An Exploration of Audience and Argumentation

Hello everyone! Thank you so much for taking the time to read this article. For the past year or so, I have been really interested in health policy and I’ve spent countless hours brainstorming article ideas, developing a platform, researching health policy issues, and developing cohesive argumentative pieces that I think you all will enjoy. My goal for the next few weeks is to expand my audience, reaching as many people as possible and I would greatly appreciate it if you shared my portfolio with people who may be interested in the topics I explore. (https://vinays-hip.beehiiv.com/subscribe)

During my time in high school, I actively participated in my school's Public Forum debate team. In this debate style, two teams (each with two debaters) argue to support or reject a proposed resolution describing a current events topic. The debate style is meant to be understandable to the average American and includes 2-4 minute speeches as well as “Crossfire” sessions, an argumentative question and answer period between two opposing debaters. It is safe to say that this style of debate is not representative of real world political debates or the legislation process. One of my favorite topics (the September and October 2020 resolution) was “Resolved: The United States federal government should enact the Medicare-For-All Act of 2019.”

When preparing for Public Forum tournaments, students generally prepare for two types of judges: the “lay judge” is a judge who is a student’s parent or someone new to the activity and the “flow judge” is an experienced judge (likely a former debater, college student, or coach). What was unique about the Medicare for All topic (or as we called it M4A) was that our arguments and the side we preferred would change depending on the judge observing our debate round. More specifically, when paired with a lay judge, we would choose a position supporting the resolution and when paired with a flow judge, we were more likely to choose a position opposing or negating the resolution.

Why is this so? What makes each side more convincing to a specific group? How are lines drawn in the real world regarding support for Medicare for All? I hope to explore the history of Medicare for All, what the policy entails, and what the current debate looks like in this article.

Medicare for All has had a long history within the United States. The first national health insurance program (which later served as inspiration for programs developed in other nations) was developed by Otto von Bismarck, German Chancellor in the 1880s. (1) In the mid-1900s, Presidents Franklin and Truman attempted to expand health care to cover more individuals, yet both were unsuccessful. (2) A Medicare plan was ultimately created on July 30, 1965, covering a smaller net than was originally hoped, focusing on the elderly only. Pushback to Medicare was inevitable as individuals became concerned about the cost of the plan; however, momentum continued to build and under the Nixon administration, Medicare was expanded to include people with disabilities and end-stage kidney disease. (3) It was at this time that Medicare for All advocates began using terms such as “national health insurance” and “single payer” to describe their vision.

In the early 2000s, Medicare for All policies began entering Congress. Senator Kennedy first proposed the idea of a national healthcare plan funded via payroll tax; Senator Javits then proposed the idea of expanding the existing Medicare plan to the entire nation. (4) Under the Obama Administration, the Affordable Care Act was established, and while it did not implement all of the benefits Medicare for All advocates were hoping for, it did create a health insurance mandate, Medicaid expansion plan, and employer requirements, among others. In 2019, Senator Pramila Jayapal updated the plan, submitting HR 1384. (5) Additionally, Senator Bernie Sanders has proposed a Medicare for All plan to Congress several times, increasing support for a universal healthcare system in the states.

I’ve been throwing around terms such as “single-payer system”, “universal healthcare/health insurance”, “public option”, and “government-run healthcare” to describe Medicare for All, so what exactly is it? Even the term “Medicare for All” does not fully capture the benefits provided by this program.

The benefits provided by Medicare for All depend on the plan in question: in this article, I will explore the Medicare Act of 2023 created by Representatives Jayapal (WA), Dingell (MI), and Sanders (VT) on May 17, 2023. (6) Not only does this bill provide all US residents with comprehensive health care coverage from primary, mental health, and dental care, to prescription drugs, maternity care, and substance abuse treatment, but it also covers long term care for chronic conditions. (7, 8) The bill also eliminates cost-sharing and premiums (explained further in the next paragraph). While Medicare for All eliminates private insurance, under this bill, individuals will have the freedom to visit any clinic or physician they choose.

