The first obvious flaw is most under 21 already have coverage through their parents. Changing who covers your children is still change. This is the right idea, though. Keep going down this path.

People who have a good relationship with their doctors will want to keep them. But people aren't wedded to keeping the exact same limitations, fees, and hassles that they have in their current plans.

I do think the idea of starting by covering all children is a good one; it was basically Howard Dean's concept, though his implementation in Vermont had some flaws.

Aiyeee! Socialimogrified communo-medicine! Hillary-care! Schools forcing children to have abortions and gay marriages!

Realistically, not only would it almost certainly work, but it probably would be MUCH cheaper, as the comparative levels of ADMINISTRATIVE healthcare costs across Western industrialized economies shows quite convincingly.

Politically, of course, it is the for-profit insurance companies who absorb all that extra money, and therein lies the rub.

Well, for starters, this would screw over everyone who wouldn't be eligible for the expanded coverage, who also happen to be in their peak earning years. If you're going to expand coverage, it should at least be an option for the people who are going to pay for it.

Ed: Actually, I agree. I think the idea of allowing people to voluntarily buy into Medicare is a good one. (Let companies do it too, if they want.) That could be in addition to automatically covering kids.

Kevin's idea is a good one though I would start the Medicare expansion at 25 and under as the 21 to 25 age group may be the least insured one now. I would like a single payer system, but understand why that is probably not politically practical in the next 5 to 10 years. Still, I much prefer Kevin's plan as a way to eventually get to full coverage (next step after under 25 is the 55 to 65 age group) to the complicated full-coverage plans of the Democratic Presidential contenders on efficiency and political grounds. I think the complications of the proposed plans invite effective political counterattacks (we will hear the word "mandatory" thrown back at them a lot in the next year).

Buying into Medicare would be relatively easy to pass, too. After all, it's just offering another choice. I'd think Clinton or Obama could introduce that bill tomorrow. Why wait?

There is absolutely no way in the world that "most" Americans are happy with the mess we've got. Keep in mind, if you can, that the median household income in the U.S.A. is about $45,000. What do you suppose the average person with a family, trying to make it on $45,000 a year before taxes, thinks about the prospect of U.S.-sized medical bills?

@W. Kiernan: It's not that we are happy with the mess we have. It's that we are worried that what we don't know will be messier. That's the key. Something here about the devil you know and all that.

Presumably this would destroy the economics of employer-paid plans as they lose all the relatively cheap to insure young workers, and provide a huge incentive encouraging businesses to get rid of any workers not covered by the new plan.

So aside from screwing up the healthcare of everyone between maybe 25 and 65, I don't see anything wrong with this at all.

Um, no. I don't have kids. Lower the age of eligibility for Medicare to 50.

No, work down in age from present medicare coverage, which would be less change than taking
kids off their parents coverage ( if they have any). And then start covering children to
work upward in age.

I disagree with the David Brooks-Ezra Klein hypothesis that “most Americans are basically happy with what they have” in terms of health care. Everybody I talk to has a horror story about having to fight a protracted battle with an insurance company over a claim, or a hospital that charged many times the normal (insured) rate to someone paying without insurance, or the inability to start one’s own business because that would mean leaving a job that has health coverage. I believe that most Americans are quite unhappy with their health coverage, and if they’re not unhappy with their own coverage, they know other people they care about who are unhappy with their coverage — or lack of coverage.

Contrary to Mr. Klein’s theory, what doomed the Clinton plan wasn’t everyone’s fear that their insurance would change. What doomed the Clinton plan was its needless complexity (compared to the simplicity of single-payer) combined with a lying advertising campaign, and the media stood by, as usual.

Matt Wilbert is right. The insurance industry works by taking money from the young and healthy and using it to pay for the treatment of the old and sick. It's the premium payments of the healthy 31 year olds that pay for the chemo of the cancerous 61 year olds. Kevin's plan to cover the young with Medicare and let them keep their coverage would deprive the insurance industry of their primary source of revenue. In response, the insurance agencies would either close up shop or find a way to cut costs. The way they've done that in the past is to deny coverage: classifying necessary treatments as "experimental", raising premiums to prohibitively high levels, or cancelling policies outright. The result: great coverage for the young who don't need it, increasingly bad coverage for the rest of us.

So let's put me in the skeptical column.

Nate W.

Here's one reason it wouldn't work: imagine that you're 22 years old right now. Every single job you apply for for the rest of your life, your potential employer will see the $10000/year healthcare pricetag hanging around your neck. And they'll hire someone a year younger.

In about 30 years, most companies would just lay off all their workers that are over age 51, because there's a huge pool of unencumbered workers available, and the competitive disadvantage is huge.

In about 40 years, people over 61 who want to work (whether it's because they need the money, or just find work invigorating), will find it a practical impossibility.

