Elections Raise Specter of ‘Medicare for All’ vs. Employer Benefits

Employers prepare for a debate over the future of health benefits

Stephen Miller, CEBS By Stephen Miller, CEBS August 15, 2018
Elections Raise Specter of ‘Medicare for All’ vs. Employer Benefits

updated on Aug. 24, 2018

Republicans and Democrats disagree on how to improve access to reasonably priced, high-quality health care, but they do agree that changes are needed.

After the 2018 midterm congressional elections, will there be a renewed and successful push to repeal and replace the Affordable Care Act (ACA)? Or will the momentum change toward single-payer health care—such as by expanding Medicare so it covers everyone ("Medicare for All"), as some progressive Democrats advocate? Alternatively, partisanship could give way to modest and moderate efforts to make the ACA more workable for more people.

Whatever scenario unfolds will hinge on which political party ends up in control of Congress next year and whether either party has a commanding majority, political analysts say.

Trying Again for 'Repeal and Replace'?

"Republicans are split on whether to renew their efforts to repeal and replace the Affordable Care Act," said Christopher Condeluci, principal and sole shareholder at CC Law & Policy in Washington, D.C., and former tax and benefits counsel to the U.S. Senate Finance Committee.

Although repeal failed last year, "conservatives are never going to give it up, while moderates say, 'Let's just try to get along' " by making modest reforms to the health care statute, Condeluci said at a July online forum streamed live by Benefitfocus, a benefits technology and services firm. "More Democratic candidates [for Congress] believe in promoting some sort of single-payer-like system, and we're going to continue hearing about single payer and Medicare for All up into the 2020 presidential election."

If the Democrats have a majority in Congress in 2020 and take the presidency, and if the new president is a single-payer proponent, "then we're going to have a big conversation about the employer-based system," Condeluci said. "It's coming, so [employers] should prepare for it, should the stars align in that way."

If Republicans keep control of both the House and Senate, however, "we're back in a repeal and replace conversation," Condeluci said, and with sufficient GOP numbers—considered unlikely but elections can upend conventional wisdom—they might succeed.

'Medicare for All' Gains Traction

A group of 70 House Democrats launched the Medicare for All Caucus on July 20, with the goal of passing H.R. 676, the Expanded and Improved Medicare for All Act. According to the bill's summary, it:

...establishes the Medicare for All Program to provide all individuals residing in the United States and U.S. territories with free health care that includes all medically necessary care, such as primary care and prevention, dietary and nutritional therapies, prescription drugs, emergency care, long-term care, mental health services, dental services, and vision care.

The bill itself states:

It is unlawful for a private health insurer to sell health insurance coverage that duplicates the benefits provided under this Act.


Nothing in this Act shall be construed as prohibiting the sale of health insurance coverage for any additional benefits not covered by this Act, such as for cosmetic surgery or other services and items that are not medically necessary.

As in the Canadian health system, private employers would be limited to providing supplemental coverage only.

"Medicare for All" is now favored by many of the Democratic Party's potential 2020 presidential candidates, The Hill reported. Progressives who champion a single-payer solution say that poll numbers are on their side. A survey by the nonprofit Kaiser Family Foundation, a health care policy think tank, last year showed that:

  • More than half of adults in the U.S.—53 percent—somewhat or strongly favor a single-payer health care plan.
  • The share rises to 57 percent when the program is called "Medicare for All."

However, 47 percent believed they would be able to keep their current health insurance arrangement under a single-payer system, which would not be the case.

"The fact that so many people don't know that a national health plan would require them to change their insurance arrangements underscores the challenge of making the transition from a popular idea to a reality for a single-payer national health plan," wrote Drew Altman, president and CEO of the Kaiser Family Foundation, last November. Unknown to many, he pointed out, is that "advocates of single payer consider it a virtue that employer-based health insurance would be eliminated."

'Advocates of single payer consider it a virtue that employer-based health insurance would be eliminated.'

"The public in some ways would be relieved if someone just came in and said, 'Medicare for All,' so to speak," said Jim Capretta, resident fellow at the pro-market American Enterprise Institute, speaking at a July forum hosted by the nonprofit Bipartisan Policy Center in Washington, D.C. "But there are implications to that," he added. "Taxes have to go up, and there's great aversion in this country to taxes."

