Defining the ‘all’ in ‘Medicare for All’

Medicare for All could cover all immigrant groups, but it also could not. Devil's in the details.

Sen. Bernie Sanders, I-Vt., right, speaks at a news conference on Capitol Hill in Washington, Wednesday, Sept. 13, 2017, to unveil Medicare for All legislation to reform health care. (AP Photo/Andrew Harnik)
Sen. Bernie Sanders, I-Vt., right, speaks at a news conference on Capitol Hill in Washington, Wednesday, Sept. 13, 2017, to unveil Medicare for All legislation to reform health care. (AP Photo/Andrew Harnik)

As progressives consider proposals to implement universal health care, it’s important to define the principle that’s driving them. What unites Democrats right now is the idea that health care is a right afforded to all. If that’s the self-imposed litmus test, it’s essential to define “all” when discussing universal health care.

Millions of people who live in the United States are currently uninsured. High costs remain a major barrier to coverage; 46 percent of uninsured adults said costs were a primary reason according to a 2015 Kaiser Family Foundation poll. Proposals by Sens. Bernie Sanders (D-VT) and Brian Schatz (D-HI), who are advocating to expand public programs like Medicare and Medicaid, respectively, strive to make care affordable.

But even if rising costs to care were miraculously resolved, one group of people would still be excluded.

In 2015, 23 million non-citizen immigrants resided in the United States, which accounts for 7 percent of the population. (Non-citizen immigrants account for both lawfully present and undocumented immigrants.) Non-citizen immigrants are significantly more likely than citizens to be uninsured. Seventeen percent of lawfully present immigrants and 41 percent of undocumented immigrants are uninsured, compared to just about 9 percent of U.S. born and naturalized citizens.


A single-payer system addresses health care financing, and a single public or quasi-public agency organizes care. Often, the progressive mission (universal health care) and the method (single payer) are conflated. But single-payer is hardly the only avenue to reach universal health care. In the various Medicare-for-all bills floating around Capitol Hill, not everyone — especially undocumented people and Deferred Action for Childhood Arrivals (DACA) recipients — living in the United States would be guaranteed government-run health coverage.

Founding member of the consumer advocacy group Families USA Ron Pollack wrote about viable alternatives to single payer, as progressives strive for high-quality, affordable health care for everyone. He outlined four ways to inch closer to universal coverage, none of which promotes scrapping the current system but instead expands upon existing plans. One suggestion: extend care to immigrants who currently are ineligible for insurance.

Under the Affordable Care Act (ACA), people with various immigrant status qualify for the marketplace coverage. Lawfully present immigrants can buy subsidized care, but undocumented and DACA recipients are unable to. Immigration status as well as mixed-status families, where one person is undocumented, largely prevent people from obtaining insurance.

Providing preventative health care to all immigrants — regardless of status —  is as politically controversial as single payer. In the Better Care Reconciliation Act, Republicans looked to bar certain immigrant groups that gained coverage under the ACA. Only permanent residents and asylum seekers qualified for care under the GOP bill.

As Medicare-for-all advocates discuss its highly ambitious health policy proposal, know that this is guaranteed universal health care for lawfully present immigrants only. Perhaps for now, that’s enough, given that key details — like the bill’s funding language — are delayed.


Sen. Bernie Sanders released his vision for universal coverage Wednesday. Sanders wants to scrap the current employer-based health care model and implement a Medicare-for-all national health insurance program. Under the “Medicare for All Act of 2017,” residents would be provided a universal Medicare card upon enrollment. Here is who would gain coverage under the bill:

The transition to the single-payer system only allows “an alien lawfully admitted for permanent residence” to buy into Medicare, as under the ACA. But once single-payer is fully implemented, the discretion of which immigrant qualifies is ultimately left to the White House, leaving the fate of every immigrants’ care in the hands of whoever is president.

During Sanders’ news conference on Medicare for All Wednesday, Sen. Mazie Hirono (D-HI) said “all the people in this country should have health care,” including the 11 million undocumented and nearly 790,000 DACA recipients. She was the only lawmaker who connected universality to immigration status.

Wednesday’s bill is hardly its last iteration, and has largely been framed by proponents as the start of the conversation. As lawmakers litigate this bill and bills similar to it, the question of who is “all” in Medicare-for-all will arise. For political purposes, it’ll be tempting to separate immigration and health care; although, for those affected, it’s hard to do that. Perhaps a comparable solution is to leave it to the states, which have largely taken it upon themselves to do so already.

California, the District of Columbia, Illinois, Massachusetts, New York, and Washington use state money to provide care to the undocumented. California, where almost one quarter of the nation’s undocumented immigrants reside, expanded coverage by innovating two existing health care systems. First, the Health for All Kids Act provides undocumented immigrant children with access to coverage through Medi-Cal, the state Medicaid program.

Second, My Health LA, which is a Los Angeles County based health program, extended coverage by not defining who’s eligible. The idea is, anyone who is ineligible for anything else should go to a contracted clinic; this is not insurance. County officials pushed for the program and said it would cut down on the use of emergency rooms by uninsured immigrants, which is costly.


It’s unclear what the aforementioned health care plans would look like under Sanders’ bill. Presumably they’d be deemed unnecessary as the health care system is streamlined. And there are a host of other concerns to address when discussing single payer, said Community Clinic Association of Los Angeles’ Cynthia Carmona. “During the four year transition, we will face significant challenges,” she told ThinkProgress. Namely, how do you phase out health plans, that know the U.S. system, for all its fragmented ways to provide care for lawfully present and undocumented people.

CCALAC has come out in support of universal health care and has worked hard to ensure that undocumented immigrants in California have access to health care. Carmona recognizes, from a provider perspective, that the devil is in the details. “Just because you create a bill like this [Medicare for All], doesn’t mean you create access,” she said.