CreditEllis Rua/Associated Press
The “Medicare for all” bill written by Senator Bernie Sanders would cover not just standard medical services, but also vision, dental and long-term care. It would offer more health benefits than the world’s leading universal health care systems.
But as some politicians who support the plan are quick to clarify when asked, that does not mean it would “abolish all private health insurance.”
The next thing they may say includes something about “a role” for private insurance or “supplemental coverage.” Senator Kamala Harris of California, for example, emphasized her support for supplemental insurance coverage last week, after she endorsed Medicare for all on the presidential debate stage.
They seem like pleasantly vague terms. The example of supplemental insurance Mr. Sanders typically mentions is coverage for cosmetic surgery.
“Under Medicare for all, we cover all basic health care needs,” said Mr. Sanders, an independent from Vermont, in an April interview with CBS News. “I suppose if you want to make yourself look a bit more beautiful, you want to work on that nose, your ears — they can do that,” he said of private health insurers.
To clarify: There is no private market for cosmetic surgery insurance.
“We are not aware of any,” said Adam Ross, a spokesman for the American Society of Plastic Surgeons, the leading professional group for plastic surgeons. “Not for cosmetic procedures.”
Medical insurance does tend to cover certain types of plastic surgery, like breast reconstruction after a mastectomy, or repair of a cleft palate. But it does not cover most cosmetic operations. The society opposes Mr. Sanders’s bill.
In general, insurance is meant to protect people against injuries or illnesses. It works by pooling together people with different health risks and averaging their costs across the whole population. Some people will get in a car accident or develop diabetes. Others will barely see the doctor. The premiums for insurance are a kind of average of their combined medical bills.
That’s why insurance companies rarely like to offer health insurance products that cover only one specific medical problem. If they offer insurance that covers treatment only for, say, rheumatoid arthritis, they will be extremely likely to attract customers who either have or think they are likely to get rheumatoid arthritis. Eventually, the cost of such insurance will begin to approximate the cost of simply buying treatment for rheumatoid arthritis.
A stand-alone policy for cosmetic surgery would have effectively the same problem. “No one would sell a cosmetic surgery plan, since the only ones buying it would be people expecting to need cosmetic surgery,” said Linda Blumberg, a fellow at the Urban Institute.
Cosmetic surgery insurance might have another problem: People who bought it might seek more and more cosmetic surgery.
“It’s taking people who are basically normal and would like to look better and feel better about themselves, and there’s nothing wrong with that,” said James Grotting, a plastic surgeon on the clinical faculty at the University of Alabama, Birmingham, and the University of Wisconsin, Madison. “But there might be no end of what patients might request if it’s covered by a third party.”
Dr. Grotting is the founder of a company that sells insurance for cosmetic surgery complications. His product, CosmetAssure, helps pay patients’ medical bills if something goes wrong in the 45 days after their operations, like bleeding or an infection. But even his insurance isn’t sold to individual cosmetic surgery patients. It’s sold to doctors on the condition that they provide it to everyone they treat.
If cosmetic surgery insurance is not a thing, why do some campaigns and journalists talk about it?
It’s because Mr. Sanders’s bill is so expansive that it’s actually quite hard to imagine many health care services that private insurance companies would be able to cover. While the bill doesn’t explicitly ban private insurance, it makes it unlawful to “sell health insurance coverage that duplicates the benefits under this act.”
Here are the benefits listed in the bill: hospital services; ambulatory patient services; primary and preventive services; prescription drugs and devices; mental health and substance abuse treatment; laboratory services; reproductive, maternity and newborn care; pediatrics; oral health, audiology and vision services; short-term rehabilitative and habilitative services; emergency services; transportation to medical appointments for patients with disabilities or low incomes; home- and community-based long-term care. The bill would also retain existing coverage for nursing home care for Americans with low incomes.
The services listed above must be provided if they are “medically necessary or appropriate for the maintenance of health.”
An aide in Mr. Sanders’s Senate office said the list was deliberately broad.
It’s easy to see how cosmetic surgery might fall outside this list. But several experts strained to come up with other examples. “You have to really rack your brains to think of anything that would not be covered,” said Cynthia Cox, a vice president at the Kaiser Family Foundation, a health research group.
Ms. Cox consulted several of her colleagues, and came up with a few ideas. The bill might leave room for private insurance for nursing home care, similar to existing markets for long-term care insurance. It might allow people to buy disability insurance to replace lost income, but not related medical treatment. And then there were the things like cosmetic surgery: services that would not be considered “medically necessary” under Medicare for all but that some people might want. She called these categories of care “loopholes,” and said it was tough to imagine private companies wanting to offer such products.
It is true that most other countries that have single-payer systems also have some supplemental role for private insurance. But those countries have systems that are different in key ways from the current Medicare for all proposal. In some countries, individuals are expected to pay deductibles or co-payments toward their treatment, and private companies offer insurance to fill those financial gaps in coverage. In others, certain benefits are left out, and private companies then offer coverage for, say, prescription drugs.
You might think that Democratic politicians who endorse the Sanders plan would embrace the bill’s comprehensiveness as a virtue. And, in some ways, they do. But some also appear nervous about saying that they will do away with an entire industry. Public opinion surveys suggest that voters are skeptical about plans that will take away their private coverage. Some co-sponsors of Mr. Sanders’s bill now say they are more comfortable with optional plans that would not bar duplicate coverage. Some others have embraced the “supplemental coverage” line.
“In order to create a role for private insurance in any of those ways, you need to weaken the main system,” said Adam Gaffney, the president of Physicians for a National Health Program, which supports a very broad single-payer plan along the lines of Mr. Sanders’s bill. He said the effective abolition of private insurance was a strength of the proposal, which doesn’t require insurance for financial or benefit gaps.
If Medicare for all became law, it is entirely possible that legislative negotiating would make the plan less broad and carve out such a complementary role for private industry.
But the Sanders plan was written to avoid such holes. It doesn’t have any deductibles or co-payments. It covers a very wide array of medical benefits. And that is why politicians are likely to keep employing their own sort of loophole, by pointing to insurance markets that may not exist.