It would be tolerably easy to cover everyone with Medicare who wanted to be covered. Anyone who wanted to pay more (almost 45% more? -- 30 of current private plan costs going to unnecessary paperwork amount to almost 45% of the necessary 70%) or whose employer wanted to pay more for private insurance would be allowed to -- and be relieved of paying the new addition to the payroll tax.

Starting everyone under 21 as proposed above would end up doing the same thing over time.

I think most Americans don't understand what they have, and unhappy with it because they believe that something out there is probably better, whether it exists now or 25 years down the line.

The big questions that I have are these --
While you can run doctors though a series of guaranteed salaries, how are you going to put a stopper on malpractice premiums, which are publicly owned companies (for the most part) and whose prices have more than tripled in the last five years?

How are you going to guarantee that landlords get paid market wages for rent?

Are you going to pick up the other affiliated employees as well --MA's, PTs,'Surgical techs, nurses, etc. under this new healthplan? Is there going to be a guaranteed level of salary increases?

Since the insurance companies pretty much run the whole industry --how are you going to make sure they get their "share" of the pie? Or are they not? RIght now, they're the ones who subcontract from the medicare/medicaid programs and they make a lot of money doing so. How do you propose taking this away from them, or are you saying they're still going to administer most of the subcontracted programs?

Ezra Klein is completely wrong.

Survey after survey shows two things about the attitudes of American towards their health care: they are the least satisfied about their care among citizens of industrialized nations AND they believe they have the best health care in the world -- showing how brain washed they are.

The WHO international survey placed America near the bottom of performance among industrialized nations. The Commonwealth Fund survey showed the US at the bottom in terms of access, efficiency, equity and cost -- only first in "right care".

The Quinnipiac Poll showed that 64% of Americans say, "It's the government's responsibility to make sure everyone in the United States has adequate health care."

The issue is not government control, it is cost and personal choice.

The answer is to tell the American people that single-payer, universal health coverage will save money and will guarantee that you can see the doctor of your choice.

Progressives need to get aggressive on this issue. Tell people that with a single-payer system you can see your own doctor and neither the government nor an insurance company will interfere and you have a winner. Tell them that a government bureaucrat will decide and you lose.

Gerard Anderson and Hugh Waters, both of Johns Hopkins, have a paper on this very idea -- they call it Medicare Part E for Everyone; they presented it at a Brookings conference last July, and noted that Karen Davis suggested this back in 1991.

In their analysis, some 121 million additional people would be covered, at a total cost of $445B, of which government (general revenue) costs are about $150B (the rest derived from employer and individual purchase and out of pocket expenses). Worth thinking about as a logical extension of current programs.

Matt and Nate are right - don't work from 21 up, work from 65 down. Also include anyone who is currently without insurance, and require any business that currently does provide insurance to divert their portion of the premium into the system if they prematurely discontinue that insurance.

After a year or so, give people the option of leaving their existing plans to go on the single-payer plan (aka medicare), and have employers divert their premiums into medicare, while at the same time lowering the minimum age for medicare.

And make sure the medicare system is as insulated as possible from being politicized, because that *never* turns out well.

Jeeeez, doesn't Ezra know that Brooksie quite often pulls ideas, as well as facts, straight out of his arse as he tries to reinforce his position as "America's thoughtful conservative".

Yikees Ezra, yikees.

"People who have a good relationship with their doctors will want to keep them."

My sister-in-law's doctor, whom she loves, has just gone "boutique" at $50,000 per year. She cannot afford to keep him.

A few other simple solutions to consider:

1) Get rid of COBRA and require that anyone who leaves an employer's group must be allowed to switch their coverage to an identical individual plan at the exact same price.

1a) Let anyone back into their last employer's group for purposes of converting to individual coverage. This will take care of anyone who has finished their COBRA. Together these two ideas would eliminate the need for COBRA altogether.

2) Create a nationwide "group" of unaffiliated individuals that anyone can opt into, with the same insurance options offered to federal employees (or just let any individual become a member of the federal employees' group so long as they pay what the feds pay).

3) Require all health plans to be not-for-profit. It's outrageous that anyone is allowed to make profit off other people's ill health when they don't even provide medical services.

It's a fresh idea, but it misses the people who most fear losing the insurance, the ones who will have a very difficult job finding a good new job if they get laid off.

