Universal coverage may not mean everyone has health insurance

The House Ways and Means Committee recently held a hearing about universal coverage, examining incremental and more sweeping Medicare for All style strategies for getting to universal coverage. That means one way or another everyone would be covered, right?

The catch: In practice, universal coverage will not mean 100 percent coverage, because making everyone eligible for some form of coverage or financial assistance does not mean everyone will actually get covered. Even under Medicare for All, some populations could be left out.

• That reality does not make it a less worthy goal to work to expand coverage as much as possible.

By the numbers: Thanks to progress made under the Affordable Care Act, we are at 90% coverage now. As the chart shows:

• More than half of the remaining 27 million uninsured are eligible for coverage now, or for subsidies to help them get coverage, but remain uninsured — mostly because insurance is not affordable for them.
• A separate significant share, 4.1 million, are ineligible because of immigration status. Only one state, California, seems interested in covering some of this population.

The big picture: Making people eligible for coverage or financial help does not assure they all get covered, and that that would remain the case whether we expanded eligibility for subsidies, expanded Medicaid in more states, put in place reinsurance mechanisms, or revitalized outreach and enrollment efforts, to pick several of the incremental policies that have been proposed.  

• A pragmatic definition of universal coverage through incremental measures might take us to something like 95% coverage of the non-elderly population. That’s a guesstimate; it could just as easily be 96% or 94%.

We could cover everyone from birth through a Medicare for All style plan. But for that to happen, progressive Democrats would have to have substantial control of the White House, the House and Senate — and overcome fierce interest group opposition.

• And to win passage, it’s possible that a political compromise would be necessary that would exclude coverage for the millions who are ineligible for coverage now due to their immigration status.

The bottom line: Universal coverage is a powerful rallying cry for Democrats and an important goal for progressive voters in the primary elections. But to appeal to as many voters as possible, making health insurance affordable for everyone — including by covering as many of the remaining uninsured as possible — might be a more effective rallying cry for the general election.