In 1998, President Bill Clinton suggested a partial solution to help millions of Americans without health insurance: The country should let those 55 and older without employer coverage buy into the government Medicare system.

A few weeks ago, Hillary Clinton brought the idea back. It’s a proposal she’s talked about before: It was part of her 2000 Senate campaign platform and an option she mentioned for health insurance expansion when she ran for president in 2008.

But a lot has changed with the passage of the Affordable Care Act, leading several health policy experts to wonder whether a Medicare buy-in would be a welcome new option, or a confounding misfit.

Medicare for more, as I’ve been calling it, would require significant adjustments to the Obamacare new markets for regulated insurance, which are currently set up for everyone under 65. It would require a new system for calculating and awarding subsidies to low-income purchasers. It would probably require changes to Medicare’s standard package of benefits. And it runs the risk of destabilizing the Obamacare marketplaces, several of which are already somewhat precarious.

A Medicare buy-in could well work, but it wouldn’t easily coexist in post-Obamacare times the way it might have in the 1990s.

“It is an approach that is somewhat inconsistent with the Affordable Care Act,” said Caroline Pearson, a senior vice president at the health care consulting firm Avalere Health, who recently published an initial analysis of the idea. That analysis found that the program could be an option for as many as 13 million Americans.

The Clinton suggestion was raised in response to a voter question, and the campaign hasn’t released any sort of formal plan. As a result, it’s hard to know how Medicare for more might actually work. Here are some important questions that would have to be resolved.


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