Setting the stage for Medicare for All and the health coverage debate

Health coverage and financing are top debate issues in this election cycle. Presidential candidates, health policy experts, and think tanks are discussing a range of proposals. It is too early to say what proposals, or which candidates, will move to center stage. That said, there is reasonable likelihood that new health coverage policies will continue to be part of the ongoing campaigns and discussions in Washington. Health care stakeholders can benefit from getting to know more about the various proposals to prepare their future strategies.

This policy brief offers a high-level overview of the main proposals, reviews some of the key policy questions, and discusses possible stakeholder implications.

Why is health coverage an issue? While the Affordable Care Act (ACA) reduced the number of uninsured in the United States, 11 percent (30 million people) were still uninsured in 2019 (figure 1). That said, the uninsured make up a relatively small share of the total population. Many more people, even if they have coverage, are worried about the costs they might face. A recent Gallup poll found that 45 percent of Americans are concerned a major health event could lead to personal bankruptcy, including a third of those earning more than US$180,000 a year.¹

People with employer-sponsored coverage, in Medicare, and in the ACA exchanges, all might face out-of-pocket expenses in the form of premiums, deductibles, copayments, and coinsurance. Employers, many of which pay a portion of premiums, have raised concerns about the cost of health care. Premiums and deductibles in the employer market increased significantly between 2009 and 2019—54 percent and 162 percent, respectively. Employees personally contribute about a third of premiums (US$6,015 for family coverage in 2019) and employers contribute the rest (US$14,561).² By contrast, wages have increased only modestly above the rate of inflation during that same 10-year period (figure 2).

Democratic presidential candidates are offering proposals aimed at expanding coverage and reducing consumers’ out-of-pocket health care costs. Some proposals would create new coverage options, while others would fundamentally change how the US health care system is designed and financed by expanding the role of government and reducing the role of private insurers.

Few of the proposals include strategies to tackle ongoing cost issues in the system, such as reduction of waste, overutilization of services, and improper payments, or address social determinants of health or other public health issues. The focus of this discussion is primarily on insurance coverage and affordability.

Download the full report to explore four coverage expansion proposals and what they mean for industry stakeholders.

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