Around every national election, the phrase Medicare for All comes up. My reaction is simple: HUH? Here’s why?

When one reviews the basic Medicare coverage one sees it lacking in scope. Basic Medicare coverage is often augmented by supplemental coverages which the beneficiary elects to get and pays for.

Thus, the lower the income level of those that might be getting any new Medicare for All expansion coverage, the less likely they are to have the resources to get additional coverages.

Let me back up and give some context.

Medicare Part A – the base coverage.
Under the basic Medicare program there is a base coverage for inpatient hospital care, skilled nursing care (under select conditions), home care, etc. These are covered under Part A of Medicare. But this basic coverage must be augmented by supplemental coverages which the beneficiary must elect to get and pay extra for (see below).

This Part A program is structured under a fee-for-service type program – the provider performs a service and then gets a fee for that service. This type of insurance plan design induces use of services. Therefore, the Part A program has various deductibles (typically a once per year type of limit, such as $1,500 for a beneficiary, that resets annually) and copayments for various services . Insurance plans generally use these types of tools which provides a disincentive for people to overuse a service.

Medicare Part B – outpatient and physician coverage which are electives and paid for by the beneficiary.
Outpatient care and physician coverage is mostly covered under Part B of Medicare and not covered under the base Part A program. 98.5% of beneficiaries pay extra for this coverage. Interestingly, the health care world is moving toward more outpatient care/physician/telehealth (Part B) and away from inpatient care (Part A).

Medicare Supplemental Coverage – covering deductibles and copays.
Most beneficiaries have additional coverage to help cover the cost of their Medicare deductible and co pays (such as from a Blue Cross Blue Shield plan). This is in addition to Medicare Part B coverage and also costs extra.

Medicare Part D – drug coverage.
Medicare beneficiaries have access to an outpatient drug benefit under Part D which they must pay for. However, they must annually elect a type of plan from a range of coverages – two popular examples are full coverage plans (high premium) and high deductible plans (low fee but higher out of pocket cost).

Medicare Part C – a combined HMO type coverage model.
This program was developed as a health maintenance organization (HMO) type program for Medicare beneficiaries. Many such programs combine Medicare Part A, Part B and may include Part D under a single insurer. However, the quality of these Part C programs is spotty at best. There is no agreed upon way to measure their quality/service making it difficult for beneficiaries to know if they are making a smart selection). Many of these Part C programs do not require beneficiaries to pay the extra fee for Part D, but to qualify one must have elected and paid for Part B (in addition to their existing Part A coverage). So, while the beneficiary does pay for Part B, they may save on Part D.

Medicare Solvency.
Over the past decades, it’s been predicted that the Medicare program will run out of money. The Medicare Trust Fund gets its money from payroll taxes, but increasingly the amount coming in is exceeded by the dollars paying providers and Part C plans on behalf of beneficiaries. Thus, there has been increased pressure on the Medicare agency to contain or reduce payments to providers because Congress doesn’t want to increase taxes.

The lower payments have created incentives for providers/physicians to avoid the Medicare program all together making it harder and harder for Medicare patients to find doctors and other health care providers who will take them.

With that understanding, you can see why I’m concerned about “Medicare for All.” Putting more people in a program that is: going insolvent, has a decreasing provider/plan participation, requires beneficiaries to pay for out-of-pocket coverages, and cannot properly measure quality of care feels short-sighted and wrong without seriously reforming the program first.