EDITORIAL: How to achieve universal coverage? Incrementally

Sept. 17--Bernie Sanders proposed his own repeal-and-replace plan for health care last week. The Vermont senator unveiled the Medicare for All Act, a version of what was a centerpiece of his unsuccessful presidential campaign last year. In expanding to everyone the popular program for those age 65 and older, he would eliminate the system of employer-based health insurance. There would be no Medicaid or online exchanges for individual buyers of coverage.

The change carries much appeal. It would achieve universal health insurance. More, the system would be simpler, the country saving on administrative costs, now roughly twice the comparable expense in single-payer Canada. Many have made the point that if the country could start over with health care, it would adopt something along the lines Sanders advances.

What others stress is the immense difficulty in starting over. That is obvious in Republican control of Congress, Sanders without the prospect of even a hearing. Yet there is more to the tough politics than the party in charge on Capitol Hill.

The past week featured an echo of the Democratic presidential race, Hillary Clinton out with a new book about her failed presidential run, Sanders out front with his plan, returning in a way to where they clashed. Sanders has a big, sweeping idea for health care. Clinton emphasizes the value of incremental steps forward. The senator appears close to making his proposal a litmus test for Democratic presidential candidates in 2020. The shame would be if that test discouraged Democrats from advocating the approach Clinton advises.

Consider that 155 million Americans have coverage through their employer. Surveys show they generally are satisfied. Would they readily embrace something new? Sanders seeks to make the transition attractive, proposing generous benefits and no out-of-pocket costs, except for prescription drugs. As analysts note, the Sanders plan exceeds the offerings of peer countries with single-payer plans, including Canada.

They still feature co-pays and deductibles.

Which invites the question of overall cost. Sanders doesn't project an amount. Would expanded use of the system outpace savings in administrative costs? Medicaid pays less than Medicare. Would its rates rise, resulting in increased spending? As practically everyone knows, the country spends far more on health care than peer countries. How would the Sanders single-payer system bend the cost curve?

Vermont and California have looked at single-payer systems and pulled up short -- because of the huge expense and tax increases required.

What Sanders suggests is that his way is the one route to universal coverage, which is the objective, after all. Yet that isn't case, as the Affordable Care Act has demonstrated. The number of uninsured Americans has dropped dramatically, 90 percent now with coverage.

What Clinton rightly has asked is: Why repeal and replace someday when you can repair now, or extend coverage to the remaining 10 percent? How? That is part of the debate reaching a head in Congress this week. Make the subsidies in the exchanges realistic relative to cost. Allow for a public option. Expand Medicaid in the states yet to do so. Fix the individual mandate.

Do these and other steps seem too difficult, not to mention reducing costs by paying for quality not quantity and allowing Medicare to bargain for lower drug prices? They are more likely than adopting a single-payer system.

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