It is still probably the safer route, but there are things that need addressing. The cost issue is one that can be worked through......but millions of primary care physicians now refuse Medicare due to its low reimbursements and that has to change (with or without Medicare for all). As for the rationing effect--we all can't have the expensive MRIs at the drop of a hat, same with the latest expensive drug--those days are coming too. Can you say evidence based medicine?

As for scaling the program to different beneficiaries, this is not impossible either. We could scale copayments or payroll tax based on income...the less you make the lower they are. Conversely, we could scale them based on age...the older you are the higher they are.

It would be a fight, but a fight worth having.

Ezra, Scott,

See the CBO's two new reports on healthcare reform.
Bob Laszewski writes about them here: http://healthpolicyandmarket.blogspot.com/2008/12/cbo-to-health-care-reformers-naive.html

They are making it very clear that Whoever pays (single payer, multiple payer), Universal Coverage Will be Very Expensive.

As Scot says we will have to say NO to many treatments.
CBO suggests that we will have to pay taxes on employer-based insurance. (If we no longer have employer-based insurance, the middle-class and upper-middle class will still have to pay higher taxes to cover the poor and lower-middle class.)

They say that Medicare payroll taxes wil have to be raised by 1%

Most radically, they suggest that fees for doctors and hospitals in high-spending wasteful regions (the East Coast from Boston south to Florida, Southern California, parts of Texas, etc will have to be lowered.

There is no reason that Medicare taxpayers in Minnesota, Iowa, Montanta, Vermont New Hampshire and Maine--where doctors and hopsitals achieve equal ooutcomes while doing far fewer tests and proccedures be paying for overtreatment in the high-spending regions.

And Scot-- NO, we cannot scale up co-payment based on age. The average Medicare recipient has total income from all sources (capital gains, dividends, earned income, Social Security etc.)
of just $20,000 a year. Half earn less than $20,000. Many cannot afford the co-pays
and

We are going to have to continue to pool our ressources (as we now do for Medicare)--even more so if we want to cover everyone.

The young,healthy, and relatively affluent are going to have to pay for the old, sick and poor. Morally this is the right thing to do. But even those who cannot see that recognize that someday they will be old, most will be sick and they may even be poor. There but for fortune . . .

Universal coverage will be most costly for the upper-middle class--those earning somewhere over $65,000 a year.

Read the CBO reports. CBO will be marking up any legislation, telling Congress whether it will cost, and they're making it clear that they be real about the numbers.

Medicare for All does provide a valuable starting point for discussing universal coverage. The biggest problem, of course, is that Medicare has a massive unfunded liability emerging over the next several years. Its replication in the general population would increase that unfunded liability by several factors.

Also, as the author notes, Medicare is much easier to administer than a broader pool - the formulary is largely composed of a handful of drugs and the population faces a handful of the same health issues, which makes rate setting much easier.

Maggie, good point about the aged not being wealthy and thus not being able to support a scaling up of copays, etc. I was trying to make the point that we could have variable benefits (based on some factor) and not be wed to one plan fits all. I could have said that more clearly, however.

Universal coverage will be expensive, but healthcare as it is now is expensive and is not geting any cheaper. And the way we have fragmented the system makes it impossible to implement the things that should be done (e-scribing, health IT, evidence based medicine, etc).

Another way of looking at this expense, is to make the changes as efficiently as possible, and then realize that much of the expense would be a massive fiscal stimulus...very needed at present. The health IT jobs alone would be huge.

But when you take a program with 44 million beneficiaries, all of whom are in the same age range, and scale it to 300 million beneficiaries across all age demographics, a lot of uncertainty is introduced Medicare

So hire some actuaries. Isn't quantifing uncertainty what they do for insurance companies?

Medicare is not a great insurance policy. It doesn't begin to compare with coverage from most private PPO's. That's why a lot of Medicare beneficiaries have a supplemental insurance policy on top of Medicare.

Medicare-for-all could work the same way. Provide basic medical and dental and allow those who choose to supplement it with private policies. Its not a perfect single-payer plan but it would move the ball forward.

It also has the advantage of already being a familiar method to an awful lot of people.

When do you think the health discussions will move from providing insurance to actually providing care? Let's use some of the discussed stimulus to build public health facilities and educate/train health care providers.

The trick is to expand incrementally. Expand S-CHIP to more and more children, and Medicare to lower and lower age groups. Establish that the sky hasn't fallen, and then expand some more. Eventually you get to single payer, and you have time to solve all the transition issues.

Certainly a much better idea than criminalizing poor people because they can't afford insurance.

