Sen. Bernie Sanders addresses the Pennsylvania Association of Staff Nurses and Allied Professionals in Wilkes Barre, Pa. (Mark Makela/Getty Images)
Opinion writer

Bernie Sanders’s Medicare-for-all proposal would transform health insurance in the United States, and you don’t have to read very far into the bill he released last week to understand just how far-reaching, and politically controversial, the change would be.

In its first few pages, well before you get to the part about zero co-pay coverage for “oral health,” Sanders announces that he would abrogate two long-standing compromises woven into the current patchwork of public and private insurance.

And we’re not talking — yet — about how Sanders would raise taxes to pay for the plan’s multitrillion-dollar cost, or how it would effectively end private insurance while empowering the secretary of Health and Human Services to make decisions about cost containment and coverage that are now more decentralized, for better or worse.

Section 102, on Page 4 of the bill, labeled “UNIVERSAL ENTITLEMENT,” conditions eligibility on “residency” in the United States — not “legal residency” — and leaves it up to the secretary of health and human services to define what counts as “residency.” Section 104, “NON-DISCRIMINATION,” on Page 5, bars exclusion from services “on the basis of . . . related medical conditions (including termination of pregnancy).”

A Sanders spokesperson confirmed via email that these provisions mean inclusion of undocumented immigrants in Medicare-for-all, in contrast to current law’s ban on participation by the undocumented in Obamacare exchanges, and that the legislation would end the existing prohibition on federal funding of abortion.

The latter prohibition, known as the Hyde Amendment, was first passed in 1976, though it was modified in 1994 to exempt abortion in cases of rape or incest, or to save a mother’s life.

It would seem to be only a matter of time before Republicans begin attacking Medicare-for-all — which is backed not only by Sanders but also by many other Democrats, including some rivals for the presidential nomination — for guaranteeing so-called illegal aliens taxpayer-funded dentist visits, while enshrining abortion-on-demand at public expense.

Radical as all that may seem, though, Sanders actually is just advocating explicitly what the country already does indirectly.

The undocumented receive billions of dollars’ worth of health care, either through employer-paid (and tax-break-subsidized) insurance or at public expense. In 2016, the Wall Street Journal  found that, of the 25 U.S. counties with the largest unauthorized immigrant populations, 20 “pay for the low-income uninsured to have doctor visits, shots, prescription drugs, lab tests and surgeries at local providers,” without regard to immigration status.

Meanwhile, the 1986 Emergency Medical Treatment and Labor Act requires all Medicare-participating hospitals to treat patients in their emergency rooms, regardless of whether they have insurance. Accordingly, undocumented immigrants flock to ERs, with the unreimbursed cost passed along to everyone else. 

As for abortion, money is fungible, so one way or another, the $563.8 million that Planned Parenthood received from federal, state and local governments in fiscal 2018 frees up resources within that organization that can be used for pregnancy terminations — even if the funding streams are kept separate for purposes of the Hyde Amendment or similar state laws. In that sense, the Hyde Amendment is a bit of a fiction.

To be sure, the Emergency Medical Treatment and Labor Act’s creation of a de facto statutory right to health care, at least in the ER, undercuts Sanders’s moralistic rhetoric about finally making “health care a human right.” If he were being precise, he would say he wants to make health insurance — and super-generous insurance at that — a human right.

Even more precisely: a human right for people who live more or less permanently in the United States, with or without legal authorization, but not so-called medical tourists from abroad just popping in to the United States from overseas to get free services. His bill authorizes the HHS secretary to define residency in such a way as to prevent that form of system-gaming. Good luck!

On the whole, though, Sanders’s bill is more internally consistent than the existing system. People are people, it proclaims, and health care is health care.

The very fact that this might be a political weakness is a reminder that ours is not a society like the European ones that established national health systems decades ago, on the basis of social solidarity, which was, in turn, a function of ethnic and religious homogeneity.

Health insurance in the United States is, in the oft-used phrase, “fragmented,” because America itself is fragmented, along lines both legitimate (religious conscience, region, federalism) and illegitimate (race). 

Our system, with its improvised accommodations for Roman Catholic and other religious believers, and its mishmash of rules regarding who, exactly, belongs to the American community, reflects that. 

Sanders’s plan would substitute criteria that are in many ways more honest and, as such, disruptive.

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