He noted, "Our system of governance doesn't lend itself easily to very big, massive changes unless we're in a crisis, which we hope we're not in."

Nevertheless, Former President Barack Obama recently spoke approvingly of Medicare for All.

[SHRM members-only toolkit: Communicating with Employees About Health Care Benefits Under the Affordable Care Act]

Update: Over 70% Say They Favor 'Medicare for All'

A 2018 Reuters/Ipsos poll shows 70.1 percent of U.S. adults favor Medicare for All, including 85 percent of Democrats and 51 percent of Republicans, Reuters reported on Aug. 23, and that:

Across 41 battleground House of Representatives districts, two-thirds of Democratic nominees want to expand the government's role in healthcare, the review shows. About a dozen support "Medicare for All," for many a reference to a single-payer system that would largely replace private insurance. In Congress, most House Democrats support a Medicare for All bill, with six members of the Blue Dog caucus of fiscally conservative Democrats signing on as co-sponsors.

The health newsletter Axios Vitals commented on the findings:

Other polling has also shown a solid base of support for some version of "Medicare for All" or single-payer, but it's hard to imagine a majority of Republicans supporting such an effort if and when a Democratic president attempts it. …

"Medicare for All" doesn't have a single definition at this point, making it something of a blank slate. … But there's no denying that something more like single-payer is on the table now in a way it hasn't been for decades.

SHRM Defends Employer-Sponsored Care

"Supporters of 'Medicare for All' or a government health care system are turning up the heat," wrote Chatrane Birbal, director of the Society for Human Resource Management's (SHRM's) congressional affairs, health and employee benefits policy, on the SHRM Blog. "The outcome of the mid-terms and the next presidential campaign will no doubt impact future employer-sponsored health benefits offerings. Employer advocate groups including SHRM are gearing up for what is expected to be a steamy debate" to defend the employer-sponsored health care system.

Health care as an employee benefit "has been in place for decades, providing quality, affordable health benefits to more than 178 million Americans," Birbal pointed out, allowing employers the flexibility to design their health benefit plans to meet the needs of their workforce. On the other hand, she noted, "the Medicare system has a lot of ordinary and some would say generic ingredients, which is not appetizing when there are many other options available" that may be more appropriate to employees' needs.

Return of the 'Public Option'?

An alternative to comprehensive single-payer health care such as Medicare for All is a more limited concept that Condeluci called "the return of a government-run public option," which some liberal Democrats unsuccessfully supported when the ACA was originally drafted.

The idea, as resurrected, is to create new Medicare Part E so that anyone, regardless of age, could purchase Medicare coverage at government-set premium rates, but doing so would be voluntary. Congressional Democrats who support this alternative released the Choose Medicare Act last April.

Employers also would be allowed to sponsor a Medicare Part E plan, "so if an employer didn't want to offer a group health plan, they could offer a Medicare Part E plan to their employees," Condeluci explained.

"At this juncture, Medicare Part E may be destined to be a talking point for Democratic candidates running for President in 2020," the legal blog JD Supra noted when the proposal was released—if it doesn't fall victim to the Democratic Party base's support for single-payer Medicare for All.

Confusion alert: supporters of adding a long-term care benefit to Medicare also refer to their proposed coverage expansion as Medicare Part E.

Elusive Bipartisanship

Some still are holding out hope for bipartisan health care cooperation.

"We are beginning to see some attempt to try to find solutions to some of the issues that have arisen as a result of the ACA," said Sheila Burke, a strategic advisor at law firm Baker Donelson in Washington, D.C., and former chief of staff to former Senate Majority Leader Bob Dole, speaking at the Bipartisan Policy Center forum.

The midterm results will be important because the most intense opposition to the ACA "tends to come out of the House rather than the Senate, where you see less willingness to go back to that basic question of repeal," Burke said. A GOP loss of the House, even if they kept their Senate majority, might open the way to bipartisanship fixes to the statute, she suggested.

"I've always been cautious about hyping health care as a factor in elections," Kaiser's Altman wrote in a July 31 column. "But if circumstances do not change, this is an election where health care may not only be a top issue, but also a critical factor in the vote."

Related SHRM Articles:

On the Menu: Employer-Sponsored Coverage or Medicare for All Health Insurance, The SHRM Blog, August 2018

House Passes Bills Enhancing HSAs, SHRM Online Benefits, July 2018



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