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University of Houston Law Center




As presidential candidates debate health reform, the expression “Medicare for All” (“M4A”) is on repeat, yet few appear to understand precisely what Medicare is or what M4A would mean. Even more striking is that Americans are vigorously debating health reform when the ACA – President Obama’s signature legislation and a health reform effort on a scale not seen in decades – turns 10 on March 23.

The ACA pioneered universal coverage, but it also ratcheted up health care complexity by building new scaffolding around an old foundation. This fragmented landscape has been exacerbated by a crazy quilt of implementation crafted in the wake of four trips to the U.S. Supreme Court in less than nine years. Even so, measured by the ACA's central goal of universal coverage, studies show successes such as decreased uninsurance rates, improved access to care, reduced health disparities, decreased financial strain, and economic benefits for both states and health care providers – especially in states participating in Medicaid expansion. These findings make the health reform clamor even more notable: why does a broad cry for health reform exist? and what does the public want? This symposium asked whether M4A is the solution.

To find an answer, this paper surveys current health reform bills and analyzes the constitutional queries they may face. Part I suggests lessons to be learned from the ACA’s enactment and implementation, contextualized by historic weak spots in American health policy. Part II surveys the structure and approach of each of the major federal health reform bills proposed in 2019, placing them on a spectrum of disruption relative to the current health care landscape and comparing a handful of key state reform efforts. This analysis exposes that most of the legislative energy is directed toward filling the gaps of the ACA by facilitating a new public insurance product, a “public option," and reveals that only one bill actually calls for one comprehensive, single-payer, government-provided public insurance program. The paper then exposes the distance between law and policy (and politics) by evaluating the constitutional implications of these major proposals. Finally, the paper considers whether existing proposals capture the health reform gestalt, which reflects broad desire for administrative simplification, fairness, and lower costs.

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