead to an inadequate supply of services and could affect the quality as well (Liu and Brook 2017). Higher rates can range between current Medicare payment rates and private insurance payment rates, but it remains uncertain whether provider capacity would be sufficient for the increased demand (Thorpe 2016). Blahous predicts that the federal cost of enacting the M4A Act would be so high that even doubling all federal individual and corporate income taxes would be insufficient to fully finance the plan.
The plan would not be fully financed even assuming that provider payment rates are reduced by over 40 percent for previous private insured patients. Such large increases in federal taxation or debt would not endure federal commitment (Blahous 2018).
The Urban institute found that federal and national spending would increase. The source of funding would shift from private and state spending to federal spending as the federal government would take over the spending currently provided by employers, households, and state and local governments. National spending would increase through increased utilization by the previous underinsured and uninsured (Blumberg, Holahan and Simpson 2019). Different taxes will finance the federal health care expenditures as huge sources for federal revenues ease away as households, employers, and states, are relieved from Medicare and Medicaid expenditures (Galvani et al. 2020).
Cai et al. conducted a systematic review including 22 single-payer plans. The findings show differences in net savings (7% to 15%) and net costs (2% to 19%) based on different input assumptions in the first year. In the first year, 19 of these analyses estimate decreasing health expenditures and long-term savings through simplified
billing, decreased drug prices, and global budgets. They conclude that a single-payer system reduces health expenditure and achieves lower net health care costs through eliminating private insurance (Cai et al. 2020).