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U.S. Senator Bernie Sanders, a Democratic candidate for president shown here at a campaign rally in San Diego last month, has put a spotlight on so-called “Medicare for all.”

WASHINGTON

Political candidates and activists in Maine, especially in rural areas, often got a sharp reaction five years ago when they knocked on doors to promote universal health care.

“The reaction was, ‘Oh, you’re a commie,’” said Phil Bailey, who back then advocated for various Democratic causes.

Now, voters in those same conservative areas have a different take.

“Of course” is a common response to calls for universal coverage, said Bailey, now executive director of Maine AllCare, part of a national coalition campaigning for single-payer health care. The organization saw enough growing momentum and received enough financial support to justify hiring Bailey and another full-time staffer last summer for the previously volunteer-led group.

What was once seen as a long-shot pitch from Sen. Bernie Sanders, I-Vt., during his 2016 presidential campaign is now a proposal for a single-payer health care plan that at least four of his Senate colleagues also running for the party’s 2020 nomination supported in the last Congress. The issue is driving the national political health care debate.

But to succeed in enacting a single-payer system such as the “Medicare for All” plan Sanders backs, liberals would need a grassroots movement propelling the effort and would have to work out complicated policy details affecting nearly one-fifth of the nation’s economy.

Democrats are already contending with industry groups hoping to shift the focus back to strengthening the current system. Most drug companies, hospitals and insurers oppose Medicare for All, which complicates progressives’ efforts. The party’s left wing is pushing a bold, expensive plan that carries risks that make Democratic leaders shudder. Despite all the political hurdles, getting a single-payer law enacted may look easy compared with implementing it.

Giant steps

The most ardent advocates for a government-run, single-payer system are not content with incremental steps. They are seeking a wholesale reorganization of the nation’s health care system.

The proposed two-year transition may be too short for the entire industry to adopt in a transformation that experts warn would displace workers and jolt the economy.

“It is going to be a big administrative and logistical challenge. When you’re talking about moving everyone in the country into a new health insurance program, that is not a small feat,” said Linda Blumberg, an institute fellow at the Health Policy Center at the left-leaning Urban Institute.

A single-payer health care system would significantly change every sector of the health care industry. Hospitals and doctors would have to adjust to a new payment system, the insurance industry would shrink significantly and the government would bring drug companies to the negotiating table to determine prices.

Supporters aren’t intimidated by such broad changes. The hope is not just to ensure that everyone has coverage, but also to take on health care companies seeking to maximize their profits, said Adam Green, a co-founder of the Progressive Change Campaign Committee, a political action committee that supports liberal candidates.

“Medicare for All boils down to two things,” Green said. “One is universal coverage. The other is corporate accountability.”

Government oversight

Setting up a single-payer system would most likely require creating a new government program to be the payer and oversee the system. A House bill by the co-leader of the Progressive Caucus, Pramila Jayapal, D-Wash., would also establish a national health care budget to cap costs.

Jayapal’s bill, like Sanders’ plan, doesn’t envision a large role for supplemental insurance.

It would be permitted, but aides say it would likely be unnecessary and used only to cover medically unnecessary treatments, like cosmetic surgery. Unraveling the current insurance system is a Gordian knot-style task all its own.

Even public entitlement programs are often administered through private plans, with 68 percent of people in Medicaid and 34 percent of those in Medicare using comprehensive managed-care plans.

The role of private insurance in a single-payer system has already emerged in the race for the 2020 Democratic presidential nomination.

Sen. Kamala Harris, of California, sparked the debate over the survival of private insurance this year when she said she favors a single-payer system that would eliminate private insurance. Harris has also backed other proposals, but called the single-payer plan her top choice.

Sen. Amy Klobuchar of Minnesota said a single-payer system would not be feasible and supports a bill by Sen. Brian Schatz, D-Hawaii, to let people buy into Medicaid. Similarly, former Rep. Beto O’Rourke of Texas, who previously supported a single-payer system, now says another path to universal coverage may be more efficient.

The single-payer bills introduced so far would not be based on the current Medicare program, but instead would greatly expand the program’s benefits.

Jayapal and Sanders both say the national health program would cover all medically necessary treatments. Those could be determined by a doctor or a newly formed national health program, said Jodi Liu, a Rand Corp. associate policy researcher.

Path of payment

One major challenge under a single-payer system would be how to pay health care providers. Advocates propose different types of plans, such as paying all providers at the same rate, possibly based on current Medicare rates, or global budgeting, through which institutions would regularly receive lump sums as payment.

Payment changes could benefit some doctors, such as those who currently treat many Medicaid enrollees and collect less money than doctors under Medicare. But providers who see mostly patients covered by commercial insurance could be paid less.

