Forbid private insurance is the new individual mandate.

Although no one knows exactly what "medicare for all" might look like in practice, it is supposed to be the antithesis of Obamacare with regard to plausible democratic health reforms. The Affordable Care Act is progressive and complicated. Medicare for all is radical and simple. The Affordable Care Act regulated the private insurance market, but did not stop it. Medicare for all would explode. The Affordable Care Act was hell to explain. (A generation of journalists have the phrase "three-footed saddles" engraved in their brains).
Medicare for all is simple: everyone gets the same government health plan, paid with taxes. Completed.

And yet, despite their fundamental differences, the two systems have at least one big point in common. Each is (or, in the case of the ACA, was) built on a central and unpopular disposition that is also a focal point for criticism, and may not be really essential to the overall goal of obtaining every generous American insurance. For Obamacare, this board was the individual mandate. For Medicare for All, it's the ban on private insurance.

The individual mandate, which required all Americans to buy insurance or pay a tax, has become a cautionary tale for politicians (with the exception of Joe Biden, who apparently wants to bring him back) and for politicians on the dangers of defeating an unpopular political health regime on the public. When Barack Obama ran for the Democratic nomination in 2008, he opposed the mandate and violated Hillary Clinton's health care regime in debates and in the TV commercials to include one, claiming that it was unnecessary and could force some families to buy a blanket that they could not afford. This has turned out to be a winning message. Once he became president, however, Obama overturned under pressure from his Congressional advisers and Democrats who were seeking a better score from the Congressional Budget Office, and supported a mandate in the Affordable Care Act.

We all know how it turned out. The warrant ended up being one of the least popular provisions of Obamacare, a magnet for Republican attacks and lawsuits challenging the constitutionality of the law, one of which currently threatens the future of the law.

What makes the history of an individual mandate a tragedy rather than a simple misstep, is that it might not have been necessary at first. Forcing all Americans to buy insurance was supposed to be an essential part of Obamacare. Otherwise, many thought that the new system would wait to be sick to be able to benefit from coverage, increasing costs for all others and destabilizing the market. But the mandate proved less effective in getting Americans to buy insurance than their architects hoped for. And after the Republicans canceled it in 2017 as part of their tax bill, the Obamacare trade continued to work well as families continued to buy subsidized coverage. In retrospect, it is quite possible that, with some structural adjustments, the ACA could have worked properly and be more popular without a warrant. The Obama candidate was probably right.

Although the mandate dominated the democratic debate on health care in 2008, the health care debate in the first year of this year focused on the banning of Medicare for All for most private coverage .
Under the law proposed by Bernie Sanders, and some candidates, including Elizabeth Warren, approved, the federal government would propose a single generous health plan. Insurers such as BlueCross, BlueShield or Aetna could technically continue to operate, but they would be prohibited from selling policies with the same benefits as the federal system – what the world of health policy calls "duplicative coverage" ". Since Sanders wants Medicare to pay for the vast majority of the services and procedures the Americans would need, there would not be much room left for private carriers. That's what makes it a truly one-payer system.

Like the mandate, the ban on private coverage is not a very popular idea. At least, that's not the case now. Polls suggest that many Americans like the phrase "Medicare for All" because they assume it means giving everyone the choice register for government coverage. Once you have explained to them that this would require them to exchange their current insurance for a public plan, the support drops off considerably.

We do not really understand why, because few people seem to really like their insurance company. Some surveys have shown that the enthusiasm for Medicare for all is rebounding if pollsters explained that even if private carriers disappeared, people would still be able to keep their doctor. This suggests that some Americans actually fear losing their favorite doctor, not their Cigna card. But for now, the ban on duplicate coverage seems to be a poison pill for public opinion. This is why NBC has made it one of the questions of "debate": it is a factor of division.

The question now is whether the prohibition of private insurance is in fact a necessary means to an end, contrary to the fact that the mandate was lacking.