It's the fear that's pulling the whole country down and must be solved: fear by individuals of total financial disaster, either if you don't have insurance now or could lose it through a layoff (which could be tomorrow); fear by companies of hiring new employees with unpredictably escalating benefits required; fear by health providers that they won't get paid, especially big costs. So focus now on eliminating the worst of those fears with absolutely universal, forever portable Federal catastrophic insurance, setting the threshold before it kicks in as low as we can go. (Brad DeLong proposed 20% of annual AGI not too long ago.) But at least take the top-dollar costs out of the equation for individuals, employers and healthcare providers. I might get hurt if I have to pay X grand, but I won't be devastated. I can finally look for a job I actually like because the risk isn't so enormous. I can even reduce that risk much more with less expensive private insurance underneath the umbrella -- less expensive because there's a ceiling to the exposure. I the employer can now decide whether I need to continue offering my employees health insurance -- most will out of union contracts or tradition -- but I can predict the costs without the worry of dramatic escalation. And I the healthcare provider know I will get paid at least the top dollar on my services, leaving, even in the case of no insurance underneath, a more manageable collection. Even I the insurance company can run the continuing employer health plans, even offer my own that, while generating less revenue, has lower exposure that is more predictable, more stable politically, and possibly for those reasons more profitable.

Isn't this win-win-win-win? Its a perfect application of the concept of social insurance, because none of us know who is going to need it when and it creates a national pool. Make a couple of rules for private insurance underneath (employer or insurance company direct): if you want to play, you have to take everyone; no more pre-existing conditions, no discrimination for same coverage. Taking everyone on the insurance underneath will work from the start because the continuing employer programs will create large enough pools for predictable cost. (If they had to do it beginning from zero, there could be losses due to getting high risks at the beginning.)

While the focus here is reducing the debilitating fear, there are huge aggregate cost reductions, too. Besides (a) reducing financing costs for consistently late payments -- add what, 10% to every billed cost for delays, or built into the billing for anticipated delays? -- there should be big reductions for (b) no more wasted time and resources on the search for and disputes over pre-existing conditions, and (c) much less time and resources required for coordination of benefits for overlapping policies -- since the underlying and the umbrella are sequential.

I've been trying to find out from someone, anyone, what's fundamentally wrong with that. It's simple, too, easy to understand, so besides appealing to what they perceive most needs a solution, I might actually be able to convince voters that I have a chance to get it passed. Because it is simple in concept and therefore bureaucratically minimalist, removes a gigantic burden from the backs of American employers, and is a perfect application of the concept of social insurance for risks we all share -- just like the Social Security risk of old-age poverty, so we have experience with this already, and even moderate libertarians should accept it in principle. It should be harder, too, for Republicans to oppose it. It is actually a form extending Medicare downward, but assumes we can't afford to do that completely at this time. Hence, for now needs to stay as catastrophic. That also allows political focus on getting one big, big thing done, again improving chances for voter belief that this time this one will finally get somewhere.

I think the Edwards, Obama and Clinton plans all miss the boat. They set up comprehensive plans that can't be explained even conceptually in 10 words or less. IT'S THE CATASTROPHIC, STUPID.

There is probably a better argument for gradually lowering the age, even if at the same time you include those who are over 21. Individuals between the ages of 55 and 65 are not among the highest cohort of uninsured, but those who do not have employer provided insurance have the most difficulty purchasing any alternative, and those who are uninsured are among those with the highest medical expenses (yeah, the two go hand in hand: those who are most likely to need can't get . . . )

That would make the transition even quicker. It would also leave private insurance with a smaller and smaller, but not necessarily more and more expensive pool of eligible population.

I think a buy-in program, or permitting a supplemental market to Medicare is the way to go.

"I've given it no serious thought at all. But why not?"

Asked and answered

Except for the age phase in this isn't much different than what Hacker proposes in "The Great Risk Shift." It's not a bad idea.

which is that most Americans are basically happy with what they have

I have to disagree with the thesis of this statement.

Some Americans may be happy with what they have, many have pre-existing conditions which insurers will not cover, an alarming number of insurance companies are denying coverage like never before, premiums have increase 71% in the past 6 years and Middle class and lower income families are most Americans and they are unable to afford any health insurance at all.

There is probably a better argument for gradually lowering the age

Politically, though, working from young to old would be more effective.

Suppose the cap is 21. When you're 22, you're thrown off medicare and have to fend for yourself with the health insurance companies. You know what you're missing, and will continue to know for the rest of your voting life.

But if the age is lowered to 55, no one at age 54 has a clue what it's like to be covered by medicare, so would still be scared of voting for any change.

I think this is actually a good idea. There is a streak of political genius to covering young people rather than old people beyond the fact that it is cheaper: everyone will have had the experience of being in the single payer system, and even better they will be kicked off of it right around when they start voting.

They will look around and say to themselves and text-message to each other "OMG ths 5uxor5", and universal health care will soon follow.

Also a lot of people who miss the starting age will have kids who are in it. They will also see how it works up close and wonder why they have to lack coverage, etc unlike everybody else in the wealthy world.