I keep wondering if we can't do it incrementally -- just lower the age for Medicare three years at a time, every year.
By the time Obama's 2nd term is done, Medicare is down to people in their late thirties.

Definitely we'd need to do separate kids version at the same time, but...

Well, first of all, health care costs money. We have to pay for it. The problem comes when we have to pay the entity that delivers it to us, 30 cents of every dollar we spend in overhead. And that figure (30 cents) has no indication that it is not going to grow to 31 cents, etc. And the entity that now delivers makes no attempt to keep that 30 cents at 30 cents, and in fact, the first sign of tightening of cost, they raise the price of delivery, because they can't justify limiting what they're delivering for the cost they charging for delivery. The answer is that we cannot afford to not have universal coverage.

A substantial bureaucracy is going to be needed to cover all aspects of the universal coverage of Medicare. First we implement it, and then we have the national debate about what will be covered, and how to keep costs down, a debate that will be a lot easier to have when the overhead cost of the delivery is 3 cents, as I believe Medicare is now.

Some other insights: any carrier who demands that he be paid whether what he delivers is successfully delivered or not, should have no choice in whether he will deliver or not. But in fairness, the deliverer would be exempt from being sued (a good selling point IMO), but would be subject to review of his delivery by a board that is part of the aforementioned bureaucracy.

Another thing, the 44 million figure would not go to 300 million, assuming the option to stay with my current deliverer remains. The universality of Medicare for all would be that all citizens have the option of taking Medicare. E. G. you have a Social Security number, you can sign up for Medicare. Another aspect that would be handled by that bureaucracy. And if we're afraid of the crap we're gonna get from the right about setting up "another government bureaucracy", there's no further need for discussion!

"but millions of primary care physicians now refuse Medicare"

Millions? Really?

"It's not hard to imagine widespread elderly opposition to opening Medicare to the general population, as they worry that an open Medicare will produce political pressure to orient the program to the average beneficiary (who is cheaper, younger, and healthier), rather than the average elderly beneficiary."

otoh, maggie's not only advocating AGAINST opening medicare to everyone, she's advocating FOR controlling medicare's rising costs by scaling waaaay back on end-of-life care. it's not the youngsters that the elderly need to be afraid of.

really, the best way to save medicare -- which right now is little more than a national high-risk pool -- is to throw as many young, healthy, inexpensive people into it as we possibly can. oh... wait... that could be all 300,000,000 of us.

Medicare is not the only federal single-payer system. The military's Tricare system covers retirees, active duty and reservists.

Tricare Reserve Select, which reservists can buy into, seems like a typical PPO package. It would be easier for Congress to just expand Tricare as-is than to simultaneously expand and modify Medicare.

For 2009, reservists pay 28% of total premium cost ($44.71 a month for an individual, $180.17 for families).
http://www.military.com/benefits/tricare/tricare-reserve-guard/tricare-reserve-select-overview

Actually, when my husband went on Medicare a year or so ago, just about EVERY doctor accepted Medicare in my area. It wasn't hard to find someone at all. We could pick and choose, and the paperwork with part A and B was very easy, compared to Part D which is a nightmare of yearly decisions, booklets with long lists, and other crap the private insurance companies throw at you.

Andre,

You have no clue what your talkign about. You can't find a single insurance company with 30% overhead. Medicare doesn't have anywhere close to a 3% overhead, and finally only a moron would compare the overhead of two plans as a % when one has a base cost of 3500 and the other 6000+. Incase your as bad at math as you are at facts 5% of $3500 is not the same as 5% of $6000.

Whats scary is people are misinformed as you get a vote in this.

Emma Zahn,

We do need to move the discussion from providing insurance to providing care, first people need to learn what insurance is. And one of the first things you would learn is next to nothing regarding dental care is insurable. Why would you insure against getting 2 cleanings and x-rays every year? You know you need them, why would you pay any mark up or administrative fee to cover them. No insurance plan should ever cover dental. It's inefficient and not not cost effective.

If your worried about poor people not being able to afford to see a dentist covering it through insurance is the worst way of solving the problem. Save the insurance premium, billing, and all the other mess and hire a handful of dentist in each county to give free cleanings and x-rays.

This same logic applies to most Rx, office visits, co-pays and low deducibles. Before you people go trying to reform the insurance market it would be nice if you first learned what insurance is!

nate is advocating here for my preferred solution -- socialized medicine, the real kind, where the govt hires all the doctors, nurses, dentists, mental health counselors, pharmacists, etc and pays them a decent salary to hand out all needed medical services, devices, and drugs for free.