Medicare Expansion as a Path as well as a Destination: Achieving Universal Insurance through a New Politics of Medicare

Published date01 September 2019
DOI10.1177/0002716219871017
AuthorJacob S. Hacker
Date01 September 2019
Subject MatterPrescriptions: Health Care
DOI: 10.1177/0002716219871017
ANNALS, AAPSS, 685, September 2019 135
Medicare
Expansion as a
Path as well as a
Destination:
Achieving
Universal
Insurance
through a New
Politics of
Medicare
By
JACOB S. HACKER
871017ANN The Annals of The American AcademyMedicare Expansion as A Path and A Destination
research-article2019
Growing interest in “Medicare for All” has revived
hopes for universal health insurance. Yet serious disa-
greements remain over how to expand Medicare and
how far to move toward a universal Medicare system.
In this article, I consider these disagreements in light of
what we know about “policy feedback”—the ways in
which policies, once enacted, reshape public opinion,
governing institutions, and political organizations.
Rather than focusing on the “political feasibility” of
proposals for Medicare expansion, I focus on their
“policy sustainability”: whether proposals, once
enacted, can be established in place, entrenched over
time, and expanded and improved as circumstances
change. Achieving these “three E’s,” I argue, requires a
flexible approach that builds on the current system
(and hence falls short of Medicare for All) but also
contains a universal coverage guarantee and other pro-
visions designed to create strong feedback effects con-
ducive to the expansion of Medicare over time.
Keywords: health care; health insurance; Medicare;
policy feedback; American politics;
Affordable Care Act
Growing interest in “Medicare for All” has
revived hope for universal health insur-
ance, after a decade of debate over the
Affordable Care Act (ACA). Yet despite a near
consensus among advocates of expanded cover-
age that Medicare should be the foundation for
future coverage expansions, serious disagree-
ments remain over how to expand Medicare
and how far advocates can and should move
toward a universal Medicare system in the rela-
tively near term. Plans for expanding Medicare
range from categorical expansions (for exam-
ple, 55- to 65-year-olds) to various types of
Jacob S. Hacker is Stanley Resor Professor of Political
Science and director of the Institution for Social and
Policy Studies at Yale University. He is the author
or coauthor of five books and numerous articles on
American politics and policy and a fellow of the
American Academy of Arts and Sciences.
Correspondence: jacob.hacker@yale.edu
136 THE ANNALS OF THE AMERICAN ACADEMY
Medicare buy-in proposals to single-payer national health insurance—each with
influential proponents within the health policy community.
In keeping with the goal of this special issue, this article considers these alter-
native policy ideas in light of what we know about “policy feedback”—the ways
in which policies, once enacted, reshape public opinion, governing institutions,
and political organizations over time. In particular, I focus on what I term policy
sustainability, which should be distinguished from the more common phrase
political feasibility. Feasibility usually concerns whether a policy can be enacted.
Sustainability, by contrast, refers to whether policies, once enacted, can be estab-
lished in place, entrenched over time, and expanded and improved as political
and economic circumstances change. These “three E’s”—establishment,
entrenchment, and expansion—are fundamentally political outcomes. Moreover,
they are political outcomes that we should expect to be heavily influenced by
policy design, as the large and growing scholarship on policy feedback
demonstrates.
Thus, my analysis of proposals for Medicare expansion really gets going where
most policy analyses end, with the question of what happens after a policy gets
passed. I start with (and hopefully justify) the premise that moving from our cur-
rent system to Medicare for All in one “big bang” will be difficult to achieve and,
even if achieved, vulnerable to backlash. But the core of this article concerns how
to design reform proposals so that they (1) move as close as possible to the elusive
aim of universal Medicare and (2) create feedback effects conducive to further
movement toward that goal—that is, to establishment, entrenchment, and
expansion.
The Opportunity—and Challenge
Advocates for fundamental reform have embraced Medicare for three good rea-
sons. First, while the ACA has produced tremendous achievements—cutting the
share of Americans without health insurance roughly in half, extending new pro-
tections to almost everyone with private insurance (for example, requiring cover-
age for preexisting conditions), and helping to moderate medical inflation—it has
not lived up to expectations in one critical area: providing affordable health insur-
ance to those without workplace protections or access to Medicaid (a problem
more glaring because of the judicially imposed incompleteness of the ACA’s
Medicaid expansion). Nor has the ACA created the kind of strong support coali-
tion associated with other landmark social policies. Though political buy-in has
increased and may well have been decisive in repelling legislative assaults in
2017, possibilities for expansion have seemed more modest. Enthusiasm for
building on Medicare is partly a reflection of these lessons.
Second, Medicare has looked better and better relative to private insurance.
It provides valuable and valued coverage through a simple enrollment and
financing system. Coverage is not contingent on whether someone has the
wherewithal or means to navigate a complex eligibility gauntlet; all eligible

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