Progressive idealism and Medicare For All
I have suggested (here and here) that idealism is leading progressives astray. Idealism leads progressives to ignore the political opposition that their proposals will encounter, and the need to win over reluctant allies through policy design, messaging, and – yes – compromise.
A clear example of the pitfalls of progressive idealism is provided by the current debate over Medicare for All.
The case for single payer health insurance in the United States is quite strong but treating Medicare for All as a short-term policy goal is a serious political error. The problem is not just that immediate implementation of single-payer health insurance will meet insurmountable political resistance, which of course it will. MFA turns social insurance – which should be one of the Democrats’ greatest electoral advantages – into a serious liability. If the election is close, which at this point seems quite possible, this unforced error may result in a second term for Trump. Since re-electing Trump would be a calamity, and MFA has virtually no chance of being passed even if the Democrats hit the trifecta and win the presidency and both houses of Congress, this is a huge mistake.
Rather than running on a platform calling for immediate implementation of MFA, Democrats should promise to protect and modestly expand Social Security, Medicare, and Medicaid, in ways that will visibly help struggling Americans. They should increase Social Security payments for seniors with limited income and assets and for the very old. They should push to expand health insurance coverage, to improve drug coverage, and for a public option at least in rural areas. They should promise paid family leave and expanded tax credits for families with children. What they should not do is insist on dismantling the existing system of employer-based coverage in a big-bang transition to a single-payer system.
Social insurance should be a huge electoral advantage for Democrats . . .
Social Security, Medicare, and Medicaid are highly popular, and people tend to trust Democrats more than Republicans on social insurance issues. This is hardly surprising, since Republicans have a long history of trying to cut or dismantle these programs.
Trump ran on a promise to protect and improve these programs. His liberal position on social insurance may have been disingenuous, but it was politically significant because most voters, including many Republicans, are liberal on economic issues. Once he got into office, however, Trump became a standard-issue conservative on taxes and on Social Security, Medicare, and especially Medicaid and the Affordable Care Act. He recently floated the possibility of cuts to Medicare and other entitlement programs. The best hope that Democrats have for prying away Republican voters is to focus on voters who are liberal on economic issues, especially social insurance.
Trump’s duplicity on social insurance is not just a policy issue. Trump played his voters for suckers, and voters hate being lied to by politicians.
Social insurance should be the political gift that keeps giving for Democrats. Most House and Senate Republicans are vulnerable on Social Security, Medicare, and Medicaid. Many of them have supported cuts to these programs, and their reckless corporate tax cuts will put continuing pressure on the financing for social insurance. Democrats can and should hold all Republicans accountable for their continuing efforts to subvert these programs.
But MFA will turn social insurance into a political liability . . .
For all these reasons, social insurance should be a huge advantage for Democrats. But MFA will turn social insurance into an electoral liability, with no compensating advantages.
Special interest opposition to MFA will be intense. All of the cost savings that MFA can achieve come from eliminating jobs and reducing the income and profits of people and companies in the health care sector. Insurance companies will lead the fight against MFA, but they will be joined by other groups – people who do medical billing, people who work for insurance companies, some hospitals and health care workers, etc. Their opposition will matter. It was Democratic Senator Joe Lieberman of Connecticut – home of the insurance industry – who killed the public option in Obamacare. Special interest opposition can only be defeated using “salami tactics” – chopping off one piece of the private health insurance system at a time, over a period of years. We need to get the camel’s nose into the tent first, the body will follow.
Critically, electing a president who stakes out an aggressive position on MFA will make reform harder to achieve, not easier, because it will make it easier for insurance companies to scare voters into opposing reform. Americans have been primed to distrust government by 50 years of “goverment failure” messages. Distrust of government will be a powerful obstacle to immediate implementation of MFA. People will understandably worry that government will screw up a quick implementation of MFA (not without reason, in my view, but here I am just concerned with the electoral politics). By emphasizing that their goal is to protect existing programs, and to build on them in modest but important ways, doubts about government competence and fairness are much less salient. There is no question that the government can run Social Security, Medicare, and Medicaid. Focusing attention on the threat to these programs from Republicans makes loss aversion work in favor of the Democrats rather than against them.
