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Up to now, single-payer and universal health coverage proposals in the United States have foundered on one shoal or another: They’re ungodly expensive; they replace plans that people like; they’re too sudden; they’re not sudden enough; they’re politically impossible, etc., etc., etc.

Michael Hiltzik mug

Michael Hiltzik | Los Angeles Times

But now take a look at “Medicare Extra for All.” It’s a universal coverage proposal released recently by the Center for American Progress, a progressive think tank associated with the Democratic Party.

It’s not quite “Medicare for All,” to cite the mantra used by Sen. Bernie Sanders (I-Vt.) and others who want a near-instantaneous, wholesale transformation of the U.S. health coverage system into a public service. Instead, it would preserve privately financed employer coverage for as long as employers want to stay in.

But within a few years it would become “Medicare for Most,” as healthcare commentator Andrew Sprung observes. That’s because newborns and those turning 65 would automatically be enrolled, along with everyone buying insurance in the individual market and all uninsured people, including legally resident noncitizens. Eventually, Medicaid and the Children’s Health Insurance Program would be folded in.

The proposal addresses many of the flaws of the Affordable Care Act, most of which could have been addressed routinely by Congress over the last seven years, if Republicans were interested in improving health coverage for their constituents instead of riding the ideological hobby horse of Obamacare repeal.

Medicare Extra confronts the reasons for the high cost of the U.S. health-care system head-on by placing caps on doctor and physician reimbursements, reducing administrative costs and negotiating with drug and medical device companies. It doesn’t treat the drivers of high costs as some sort of opaque mystery requiring the genius of Jeff Bezos, Warren Buffett and Jamie Dimon to unravel — because they’re not a mystery.

That brings us to the politics of the plan. Plainly, it goes nowhere in a Republican-dominated Congress. If Democrats win control, however, Medicare Extra for All must be considered the best template for completing the transformation of the dysfunctional U.S. health coverage system begun by the Affordable Care Act and reversing GOP sabotage of the ACA and Medicaid.

Extra also may be the only chance Democrats have to resist opposition by stakeholders in the present system, such as physicians, hospitals, drugmakers and medical device manufacturers.

“The lesson Democrats have learned politically is that they’re alone,” health economist Harold Pollack observed at “They’re not going to get Republican support. They’re not going to get stakeholder support for some of the most critical things.” After seven years of sabotage by the GOP, he predicted, “Democrats will be much more ruthless the next time around.”

Let’s examine the most important elements of Medicare Extra for All.

In addition to the automatic enrollment of newborns and the uninsured, every legal resident in the U.S. would be eligible for Extra: Traditional Medicare, Medicare Advantage, employer coverage and federal programs for military families, veterans or government employees would remain in place, but their enrollees could switch to Extra if they wished.

Extra would provide free preventive care, free treatment for chronic disease and free generic drugs, as well as services deemed essential by the Affordable Care Act such as hospitalization, prescriptions, maternity care and mental health and substance abuse treatment. It also would cover dental, vision and hearing services. Enrollees could choose from any doctor or hospital participating in Medicare, which is most of them.

Premiums and co-pays would be charged on a sliding scale. For households with income up to 150 percent of the federal poverty line — $18,210 for individuals and $37,650 for a family of four — there would be no premium or deductible. From there to 500 percent of the poverty level — $60,700 for one, $125,500 for four — premiums would be capped in a range rising with income, but no higher than 10 percent of income. Over 500 percent, the 10 percent premium cap would apply.

As we’ve reported recently, this would solve one of the most irritating aspects of the ACA — the sudden cutoff of premium subsidies for families making 400 percent of the poverty line, which means $1 in additional earnings can result in a loss of all subsidies.

With the exception of employer plans, commercial insurers would be barred from duplicating Medicare Extra, though they could offer other benefits — cosmetic surgery coverage, for instance.

That’s wise, because U.S. employers currently provide coverage to 152 million Americans, paying $485 billion in annual premiums. Those that continued their plans could keep the tax deduction they get on those costs.