The same goes for access to providers, Liu said. Since not all providers accept Medicaid, many patients would probably have an easier time finding doctors.

The government would face significant pressure to ensure that providers are compensated at the “right” rate, Blumberg said. Controlling health care costs would be one goal, but the government would not want to skimp on quality or access to a sufficient number of providers.

In making decisions that affect the entire health care system, selecting the wrong payment rate could have serious ramifications, Blumberg said. “That process in and of itself is going to require a huge amount of attention and analysis and monitoring.”

Under the Jayapal bill, hospitals and the government would negotiate a budget based on factors like the historic volume of services over three years, a hospital’s normal spending and standard payment rates.

Hospitals would also get funding to cover their uncompensated care costs under an all-payer system.

Global lump-sum budgeting, which would give institutional providers an amount of money for health care services over a set amount of time, could control costs, which advocates call a key benefit.

“If there was a national global budget, that’s certainly a direct lever to address how much spending there is on health care, but of course, there’s a lot of political issues that would come up,” such as budgetary pressures, Liu said.

While hospitals and other institutions would be paid quarterly through a capped budget under Jayapal’s proposal, individual doctors would be paid through a fee-for-service system for every procedure. The Health and Human Services secretary would have one year to set those providers’ fees.

Hospitals are already sounding the alarm about receiving lower payments under Democratic proposals.

Whether Jayapal’s two-year transition is feasible is another question. A Jayapal aide said a fast transition provides less time for the industry to push back.

Still, Blumberg suggested a 10-year transition is more feasible.

“The change for a lot of providers could be very substantial, and doing that in a very short period of time may have implications for disrupting the operation, the ability for these providers to continue to operate and the access for the patients,” she said.

Universal access

Although the challenges are great, Medicare for All advocates note that other large developed countries ensure that all citizens can access health care.

“Across industrialized countries, the hallmark of the health care system is universal coverage,” said Robin Osborn, a Commonwealth Fund vice president and director of international health policy and practice innovations.

Of all the questions about a single-payer system, the biggest may be how to pay for it. Neither Jayapal or Sanders included a financing plan in their bills, although Sanders released a list of possible ways to pay for his.

The cost of Sanders’ vision would be roughly $32 trillion over 10 years, according to two outside analyses of proposals Sanders put forward in 2016 and 2017, the first from the Urban Institute and the other from the libertarian Mercatus Center.

That’s an eye-popping balance, although Sanders emphasizes findings that the U.S. would actually save money on health care spending over a decade. Single-payer advocates argue that the U.S. health care system is already the most expensive in the world and would be more efficient under a new program.

“When you think about the fact that people are already paying, you have to recognize that this is just a scare tactic, primarily from the right, saying you’re going to end up paying much more,” Jayapal said.

Still, asking taxpayers to pay the whole bill causes even some Democrats to balk.

House Speaker Nancy Pelosi of California said in a recent Rolling Stone interview that a single-payer system may be easier administratively than other ways to reach universal coverage, but questioned how to pay for it.

Pelosi says that Democrats should build on the 2010 health care law, which she helped shepherd through Congress a decade ago. Expanding the current Medicare program would not be as beneficial to Americans as that law, she argues.

“All I want is the goal of every American having access to health care,” she told Rolling Stone. “You don’t get there by dismantling the Affordable Care Act.”

Financing plan?

Critics will likely highlight the lack of a financing plan — and the expected high tax increase — that would come with implementing a system that would cover essentially all medical expenses.

Sanders’ financing options include ending tax breaks that would become obsolete under a single-payer plan, adding a 4 percent income-based premium paid by households, imposing a wealth tax or a more progressive personal income tax, or leveraging fees on corporations, such as a one-time tax on offshore profits.

Other possibilities include ending parts of the Republican 2017 tax law or creating a tax on employers, which could mean that employers would not see much savings from not providing coverage to workers.

High-income earners are particularly at risk, said Larry Levitt, senior vice president for health reform at the Kaiser Family Foundation. “Depending on how it’s financed, high-income people could end up paying much more in taxes than they now pay for health care,” he said.

Because a transition to a single-payer plan would effectively eliminate most of the insurance industry, possibly 1 million to 2 million people who work in that industry would be displaced, according to Jayapal. Both Jayapal and Sanders proposed assistance for those workers with job training, education or other programs.

Some Democrats doubt that a Democratic president and Congress would implement a single-payer system.

Bob Kocher, a partner at Venrock and a former senior Obama administration health care official, said actions in office typically don’t match the aspirations candidates invoke while campaigning.

“When you try to do it, the details matter and are hard and are often less disruptive and ambitious than what your poetry was,” he said.

Liberals insist that a single-payer system is the only path forward. “This is not a messaging event. We are going to get health care for every American,” said Rep. Debbie Dingell, D-Mich.

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