Some form of single-payer health insurance makes sense for the United States. It’s fine for Democrats to say this. But they need to acknowledge that putting such a plan in place will take time and needs to be done carefully to build voter support, overcome resistance by vested interests, limit job losses, and avoid major implementation disasters. If we play our cards right, we can build on the Affordable Care Act and position ourselves to have some kind of single payer system in place in 20 years. If we overplay our hand, we may end up with four more years of Trump.
My guess is that most of the candidates for the Democratic nomination are aware of all this. They could explain to Democratic voters why implementing Medicare for All will be a long, drawn-out struggle. They could teach voters to distinguish between universal coverage, which should be achievable in the short-run, from single-payer, which is not achievable in the short-run and may lead to electoral disaster. They could encourage Democrats to be hard-nosed, patient, and strategic. Instead, they are pandering to idealistic primary voters. The path to a realistic progressive politics will be long . . .
Agree with almost everything you say except for Dems prying votes from the Reps.
That has never happened in my lifetime. Not in any number that mean anything at all.
Right on cue with your main point, but the question is will this only affect votes in the primary and not the general?
“Not five minutes after Bernie Sanders had finished his victory speech Tuesday night, and not 10 minutes after Sanders had bum-rushed Pete Buttigieg off the networks in mid-platitude, the essential Jon Ralston dropped this little item from Nevada onto the electric Twitter machine. From the Nevada Independent:
‘Vermont Sen. Bernie Sanders would “end Culinary Healthcare” if elected president, according to a new one-pager the politically powerful Culinary Union is posting back of house on the Las Vegas Strip.
The new flyer, a copy of which was obtained by The Nevada Independent, compares the positions on health care, “good jobs” and immigration of six Democratic presidential hopefuls who have come to the union’s headquarters over the last two months to court its members. But the primary difference outlined in the document, which is being distributed in both English and Spanish, is in the candidates’ positions on health care, taking particular aim at the Vermont senator over his Medicare-for-all policy, which would establish a single-payer, government run health insurance system. ‘
The flyer says Sanders, if elected president, would “end Culinary Healthcare,” “require ‘Medicare For All,’” and “lower drug prices.” The language it uses to describe the position of Massachusetts Sen. Elizabeth Warren, who also supports Medicare for all after a transition period, is much gentler: “‘Medicare for All,’” “replace Culinary Healthcare after 3-year transition or at end of collective bargaining agreements,” and “lower drug prices.”
This is a huge and diverse union and it does not play games.
‘The union, considered an organizing behemoth in the Silver State, has been known to tip the scales in elections in the past. Though the 60,000-member union has not yet decided whether it will endorse in the Democratic presidential primary, the flyer appears to be part of a coordinated campaign ahead of Nevada’s Feb. 22 Democratic presidential primary and shows the union will not be sitting idly by, with or without an endorsement. A spokeswoman for the Culinary Union said the flyer is also going out to members Tuesday night via text and email.'”
If Medicare-for-All is thought to be politically untenable (for reason of cost or resource availability), why not propose reducing the Medicare eligibility age in steps to see how it goes. That doesn’t appear very threatening, yet could eventually achieve the goal.
You really do not need to expand Medicare. Just offer Medicare Pricing for all. It is not going to touch Pharma.
Ed: that counts as “salami tactics” in my book.
EMichael: there are still swing voters and swing states . . . remember how close the 2016 election was . . . and Dems stand a real chance of gaining voters due to attitude and demographic change (see my earlier post) . . . we need to win in 2020, and also play a long game.
I had written on Single Payer here a while back comparing Japapal’s plan to Bernie’s version as taken from Kip Sullivan’s discussion comparing the two. It is a serious flaw when Democratic Candidates do not understand what Single Payer really consists of and how to explain it. There is also several other plans out there which are intermediate steps to Single Payer, using the ACA, and bringing “costs” down. I say costs because this should be the goal and not the discussion on prices. Our candidates do need advisers on healthcare.
There are 4 components of Single Payer:
Single Payer: relies on one payer (HHS, not multiple payers called ACOs) to pay hospitals and doctors directly,
it authorizes budgets for hospitals and nursing homes,
it establishes fee schedules for doctors,
and it has price ceilings on prescription drugs.
While Kip says price controls, he is really talking about cost containment to the patient and to overall healthcare from the healthcare industry. Jayapal has all 4 elements while Bernie’s lacks the first two and depends upon ACO’s to administer and pay hospitals, doctors, etc. Think of 5000 or so hospitals doing so. Bernie bill specifically points to ACOs.
