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

Growing interest in “Medicare for All†has revived hopes for universal health insurance. Yet serious disagreements 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 provisions designed to create strong feedback effects conducive to the expansion of Medicare over time.