So what are copays, deductibles, and co-insurance? These terms determine how much the patient pays after receiving care. Let’s assume a patient, Jake, travels to the hospital for his annual wellness visit. Jake’s health insurance provider is Blue Cross Blue Shield. Now, let’s discuss some of the costs Jake pays for care. These costs are fictitious and provided solely for clarity. Every month, Jake pays $50 to Blue Cross for health insurance. This amount represents Jake’s premium, the amount the individual pays regularly in exchange for healthcare insurance. (9) When Jake visits the hospital, the hospital charges $25 for his visit. This $25 represents Jake’s copay, the fixed cost paid for care (usually different for prescriptions and visits). (10) After receiving his annual checkup, Jake returns home and gets a bill for his visit. His insurance, Blue Cross, states that his deductible is $75. This means that before Jake’s insurance begins to pay off a portion of the total cost of his visit, Jake must pay the first $75. (11) Finally, after paying this deductible, Blue Cross tells Jake that his coinsurance is 30%. This means that after paying the initial $75, Jake must pay 30% of the rest of the cost of the visit, while Blue Cross will cover the remaining 70%. Because copays, deductibles, and coinsurance refer to costs shared between the insurance provider and the patient, these terms are also classified as cost-sharing. (12)

Because the Medicare for All plan provides government-backed universal health care coverage, cost-sharing and premiums are eliminated, reducing the cost the consumer pays per hospital visit.

Before I discuss the current debates around Medicare for All, I’ll pivot to the pros and cons of the policy. While it is impossible to provide a quantitative cost-benefit analysis for Medicare for All, we can assess who is benefited by the policy and who is left worse off.

Pros:

• Decrease administrative and healthcare costs. Medicare for All eliminates cost-sharing and premiums making healthcare more affordable. Furthermore, by consolidating health insurance plans, Medicare for All streamlines the administrative process, reducing administrative costs for patients and physicians. (13)

• Reduce disparities regarding quality and access. A 2020 study finds that 12.5% of American adults do not have health insurance. (14) Providing universal coverage and enabling patients to choose which physician they see further reduces healthcare quality and access disparities.

• Reduce physician burnout by decreasing administrative duties. Eliminating the need for multiple insurance plans will reduce the amount of time physicians spend on administrative duties, improving their quality of life and reducing burnout. (15)

Cons:

• Increase consumer expenses (taxes). While we cannot be certain how much the plan will cost (some people believe Medicare for All will actually save money on net), many believe that the plan will cost trillions of dollars. If the program is financed through tax dollars, consumers and producers can expect significant price increases in other industries, stifling the economy.

• Reduce healthcare jobs (especially health insurance related). Condensing the health insurance market into a single government-sponsored insurance program will eliminate many healthcare insurance jobs, increasing unemployment in the industry. (16)

Neither:

• Wait times. One of the main arguments against Medicare for All is the idea that nations with a universal healthcare program have longer wait times than the US and by adopting Medicare for All, healthcare quality will decrease. However, data suggests that nations with a universal healthcare program actually have similar or shorter wait times than in the US, so more research should be conducted to determine the effect of this plan on lengthening or shortening patient wait times. (17)

Most Progressive Democrats support Medicare for All, as it improves healthcare coverage and affordability. (18) Labor Unions, Patient Advocacy Groups, and Activist Organizations also support the bill, arguing that Medicare for All provides better coverage to patients and workers, improving their quality of life. (19) Finally, small firms tend to support the bill as it provides employees with health benefits without the firm having to pay additional expenses.

Most Republicans and some Independents oppose Medicare for All, arguing that it would increase taxes and result in lower quality care for patients. (20) Pharmaceutical companies have shown little support for the bill, claiming that it may result in government regulated pharmaceutical prices. Health Insurance firms, afraid of going bankrupt or laying off thousands of employees under a single-payer system, tend to oppose the bill also.

Finally, physicians and care providers have reason to support and dislike Medicare for All. While many physicians argue that Medicare for All will improve the accessibility and affordability of quality care, others believe that the bill will result in decreased revenue because of limited reimbursements under the Medicaid plan.

Clearly, Medicare for All is a controversial plan. Opposition to the plan seems high yet recent policies improving healthcare access (including Medicaid expansion across many states) seem to indicate a shift in the health agenda, focusing on improving healthcare quality and access, at least for now. While there is still significant research to be done on the feasibility of such a plan and the effect it might have on the economy and the quality of patient care, it is important that we continue seeking ways to improve healthcare access and reduce the costs that come with seeking care. Medicare for All is simply one of many proposed policies to achieve that goal and while it is likely some form of expanded Medicare will be established at some point, it is important that we first analyze the costs and benefits of such a policy and the effects it will have on all individuals involved.