The cry on the progressive left s “Medicare for all” now that the GOP has failed to repeal ” Obamacare”. It, they say, is the answer to providing universal health care for all Americans. If we don’t start sweating the detail however, the progressive left will fail again to achieve anything substantial.
The conversations within the Democratic coalition over health care have definitely moved to the left. Mainstream figures like Senator Kirsten Gillibrand, a potential presidential candidate in 2020, are embracing single payer. Representative John Conyers currently has a Medicare for all bill with 115 Democratic co-sponsors in the House and Chucky Schumer has publicly stated the “Single payer is on the table.”
If we have free and fair elections in the future and the dems regain power, the outlook for single payer looks bright. But that momentum is tempered by the fact that the activist left, which has a ton of energy at the moment, has for the most part failed to grapple with the difficulties of transitioning to a single-payer system. A common view is that since every other advanced country has a single-payer system, and the advantages of these schemes are pretty clear, the only real obstacles are a lack of imagination, or feckless Democrats and their donors. But the reality is more complicated.
For one thing, a near-consensus has developed around using Medicare to achieve single-payer health care, but Medicare isn’t a single-payer system in the sense that people usually think of it. This year, around a third of all enrollees purchased a private plan under the Medicare Advantage program. These private policies have grown in popularity every year, in part because the field has been tilted against the traditional, government-run program.
Around one-in-four Medicare enrollees, including me also purchase some sort of “Medigap” policy to cover out-of-pocket costs and stuff that the program doesn’t cover; and then there are both public and private prescription drug plans. Medicare will pay for 80% of covered services; without a “Medigap” insurance policy purchased in the private insurance market I would be stuck with the 20% My cost for the Medigap insurance which covers 20% of the bill is greater than the cost of Medicare which covers 80%.
At the same time, Medicare-for-All is really smart politics. Medicare is not only popular, it’s also familiar. Many have parents or grandparents who are enrolled in the program. I haven’t received a bill for any of my medical needs, other than my drug co-pays since I retired 13 years ago. But from a policy standpoint, Medicare-for-All is probably the hardest way to get universal health care. In fact, a number of experts who tout the benefits of single-payer systems say that the Medicare-for-All proposals currently on the table may be virtually impossible to enact. Conyers’s House bill would move almost everyone in the country into Medicare within a single year. We don’t know exactly what Bernie Sanders will propose in the Senate, but his 2013 “American Health Security Act” had a two-year transition period. Radically restructuring a sixth of the economy in such short order would be like trying to stop a cruise ship on a dime.
The most important takeaway from recent efforts to reshape our health-care system is that “loss aversion” is probably the central force in health-care politics. That’s the well-established tendency of people to value something they have far more than they might value whatever they might gain if they give it up. This is one big reason that Democrats were shellacked after passing the Affordable Care Act (ACA) in 2010, and Republicans are now learning the hard way that this fear of loss cuts both ways.
Remember how much trouble President Obama got into when he said that if you like your insurance you can keep it? For something like 1.6 million people, that promise turned out to be hard to keep. And that created a firestorm. Those 1.6 million people represented less than 1 percent of the non-elderly population, and most of them lost substandard McPlans which left them vulnerable if they got sick. The ACA extended coverage to almost 10 times as many people, but those who lost their policies nonetheless became the centerpiece of the right’s assault on the law. They became the “victims of Obamacare.”
Under the current Medicare-for-All proposals, we would be forcing over 70 percent of the adult population—including tens of millions of people who have decent coverage from their employer or their union, or the Veteran’s Administration, or the Federal Employees Health Benefits Program—to give up their current insurance for Medicare. Many employer-provided policies cover more than Medicare does, so a lot of people would objectively lose out in the deal.
Some large companies skip the middle man and self-insure their employees—and many offer strong benefits. We’d be killing that form of coverage. If we were to turn Medicare into a single-payer program, as some advocates envision, then we’d also be asking a third of all seniors to give up the heavily subsidized Medicare Advantage plans that they chose to purchase. Consider the political ramifications of that move alone. And because some doctors would decline to participate in a single-payer scheme, which would come with a pay cut for many of them under Medicare reimbursement rates, we couldn’t even promise that if you like your physician you can keep seeing him or her.
Don’t be lulled into complacency by polls purporting to show that single payer is popular—forcing people to move into a new system is all but guaranteed to result in tons of resistance.
It’s true that every other developed country has a universal health-care system, and we should too. But make no mistake: Moving the United States to national health care would be unprecedented, simply because we spend more on this sector than any other country ever has. Everyone else established their systems when they weren’t spending a lot on health care, and then kept prices down through aggressive cost-controls. Bringing costs down is a lot harder than starting low and keeping them from getting high.
Andthe term “single-payer” is itself misleading. The truth is that many of the systems we refer to as single-payer are a lot more complicated than we tend to think they are. Canada, for example, finances basic health care through six provincial payers. Its Medicare system provides good, basic coverage, but around two in three Canadians purchase supplemental insurance because it doesn’t cover things like prescription drugs, dental health, or vision care. About 30 percent of all Canadian health care is financed through the private sector.
Germany’s “single-payer” system has 124 not-for-profit insurers participating in one national exchange. About 10 percent of Germans—the wealthiest ones—opt out of the national system and go fully private, and most of them buy plans from for-profit insurers.
Understanding that other countries’ schemes vary significantly in the details—and that in the United States, the cost of care would remain a serious challenge under any system—should lead to a different conversation among progressives. Rather than making Medicare-for-All a litmus test, we should start from the broader principle that comprehensive health care is a human right that should be guaranteed by the government—make that the litmus test—and then have an open debate about how best to get there. Maybe Medicaid is a better vehicle. Perhaps a long phase-in period to Medicare-for-All might help minimize the inevitable shocks. There are lots of ways to skin this cat.
At a minimum, it’s time to get past the idea that anyone who doesn’t embrace Medicare-for-All, as it’s currently defined, must be some kind of neoliberal hack.
An obvious alternative to moving everyone into Medicare is to simply open up the program and allow individuals and employers to buy into it. We could then subsidize the premiums on a sliding scale. But recent experience with the ACA suggests that this kind of voluntary buy-in won’t cover everyone, or spread out the risk over the entire population.
Yale political scientist Jacob Hacker’s “Health Care for America” proposal would have left employment-based insurance—and Medicare coverage for the elderly—intact, and created a large new Medicare-like public insurance program that would have been far more robust than anything contemplated during the development of the ACA. Hacker still thinks that, in broad terms, this is the best approach. He calls it “Medicare for More.”
With Hacker’s program, perhaps to be called Medicare Part E, employers would have a choice of providing their employees with coverage as good as they would get in this big public insurance pool, or buying into the scheme. Premiums would vary based on workers’ incomes.
Hacker says he has various ideas for bringing people who aren’t attached to the labor force into the system. One possibility would be to automatically enroll everyone at birth, and cover them until they have a choice of switching to an employer-based plan. Call it Medicare-for-All-Who-Need-It. While the savings would be larger if everyone participated in a single pool, they’d still be significant,
We shouldn’t make promises that we aren’t going to be able to keep; Republicans are learning abut the politics of loss aversion. . “It’s not going to be easy to do,” Jacob Hacker says, “and anyone who tells you that the most expensive health-care system in the world is going to undergo a sudden shift to highly efficient and low-price medicine has not been studying American medicine.”
Achieving universal coverage—good coverage, not just “access” to emergency-room care—is a winnable fight if we sweat the details in a serious way.
Much of the research in this post came from an article in The Nation magazine
And then of course we must put up with this