Posted on April 28, 2007

Kennedy/Dingell Medicare for All Act


The time is now: Medicare for all

By Senator Edward M. Kennedy
The Politico
April 24, 2007

If there is ever a time to solve our national crisis, it is now. I believe that the best plan for the nation is to build on a program that all Americans know and respect by creating Medicare for All. Medicare administrative costs are low. Patient satisfaction is high. Patients can choose their doctors and hospitals. And all Americans will be free from the fear of medical expenses and able to seek the best possible care when illness strikes.

Today, House Committee on Energy and Commerce Chairman John Dingell (D-Mich.) and I are introducing legislation to extend Medicare to all Americans, from birth to the end of life. In addition, our plan will reduce costs and improve quality, including more effective use of health information technology. It also puts a new emphasis on preventive care, because preventing illness before it occurs is always better and less expensive than treating patients after they become ill.

Our proposal will be entirely voluntary. Americans who wish to stay in their current employer-sponsored plans can do so, and employers can tailor their health plans to provide additional services to their employees that wrap around Medicare coverage. Those who prefer private insurance can choose any of the plans offered to members of Congress and the president.

For the full text of S1218 & HR2034, the “Medicare for All Act:” (Insert “HR2034” into the search box, click “Bill Number” and click “Search”. S1218 is the same bill, but it has not yet been posted on Thomas.)


By Don McCanne, MD

Congressman Dingell and Senator Kennedy for decades have been leaders in the effort to obtain comprehensive health care coverage for everyone. The introduction of their Medicare for All Act is a very welcome addition to the national dialogue on reform. Their proposal would result in a definite improvement over our current dysfunctional system of financing health care. That’s the good news.

So what could be bad about this? Well, first a brief word about the respective roles of those of us involved in the health care reform movement. John Dingell and Ted Kennedy are politicians, in fact, master politicians. Their role is to negotiate the political process, carefully traversing the minefields, to make reform a reality.

The role of those of us in the policy community is quite different. We advocate for the most effective policies that will bring high-quality, comprehensive health care services to everyone. Policy and politics frequently can clash. The political process involves compromise so that the perfect does not become the enemy of the good. The policy community advocates for the perfect, unrelentingly so, so that the good does not become the enemy of the perfect. The policy community informs, but does not compromise. It is imperative that when the political community is negotiating compromise, the policy community be there to inform the participants of the process on the tradeoffs that are being made that will have an adverse impact on the health and/or finances of patients.

There is much to complain about in this bill, but my brief comments will be limited to the general structure of the reform proposed.

The bill leaves in place the private insurance industry. In fact, it encourages a greater participation by private insurers by creating a new insurance program optionally available to everyone, designed after the private plans in FEHBP (Federal Employees Health Benefits Program). This satisfies the political rhetoric of offering to everyone the same coverage that members of Congress have.

They even included in the legislation an explicit call for cost sharing in the form of deductibles, coinsurance, copayments, and even premiums. Previous studies have demonstrated that the cost sharing levels in FEHBP can create financial hardships for individuals with modest incomes and significant medical needs. Other nations that provide comprehensive services to everyone at a much lower total cost than in the United States have been able to do so without the necessity of using cost sharing to control health care spending. There are far more effective and more humane methods of containing costs that won’t be covered here (hint: single payer).

If we are going to fund our health care system equitably and efficiently, it is essential to establish a universal risk pool. This proposal not only perpetuates the private plans, it also isolates the pool of the new FEHBP program from the established program. It does call for risk adjustment of pools, but that has proven to be a difficult and imperfect process and opens the system to nefarious gaming.

The proposal leaves in place our welfare programs such as Medicaid and SCHIP. Chronic underfunding plagues both the beneficiaries of these programs and the providers. A Medicare program accessible to everyone risks becoming a welfare program for individuals with higher health care costs, and risks underfunding due to the “death spiral” characteristic of high risk pools.

Their proposal perpetuates the administrative complexity of our current dysfunctional, multipayer system, resulting in a profound waste of resources that should be used for health care instead.

Should we oppose this bill? Going back to defining the relative roles of supporters of health care reform, it is not the job of policy wonks to engage in political activity in an effort to obstruct measures that would have a modest beneficial impact on our health care system. But if you consider continual harping on the best policies that would have the most favorable impact to be political, than maybe we are guilty of that. But that’s our job.

When the politicians privately concede that a single payer system is the ideal, but tell you go away because your concepts aren’t “feasible,” don’t do it. Stay there and remind them of the financial hardship, suffering and death that each one of their politically-feasible compromises would cause.

Don’t let the good be the enemy of the perfect.