Does the Supreme Court's majority opinion upholding the Affordable Care Act (ACA) open the door for a broader expansion of Medicare called Medicare for all (MFA)?

Medicare-for-all, also known as "the public option," is a simple concept: The Medicare program would be expanded to all Americans without health insurance. Someone could not be turned away because of a pre-existing condition, and the premiums would be affordable.

Long before the Supreme Court started examining the constitutionality of the ACA, several groups championed extending Medicare to all Americans. They are gaining increased attention these days and say their cause has ricocheted back into the national discourse thanks to the Court's ruling.

By employing a single-payer model, in theory, MFA provides economies of scale for the purchasing of medical services, drugs and medical equipment, only on a much larger scale than the present Medicare system.

Instead of insuring some 47 million beneficiaries, Medicare under MFA could cover an additional 50 million uninsured people and perhaps tens of millions who are underinsured. The uninsured rate in the United States is roughly 16 percent of the population, according to the Census Bureau, reflecting the largest number of uninsured Americans on record.

According to some physician groups such as Physicians for a National Health Program (PHNP), a nationwide organization of 18,000 physicians, the lack of a single-payer program for the uninsured is still a life-and-death issue.

"Unhappily, the ACA is guaranteed to produce one sure-fire result. Americans will become more dependent than ever before on private health insurance for their only access to health care," wrote Samuel Metz, M.D., in a July 2 op-ed piece in The Oregonian. Metz is an advocate of publicly financed health care and a member of PHNP, a nationwide organization of 18,000 physicians. "If you like what private health insurance has inflicted on our society up to now, just wait until you see what the newly approved ACA will do to us in the future." The PHNP cites figures from the Congressional Budget Office, which estimate that 23 million will still be uninsured by 2019.

Much of the criticism of the present private health insurance system is centered on its fragmentation, inefficiency, cost and lack of patient protection. Before the ACA, there were no legislated consumer protections for those with pre-existing conditions. Private insurers generally avoided offering policies to the chronically ill and screened out potential customers who had an array of ailments or conditions in their medical history.

Critics of the ACA counter that although it has a prohibition against coverage denials for pre-existing conditions, starting in 2014, the law will do little to ensure that the price of private policies is affordable. That drew severe criticism from the single-payer advocates who saw loopholes in the ACA that would prevent tens of millions from obtaining adequate insurance, even when mandated to buy it.

Single-payer advocates like the PNHP and National Nurses United claim that MFA would pay for itself by eliminating most private insurers' marketing and administrative expenses. Garrett Adams, M.D., M.P.H., president of PNHP, has maintained that, "Single payer would streamline bureaucracy, saving $400 billion a year on administrative overhead, enough to pay for all the uninsured and to upgrade everyone else's coverage. The new system’s bargaining clout would also help rein in rising costs."

MFA might gain some political traction from that economic argument, but also if the composition of Congress changes dramatically in November. If Democrats retain control of the Senate and take more seats in the House—a big “if” at this point—the health care debate could expand to cover more Americans.

In contrast, if Republicans take the Senate and retain control of the House (or White House), they may move to dismember the ACA, as advocated by many conservative groups and most of the GOP House members. Another political possibility under the GOP "big win" scenario in November is that dismemberment of the ACA could leave the door wide open to new political posturing from progressives. While conservatives may maintain that the ACA was flawed to begin with and must go, progressives could say that MFA was the best solution all along, starting a renewed push to get it back on track.

MFA still remains a potential solution at the opposite end of the political spectrum with virtual privatization models advocated by the presumptive GOP presidential nominee Mitt Romney and U.S. Rep. Paul Ryan (R-Wisc.).

As it stands now, the last groundswell for MFA was seen during the drafting of the ACA: Prior to the law's passage in 2010, there was a cadre of progressives who insisted that the "public option" be part of the final bill. It was scrapped during subsequent negotiations.

Ultimately, though, MFA would face an incredibly steep uphill battle no matter what happens to Congress with the election. Medicare reform by itself and the need for cost reductions may dwarf any new momentum for a single-payer system.

The ACA, for example, contained some 165 provisions directly impacting Medicare funding and operations, including myriad cost-saving measures. Under current assumptions, the most recent Trustee's Report predicted that Medicare "is not adequately funded for the next 10 years" and will exhaust its hospital insurance fund in 12 years. This means that the looming fiscal meltdown may trump any political idealism.

MedicareNewsGroup.com (MNG) original articles and Medicare Matters news summaries can be reprinted or republished with credit to the Medicare NewsGroup. To use our content, simply copy and paste text from the MNG website. Use of our content is done in compliance with our Terms and Conditions but does not extend to material from other sources that are subject to their copyright.

John is the award-winning author of 13 books and is a personal finance columnist/blogger for Reuters. His columns have been published in newspapers on five continents and he has appeared on various broadcast outlets including NBC, CNN and Bloomberg TV. He has earned 18 awards for his columns and investigative reporting, including the National Press Club award for Consumer Journalism.