When Sanders and Warren recently spoke of the need to remove most private insurance, they tended to focus on the billions of dollars generated by the insurance industry's profits rather than on the treatments, as well as on the need to transform health care into human resources. right. And if you talk to health policy actors at Capitol Hill and think tanks, you will usually hear three main reasons to believe that it is essential to take an active part in the insurance industry.

The first is simplicity. Nobody likes to buy insurance. Nobody likes to deal with his insurer. And no one likes it when they lose an orthopedist because he has decided to no longer accept their AOPA Select PPO. Putting everyone on the same level of government health eliminates these headaches. It would also prevent the poor from getting through the bureaucratic cracks of the system. Today, many Americans do not enroll in Medicaid because they do not realize they are eligible. under single payer, this should not be a problem.

The second reason is profitability. American medicine would be cheaper if you removed private coverage, because insurance companies were no longer making profits and hospitals would not have to hire as many administrators to manage them.

Third, and finally, there is equity. Most single-payer advocates believe that every American should have access to the same level of medical care, whether rich or poor, and that the cost should be borne collectively by taxpayers. Leaving private insurance in place would allow the rich to buy benefits and relieve some of the financial burden on individuals.

These are all admirable reasons. But at the end of the day, none of them is really necessary for universal, affordable insurance, which most Americans seem to want out of health reform. It is quite possible to design a program that broadens Medicare and allows anyone to enroll (you can even enroll people without coverage automatically) while leaving some room for private insurers to continue to operate. This is the idea of ​​Medicare for America, the single payer plan that has been supported by some progressive democrats. It is also how most countries with universal health systems operate.

The Sanders bill is inspired by many elements of Canada, which prohibits duplicate coverage. But in countries like Britain, Australia, Denmark and New Zealand, people can take out private insurance allowing them including faster access to doctors and hospitals. This adds an inequality to the mix, but gives patients a chance if they do not want to wait for months for an MRI or surgery. It is a pressure valve for discontent in the system.

The fact that unless there is duplicate coverage is not essential Making universal health care a reality is not necessarily a reason for not doing it. But there are also reasons of general politics for which it may not be such a good idea.
Like the mandate, it can simultaneously generate feedback, while operating less efficiently than expected.

For starters, the Canadian health care system is known for its long wait times. They tend to be worse for non-urgent care such as hip replacements. But they are a constant source of frustration for patients and it is very likely that the United States, already suffering from physician shortages in large parts of the country, could face similar problems. It's not hard to imagine the fury this would create.

At the same time, the ban on private insurance would not prevent some wealthy patients from buying better care. In Canada, private clinics have found ways to circumvent the rules and charge high annual fees for "executive health packages" that are supposed to provide services that are not covered by the government, but that generally appear to be coverage that allows wealthy customers to quickly purchase free services. call for access to a doctor. In the United States, they may not even need this type of legal fig leaf. As recently pointed out by Jon Walker in the American Prospect, single payer bills that circulate in Capitol Hill would let doctors opt out of Medicare and bill patients directly. As a result, you could start seeing private health care clubs – Cleveland clinics for the very wealthy. I am told that hospitals or doctors could possibly charge patients for membership fees for guaranteed appointments. In other words, even if you ban private insurance companies, you may end up with a two or three tier health system.

Of course, this would be a problem only if the single payer passed. The reality is that even if Sanders or Warren became president and wanted to erase the rules of procedure of the Senate in order to adopt a single-payer plan by absolute majority, they probably could not get the votes. Whatever the Democrats adopt, they will have to be heard by lawmakers like Michael Bennet of Colorado, who is currently running for president. against Medicare for all.

In the end, this could be one of the most important differences between the individual mandate and the prohibition of duplicate private insurance. The mandate could have been a well-intentioned and unpopular idea that failed in many ways. But at least, his inclusion at the time allowed Obamacare to pass. Except private coverage would not even do that.