Is Medicare for “More” a Step toward Medicare for “All”?

One of the new approaches for resolving the political debate over the public option is a return to an old idea: allow certain 55-64 year old individuals to buy Medicare coverage. Is this increase in the population that could be covered by Medicare a step toward Medicare for all, an idea supported by some single payer advocates?

The short answer is probably “no,” though it depends on the details of the legislation. The longer answer begins with an examination of Medicare’s dual role. First, and mostly, it provides coverage for 65+ year-old individuals, often called “retirees” or “the elderly” (neither term is ideal). From this perspective, stepping down the minimum age of eligibility certainly looks like a dramatic expansion and seems to set the precedent for future age-based increases in eligibility. I think this is not the correct view of what is likely to pass.

Then there is Medicare’s other role. It provides coverage for certain eligible individuals with disabilities or chronic illness, independent of age. This is probably the right way to view the type of Medicare expansion currently being considered. It is very likely that only individuals meeting certain criteria palatable to the insurance industry will be eligible for expanded Medicare. My guess is that it will be individuals with access to the exchange(s), individuals unable to obtain coverage elsewhere (the medically uninsurable), or both.

That is, Medicare for the 55-64 age range will probably only be available to those who meet certain tests of neediness, which is closer to the way it operates for disabled individuals than for the elderly. In effect, Medicare will likely be a dumping ground for bad risks, risks that the insurance industry is happy to transfer to the federal government.

This version of Medicare for more will not lead to Medicare for all, it may only lead to Medicare for all bad risks. That’s also why it may pass.

Later: Sam Stein confirms the Medicare expansion might serve as a high risk pool (h/t Ezra Klein).

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