Dr. Clif Cleaveland

Politicians across the political spectrum have advanced 'Medicare for All' as a solution to our nation's continuing struggle to find consensus in the provision of affordable health care. Few details have emerged about the workings of such a program.

Before the enactment of Medicare and Medicaid in 1965, a majority of Americans on Social Security lacked health insurance. A major illness or injury could devastate a family's finances.

When launched, Medicare covered 19 million Americans with an annual budget of $10 billion. Funding, then and now, comes from payroll taxes, taxes on Social Security benefits and premiums. Today, Medicare provides coverage for 58 million people at an annual cost that exceeds $700 billion, or 15 per cent of total federal spending. Twenty percent of enrollees depend upon Medicaid to pay their premiums and deductibles. Increasing numbers of Medicare-eligible Americans and sharply rising costs of care pose challenges for Medicare's future.

Medicare Part B plans, which are offered through private insurance companies, cover physician and other outpatient services. Part C, Medicare Advantage, offers an alternative, comprehensive, managed care plan of care through private companies. Medicare Part D provides prescription drug coverage.

Medicare for All (MFA) could follow three paths:

* Replacement of all existing health insurance plans, public and private, with a single-payer, government-run program. In my opinion, enactment of this proposal would create a bureaucratic nightmare for everyone — providers and patients alike. Traditional Medicare has required more than 50 years to work out its protocols and pay scales.

* MFA would offer optional buy-ins for people of all ages who desired an alternative to private, health insurance plans. The risk to this proposal is that MFA might attract older and sicker individuals, leading to disproportionately higher premiums. Competition between MFA and private plans would only work if each plan operated under identical rules about eligibility and benefits. No plan could discriminate against persons with pre-existing conditions. Plans would compete on the basis of service and customer satisfaction.

* MFA would limit optional buy-ins to people in the 50 to 64 year age-range. Self-employed persons or others with individual, health insurance plans might choose this alternative.

Public support for MFA varies, depending upon how questions are phrased. Support for MFA dwindles if tax increases or lack of choice of provider is linked to a proposal.

A better alternative would be to continue work on Medicare. Competition between traditional Medicare and Medicare Advantage could define ways to simplify administrative functions, reduce costs and improve the often laborious process of obtaining clinical referrals. Medicare also includes demonstration projects to determine the most effective means of providing care to patients who suffer from multiple chronic illnesses or who are home-bound.

Costs must be brought under control for any new health care initiative to succeed. The U.S. continues to spend far more of its Gross Domestic Product (17.3 per cent) for health care than any other industrialized country. We are the only industrialized country that does not provide universal access to health care. More than 30 million people have no health insurance. Health-related expenses are the leading cause of personal bankruptcies in the U.S. For two years, average life-expectancy for Americans has dipped.

To paraphrase the Rev. Martin Luther King, Jr., "I have a dream that one day Republicans and Democrats and all those in-between will sit down together and find the will and the means to assure that every American has access to excellent, affordable health care that will lift the burdens of illness and assure his and her pursuit of happiness."

Contact Dr. Clif Cleaveland at