By James W. Russell

If the Bernie Sanders momentum continues, his signature Medicare for All proposal will become an even more intense subject of national debate than it already is.

Attaining universal health insurance has never been a technical problem in the United States. We know that because every other major country and a number of minor ones have attained it at much lower cost and with better health outcomes than the private health insurance system that we have. If they can do it, so too could the United States.

It is rather a political problem that has two sides: opposition from the private health insurance industry that profits excessively from the existing system and opposition from members of the public who fear losing their existing private insurance.

There is very little that the proponents of Medicare for All can do about the first source of opposition. It is what stopped the Clinton health reform and resulted in the Affordable Care Act being considerably weakened in return for the support of the private health insurance industry—the political lesson learned from the Clinton debacle.

The private health insurance industry has at its disposal a powerful arsenal of political contributions, lobbyists, and public relations firms to fight any reform to the health care industry that it sees as inimical to its bottom-line interests.

A part of its strategy, beyond direct influence of politicians, has always been to use public relations firms to mold public opinion so that it will be on their side in any fight over health insurance reform. Even if opinion polls show majority support for some form of Medicare for All, having a significant active minority opposition will make passage of enabling legislation very difficult.

Then there is partisan Republican opposition to anything Democrats do to reform healthcare. Witness the town hall near riots that greeted the Affordable Care Act (Obamacare) that Democrats had carefully crafted to have the support of the private health insurance industry.

Winning significant progress toward universal quality health insurance will require being willing to proceed against the inevitable opposition of the private health insurance industry while diminishing public opposition, even if that is already a minority sentiment.

That’s where a transitional Medicare for All proposal comes in as opposed to an all-or-nothing, all-at-once one.

A transitional proposal is not to be confused with the current public option ones. Those proposals diminish public opposition at the cost of effecting the needed transformation of health insurance. There are multiple ways that private insurance companies can manipulate risk pools to make sure that public option plans get the sickest most expensive patients, what is called adverse selection.

A transitional plan would lead to the transformation of the health insurance system in a way that would diminish sources of public opposition, thereby making it more politically possible.

A transitional Medicare for All would allow people to keep their existing private insurance if they wanted to or join a new Medicare for All plan with equal or better benefits.

At the same time, all new health insurance participants would be enrolled in Medicare for All.

This is similar to when employers soft freeze a pension plan. Existing pension participants continue with the plan but all new employees receive a 401(k) instead.  The difference is that while soft freezes represent benefit cuts, enrollees in Medicare for All would receive equal or better benefits.

Requiring new enrollees, who would be mostly young, to join Medicare for All would solve the risk pool adverse selection problem.

Put differently, everyone would automatically be enrolled in Medicare for All with the right to opt out if they had a private plan they preferred.

Having quality Medicare for All or keeping existing private insurance as options will quickly diminish public opposition from those who, rightly or wrongly, fear losing their private insurance. They may not become in favor of it, but at least they would not continue to actively oppose it. Removing that source of public opposition would, in and of itself, greatly enhance the legislative prospects for passage of Medicare for All.

And what person without insurance would be opposed to automatically receiving free or low-cost quality Medicare for All?

About the Author 

James W. Russell ([email protected]) is the author of Social Insecurity: 401(k)s and the Retirement Crisis. An authority on retirement policy in the United States, Europe, and Latin America, he led one of the first employee movements to successfully challenge the dominant trend and replace a 401(k)-like plan with a more secure traditional pension plan. He has taught at universities in the United States and as a Fulbright professor in Mexico and the Czech Republic. He currently teaches Public Policy at Portland State University. Connect with at jameswrussell.com and on Twitter at @jwrpdx.