By covering old people you convince them just as they drift off into political powerlessness and death. You are also less likely to shift the voting habits of the elderly even when they do find they were wrong all those years.

Also you can simply cover more people. I would not be at all surprised to find that covering all people under 18 would cost less than reducing the Medicare age by 5 years... actually guesstimating based on what the catastrophic coverage I had for a while cost at various ages you can probably get around 5 young person-years per old person-year.

Of course the republicans know this (for example that Kristol memo about the Clinton plan). It part of why they are so desperate to avoid expanding SCHIP, while they didn't mind the Medicare drug benefit so much. As long as they can keep government care ghettoized to the poor and elderly it is easier to keep regular working Americans from noticing their health care system is insane.

I suspect Brooks/Klein are talking about people working for giant corporations when they say people are happy with their healthcare and fear any change. I'm self-employed and hate my healthcare even though it's a great plan. It just costs me $13-15,000/year with a $4,000 deductible for a family of four. Oh, and no dental and no vision. It's really an outrage for a country like ours.

More to your point, it's a great idea to pick an underserved market to expand Medicare. That's essentially why S-CHIP works. The question is which market(s) to target first, second, third.

I'd vote for extending Medicare to small businesses with less than 10 employees. Not only is it hard to get affordable health care for this group, it has a crippling effect on the ability for these businesses to survive, to grow into larger companies or expand their markets. Yet health care companies tend to price them out of the market, or provide crappy plans.

I'd also add that it would be easier to buy into your idea if it explicitly includes transparency and accountability. I don't mind trading my obscene health care payments for higher taxes (hopefully less than what I pay) if I know the outcomes are optimal, fraud is being constrained, and changes can be highlighted and debated in public. You can't get any of that with private health insurance companies.

Great discussion, thanks.

Starting with the youngest first would be easier to sell politically. I have been licking my partisan chops at the thought of the Republicans who sided with Bush trying to explain their vote on SCHIP next year.
So, start young and work upwards. Ten year cohorts (0-9, 10-19, etc), adding one cohort each year (or every other year as a second best option). Within five years, ten at most, everyone who wishes to be, would be covered.
Starting any program will not be easy; the Health Industry will let loose with everything it has, so the opening wedge would best be by starting with children.
The incremental approach would scuttle any attempt by employers to replace employer-insured workers with those covered by Medicare.

So your plan is that people over 21 today get to pay other people's health insurance for the rest of their life, but never get any benefit from paying all those extra taxes, ever?

Doesn't sound like something people over 21 will vote for.

On the other hand if you financed it by making those people in the 18-21 range today pay for it through a payroll tax, and let people over 21 today voluntarily opt-in, it could work.

Heh. So it is ridiculous for people 22-64 to pay for health care for those 0-21, but it is fine for 18-21 to pay for 0-17?

18-21 year olds don't make much money. What 40%? of them are in college, and what do you suppose the rest are making with their high school educations?

I do think that 21 is to high, under 18 you get to say its to cover all children, over 21 you loose that marketing tool to overcome selfishness.

With all due respect, David and Ezra are engaged in a conversation with themselves and their equally well-off friends.

Most Americans covered by employer-sponsored health insurance plans, unlike David and Ezra, are caught in the vise between spiraling health insurance premiums and their employers' efforts to shift additional costs and risks to them. But their employers are also being squeezed as health insurance premiums as a percentage of revenues have risen to unstainable levels.

A significant driver of the increase in uninsured Americans is the number of working families who waive participation in employer-sponsored plans because they cannot affford the premiums. At the same time, the competitive position of American businesses in the international economy is being eroded by the excessively costs of an outmoded employer-sponsored plan model. As a result, Medicaid has increasingly become not a government-sponsored health insurance plan for the poor, but for working and lower middle class Americans, i.e. a taxpayer subsidy for stagnant wages and out-of-control health care costs.

Reform around the margins will neither address nor resolve this problem. The time for a single-payer system has arrived.

Bob hall

Where does Brooks find support for his statement that most people are happy with the coverage they have? He must've pulled that one out of his ass. Most people are definitely NOT happy with the coverage they have, which is skimpy, marginal, and designed to shift most of the burden back on them. I work for a multi-national corporation, and it's benefit enrollment time for us. As usual, this upcoming year's plans cost much more, have even higher deductables, and cover less than in previous years. Everyone I work with has horror stories about fighting with our insurance administrator to get their claims approved. For the first time EVER I'm hearing even the die-hard ditto heads moaning about the skimpy coverage, and have even heard some of them start to make statements about the Democrats plans being maybe not so bad after all.

That David Brooks is an ass-hat.

I'm happy with the double digit inflation in medical insurance I currently have? Every Oct. 1 my paycheck goes down. What the fuck are you doing giving Brooks any credit for good faith argument?

jksDZR comment2 ,