Or they could shift their employees to Medicare Extra by contributing at least 70 percent of the premium or making lump-sum payments to the government.

They’d lose the tax break in those cases, however. Employers with fewer than 100 full-time workers wouldn’t have to make the payments.

Medicare Extra would save money by setting provider rates roughly at an average of Medicaid, Medicare and commercial reimbursement rates, which the drafters say would end up somewhat higher than Medicare but lower than commercial rates.

Primary care doctors would get a bump up in reimbursements relative to specialists, to reduce the incentives for excessive specialty referrals.

Medicare Extra would have the authority to negotiate prices with drug companies and medical device and equipment manufacturers. The system, moreover, would cut administrative costs sharply by paring the role of commercial insurers — a boon to doctors and hospitals that have to spend heavily to manage claims.

The program still would need more revenue than what currently goes to Medicare, Medicaid and other government healthcare programs. Among the options are a surtax on high-income taxpayers, including a higher tax on capital gains.

Medicare Extra for All is not single-payer exactly, but only single-payer dead-enders could object to its payer provisions.

It’s the best solution to the realities, politics and drawbacks of the U.S. health insurance system yet to appear, and the time to start pushing it is now.

Columnist Michael Hiltzik wrote this for the Los Angeles Times.


(7) comments


I read the word ‘free’ several times. Tell me again where this money tree is. As far as the republicans being obstructionists, please list the items the Dems have backed Trump on. It should be very easy to list them. I’m sure you won’t go over the word limit. Hypocrites


well I can give you the list dems have blocked Trump on. The number is zero. Republicans have the majority in congress, both houses, so Dems have little power to do anything. You saw the word free for out of pocket costs of certain medical procedures. Yes and that money comes for the premiums paid. Very simple.


where are all the right wingers on this thread. Health care is one of the biggest issues facing this country, and they are deadly silent. Nothing to offer is seems, no new ideas, no innovative approaches to this serious issue. Just silence won't cut the mustard. Or are they just waiting to criticize, obstruct, and tear apart anything new offered. That has been their forte for years. Its too bad, we need everyone to offer and contribute pertinent ideas than can help this country forge ahead in realizing comprehensive healthcare for all.


I very much like what he is suggesting. I think it would result in me paying more in taxes, but I think it is a bargain when it comes to making healthcare a human right for all people. And it would remove the threat of me, my children and my grandchildren going bankrupt over the very serious illness or injury to just one of us. I'd pay a lot for that peace of mind.


This plan certainly seems doable. Its not perfect by any means, no plan is. Leave it to the progressives to come up with a comprehensive plan that can cover all people and puts caps on what can be charged thus controlling costs. What are the republicans proposing? Over a year into the Trump administration and total control of congress and nothing has happened. Nothing is even on the table. Just back to buffalo plans that are junk insurance. All you conservatives out there, step up and offer your plans to bring comprehensive healthcare to all at a cost we can afford. Enough of the criticizing Obama care, come up with some solutions.


For progressives to enact this program they must gain the support of the progressive cohort that already has insurance that provides better value than this program would offer. Many loyal Democrat union workers and government employees who pay insurance premiums less than 10% of their wage and who pay less out of pocket will not be enthusiastic supporters of this plan. Do you remember the demonstrations when Act 10 became law and it required government employees to pay part of the cost of their health insurance premiums? If this plan were ever put to the vote it would fail on a bi-partisan basis because people will vote with their own interests in mind and much of the Democratic party base will not see this plan as being in their interest.


if you read the article it says that employer provided health care insurance could remain the same, along with veterans health care. As the pool of union workers shrink in this country, if they oppose this, it would be insignificant. They only government workers who would oppose this plan would be the higher ups in government offices, and they are non union. I do believe the majority of democratic voters would support this type of universal health care. Its the republican side that would be against it by a wide margin, like you said, because of their own self interest.

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