The political momentum on the left for Medicare for All, fueled by Republicans’ dramatic failure to repeal Obamacare, has been tempered lately by an attack of the piecemeals. Some liberals are warning that the political hurdles for government-provided health care cannot be surmounted at once—that advances must ushered in slowly and incrementally, to minimize disruption.

Joshua Holland argued in The Nation earlier this month that, “from a policy standpoint, Medicare-for-All is probably the hardest way to get” to universal health care. Moving to single-payer within a year or two “would cause serious shocks to the system,” and “compelling the entire population to move into Medicare, especially over a relatively short period of time, would invite a massive backlash.” The New York Times’ Paul Krugman, meanwhile, wrote last week that single-payer “would be much harder politically than its advocates acknowledge; and there are more important priorities.” He recommended “improving the A.C.A., not ripping it up and starting over...”

Holland and Krugman endorse a public option, a government-run competitor to private insurance that individuals or employers can purchase. Several Senate Democrats have introduced a bill that would allow people aged 55-64 to buy into Medicare. Gradual access, the theory goes, can flower into one of the various program designs that industrialized nations use to provide universal health care to their citizens. But why is increased access to Medicare, which is solid but inadequate, the obvious first step? If the plan is to transition to something like Medicare for All, shouldn’t the strategy begin with making Medicare great?

The secret about Medicare is that it should fulfill many more health care needs than it currently does. Making Medicare great would be politically popular and eliminate needless fragmentation in the system. And yet, nobody wants to talk about it.


I don’t mean to suggest that Medicare is a bad program. It’s very popular, although that’s in comparison to other forms of insurance for Americans. People like employer-based insurance, but have seen co-payments and deductibles grow, and the individual market, both before and after Obamacare, has always been fragile.

Medicare—and also Medicaid, which generally is for low-income Americans—represents a basic bargain: You pay into the system, through taxes, so it’s there for you when you need it. As the Trumpcare debate showed, public-run systems have lots more support than private alternatives. Medicaid covers more enrollees (75 million), but the universal nature of Medicare—everyone over 65 gets it, or 55 million people—makes it a more attractive launching pad for single-payer enthusiasts.

But Medicare has holes in it. There’s no routine dental, hearing, or vision care included in Medicare parts A and B (otherwise known as “Original Medicare”). Some standard foot care like removing corns or buying orthopedic shoes, a significant problem for the elderly, isn’t covered. You pay for copies of your X-rays.


More important, Medicare deductibles, hospital costs, and co-payments have been on the rise. The standard premium is between $109 and $134 a month, and for hospital visits, the first $1,316 per year is on the patient. Long-term care assistance for nursing or rehabilitation is capped at 100 days. Prescription drugs through Medicare Part D have various premiums and co-pays. And there are no annual or lifetime limits; patients keep paying cost-sharing regardless of how many bills pile up. Even Obamacare exchange insurance caps how much you have to pay over a year or a lifetime.

For this reason, nearly 12 million Medicare enrollees purchase a privately issued, supplemental “Medigap” policy to cover copayments, deductibles, coinsurance, and other costs that Medicare doesn’t; that represents almost one in four people in Medicare. Most countries’ universal programs shield the vulnerable from runaway health costs; in Medicare, you have to buy that protection.

As if this isn’t complicated enough, there’s also Medicare Part C, or Medicare Advantage, which is privately offered insurance that usually has narrow networks like an HMO. Often Medicare Advantage offers special perks that neither Original Medicare no Medigap plans do: dental care, vision, and “wellness programs” like free gym memberships. And by law, these plans cap out-of-pocket expenses, unlike Original Medicare.

The promise of more benefits and ease of use has made Medicare Advantage popular: one in three seniors have a Part C plan rather than Original Medicare. This is supposed to save taxpayer money, but it’s actually a private boondoggle. The government pays more for Medicare Advantage than Original Medicare, while those plans pay out 10-25 percent less in services, according to recent studies. And stories of Medicare Advantage plans systematically overbilling Medicare are alarming.

Private insurers, and partners like AARP, make lots of money from this status quo. But it just adds unnecessary confusion and waste into the system. As Adam Gaffney writes at Jacobin, we can jettison these privately run supplements and add-ons and just build them into the Medicare benefit. That’s what Democratic Congressman John Conyers’ longtime model bill, HR 676, does: It makes Medicare coverage comprehensive for a non-elderly population, and eliminates cost-sharing. But incrementalists who caution against a Conyers or Bernie Sanders–style sudden change never consider improving Medicare to prepare the ground for such a change.


Naysayers might consider improving Medicare too expensive a burden for the government to take on. But you wouldn’t have to spend much more for better quality; savings can be found within the current program. For instance, private pharmacy benefit managers negotiate with drug manufacturers for discounts in Part D, when they have been shown to extract profits at the expense of consumers. Direct negotiations with drug manufacturers would lower costs. Medicare Advantage also costs the government more. A unified service, single-payer activists have long insisted, would be simpler and cheaper to administer.

Many (not all) universal programs around the world have some form of cost-sharing inside the government system, and virtually all allow residents to purchase supplemental plans that go beyond the basic benefit. But Medicare passes off too many of these costs to individuals. Its patient pool is big enough that it can fight the dominant health industry and get better outcomes for its users, reducing the need for supplemental protection.

It would be far cheaper to improve Medicare in its current state than to do it while simultaneously opening it up to everyone. That’s not a reason not to go for both in one shot. But I’m curious why you never see the promoters of caution arguing to improve Medicare before expanding access. Helping 55 million on Medicare would benefit exponentially more people than a public option or partial opt-in, which the Congressional Budget Office found in 2013 would have “minimal effects” on the number of uninsured. And if universal coverage is the goal, creating a great government plan that’s ready for expansion goes a hell of a lot further than making available a cramped, confusing benefit that isn’t designed for the people it will be taking in.

Even if you don’t think such change should be gradual, it’s not like President Donald Trump is signing a single-payer bill anytime soon. So where are the messaging bills to simply improve Medicare? There are political benefits, after all, to advocating for better health care for the target group that turns out to vote more than any other. The Democrats’ “Better Deal” plan does call for negotiating Medicare drug prices directly, which is a good start (they broke that promise in Obamacare). But there’s lots more value to be gained in showing people what a really great Medicare program could look like.

I fear that incrementalists are more interested in putting off single-payer supporters than actually devising the best step-by-step process that gets you to a universal system. Access is important, but so is adequacy. Bloated health care spending is crowding out the progressive agenda. Either you have the ambition for better health care for everyone, or you just want to put some spackling on a creaky building.