During the Democratic primary, Joe Biden promised to veto Medicare for All legislation — two days before the World Health Organization (WHO) declared COVID-19 a global pandemic. COVID-19 has exposed the inadequacies of private health insurance. Approximately 49 percent of Americans depend on their employer for health coverage. Amid historic unemployment, 12 million Americans have lost their health insurance since February 2020. Enrolling these individuals into Medicare would provide them immediate relief that is impervious to negative economic trends. President Biden received the most votes of any presidential candidate in history in an election with the highest turnout since 1908. He should leverage his historic mandate and considerable popularity to usher in this change. Following the ripple effects of coronavirus deaths and the subsequent mushrooming unemployment, unprecedented and bold action is a necessity.
MEDICARE EXPANSION CASE STUDY
Throughout 1990, Libby, Montana produced 80 percent of the world’s vermiculite supply. Vermiculite is a mineral predominantly used to manufacture fertilizer and insulation. It is benign on its own, but the vermiculite in Libby was contaminated with asbestos.
In 2010, Sen. Max Baucus (D-MT) amended the Affordable Care Act to address the Libby crisis. Under this provision, which became codified in Section 1881A of the Social Security Act, individuals exposed to dangerous environmental conditions (through no fault of their own) that make them vulnerable to long-term medical complications can be absorbed into Medicare. Additionally, the individuals must be present within a certain geographic area for at least six months. All 2,628 residents of Libby were granted Medicare eligibility. Based on this historical precedent, Biden is within his legal right to enroll most if not all Americans into Medicare.
Although the Biden administration’s robust vaccine rollout has helped subdue the pandemic, its disastrous effects still linger. A Harvard Medical School study estimates that 50 to 80 percent of individuals infected with COVID-19 continue to experience symptoms three months after its onset. Notable long-term symptoms include shortness of breath, joint pain, chest pain, difficulty concentrating, depression, insomnia, heart palpitations, and acute kidney injury.
Like the residents of Libby, many of those infected with COVID-19 will be afflicted with long-term health complications through no fault of their own. Since the pandemic has occurred throughout the whole United States for well over six months, the geographic and temporal requirements are also satisfied.
Even if President Biden does not want to expand Medicare to all Americans, he can at least extend eligibility to individuals residing in regions hit hardest by the pandemic. Section 1881A allows for the establishment of Medicare pilot programs that could specifically target these populations.
AFFORDABLE CARE ACT SHORTCOMINGS
Every year, 530,000 Americans declare medical bankruptcy. Roughly two-thirds of all bankruptcies are connected to exorbitant medical expenses. Despite President Obama’s intentions, the Affordable Care Act (ACA) has failed to reverse this trend. Medical bankruptcies have continued to rise since the law’s implementation. Prior to the ACA, 65.5 percent of bankruptcies were caused by medical issues. Three years into the law’s passage, the proportion ascended to 67.5 percent.
The ACA possesses considerable merits. It expanded Medicaid and subsidizes premiums for individuals and families with incomes below 400 percent of the poverty line, which helped to reduce the national uninsured rate from 15 percent to 8.5 percent. Adoption of Medicaid expansion is left up to state discretion, however, presently, 12 states have not embraced the expansion. This has resulted in a coverage gap where two million individuals either earn too much to qualify for Medicaid or too little to be eligible for the premium subsidies.
By closing the coverage gap, Medicare for All would save approximately 68,500 lives annually. The elimination of premiums, copayments, and deductibles would slash yearly health care expenditures by $458 billion. For context, ending homelessness and making public colleges and universities tuition-free would amount to an annual cost of about $120 billion.
Close to 31 million Americans have been infected with COVID-19. The pandemic contracted the U.S. economy at its worst rate since 1946. It also plunged nearly 8 million Americans into destitution — the highest one-year increase in the poverty rate since 1960. Unprecedented action is needed to overcome these exceptional circumstances.
PUBLIC SUPPORT
In 2020, the ACA reached peak popularity, with 55 percent of voters expressing approval. However, Medicare for All is significantly more popular. Since October 2018, support for Medicare for all has consistently hovered at around 70 percent.
In 2018, Democrats reclaimed the House largely because voters preferred their message on health care. Two years later, Georgia Senate candidates Raphael Warnock and Jon Ossoff ran unapologetically on expanding the ACA by adding a public insurance option. This political calculus proved fruitful in a state where one-quarter of residents suffer from a preexisting condition.
The public option enjoys a nearly identical level of commanding support as Medicare for All. Unlike Medicare for All, however, it would leave millions uninsured or underinsured and force businesses to foot the bill when providing coverage to employees. Additionally, private health providers would be incentivized to avoid risk by rejecting unhealthy applicants — thus overburdening and potentially bankrupting the public alternative provider.
CONGRESSIONAL HURDLES
The composition of the Senate is currently evenly split 50-50 between Democrats and Republicans. Regular legislative progress (requiring 60 votes) is impossible since no Republican would support Medicare for All.
The likelihood of the Senate passing Medicare for All via budget reconciliation (the method used to circumnavigate the 60-vote filibuster threshold) is dubious. The legislation would likely violate various parts of the Byrd Rule—which outlines six criteria that all bills must fulfill if they are to pass through reconciliation, which bypasses the filibuster by only requiring support from a simple majority. The proposal would likely fail to meet the Byrd Rule stipulations because its effect on spending and revenues would only be incidental to its policy impact, it would likely raise the federal deficit after 10 years, and its failure to reduce the federal deficit would severely hinder its funding options. Passing Medicare for All through Congress only becomes plausible if Democrats abolish the filibuster, enabling them to move forward with a 51-vote majority. However, at least five Democratic senators and Sen. Angus King (I-ME), who caucuses with the Democrats, support retaining it.
To avoid a procedural nightmare in the Senate, President Biden should use his executive authority via Section 1881A to swiftly enact a popular policy during a time of great need.