Enough of the introduction. What Dems are not doing is explaining the amount of cost incurred by using ACOs (1,000 ACOs in operation) and that by eliminating the administrative costs for the ACOs and also by insurance companies, much of the switch to Single Payer would be paid.
MA plans are a rip off and they are over charging.
The other avenue to driving costs down is in setting fees for various serves in Hospitals through the budget process. It is no mistake that Kocher and Berwick as well as JAMA identified Hospital in and out patent care as the leading cause of increases in Healthcare Insurance Premiums.
I read a lot on Pharma costs and the distribution/supply chain using PBM. The latter is an issue and can be done away with while the former is still the larger of the two issues and can be controlled (which I will not get into here).
All of this has not been told to the voting public and remans a mystery to them. They will resist until they understand how it helps them. Warren, Sanders, Bidens etc. either do not know how to explain the dynamics of single payer or are just talking to talk. he three, Warren could do it. Kocher and Berwick have the best intermediate plan that I have read to date.
Run75441: Agree on cost control. Eventually, hopefully, the U.S. can reduce costs to be more in line with other high income countries. Closing 50% of the gap would save over $5,000 per household per year by my back of the envelope calculation. ($1 trillion savings, 130 million households.) The difficulty is that all this money comes out of the incomes of providers, drug and device manufacturers, etc. Politically, most of this can only be accomplished slowly, by capping spending increasing. We need to play a long game here.
We need to look at costs and begin to ask the 5-Whys? Starts, such as Why is healthcare CPI twice that of normal CPI (example)? Why do you need 10 years of exclusivity when costs are recouped in 5 years after risk adjusted sales are taken into consideration (WHO)? What value increase is being delivered by a drug to justify a price increase (ICER – 7 top drugs with price increases did not deliver more value to the patient, etc.)? There is more to this than just what I stated.
You are correct there is a “huge” savings to be had which would pay for Single Payer. We as Democrats do not explain this and all we talk about are increased taxes to pay for Single Payer. Others wish to skip the conversation with a “try it you will Like it attitude.” Because of Repub lies on the ACA, they do not believe it.
If you like, we can exchange message offline. I have a ton of references.
By the way European countries are have the same issues with increased costs. WHO complains of a lack of transparency when they negotiate for drugs for different countries. Pharma tells the various countries not to disclose prices. . To get control of insulin costs, WHO has started a program of testing Biosimilars. Congress took the 10 years of exclusivity out of the USMCA and put it in the House Budget. Surprise Billing is another way to shuffle what a hospital pays a surgeon, doctor, anesthesiologist, etc. (3rd party) to the insurance company and patients. Many hospitals favor of it. Texas has more of it.
Medicare has an existing price control, payment processing & policing infrastructure that works very well based on my experience as a user for almost 30 years. IMO, any change other than eligibility age (except possibly bringing pharma under their control) would be wasteful at best & unworkable at worst.
This might work for the 50 and older crowd. A lot of people still want their own insurance. We have not done a good job of explaining it.
@Ed Zimmer, February 12, 2020 3:30 pm
Looks like a very elegant idea. Compete opposite of what Greenspan did with Social Security.
Thank you !
I don’t believe that there are swing voters in any number that is not insignificant. The whole key is about who turns out to vote.
I have met as many ahs as anyone else in this country. People who are so weird that the only thing you can do is stay away from them. Yet I have never met anyone so weird as to vote for Obama and then vote for trump.
And that is what the “swing voters are real” people point to.
I’m sorry, I just cannot believe that.
“In July 2018 the most widely-respected analysts were decidedly uncertain whether the Democrats could retake the House—they were favored, but not by much. On July 6, Cook Political Report, for example, listed 180 seats as “solid,” and 21 “likely/leaning” Democratic, plus 24 “toss-ups” — meaning Democrats would have to win toss-ups by more than 2-1 (17 to 7) to take the House. In mid-August, 538’s first forecast had “only 215 seats rated as favoring Democrats — ‘lean Democrat’ or stronger — which is fewer than the 218 they need to take the House.” And on August 30, 2018, Sabato’s Crystal Ball published a model prediction, based on 3000 simulations, with an average Democratic margin of 7 seats. Editors noted this was close to their own assessment: “Democrats as modest favorites but with Republicans capable of holding on to the majority.”
But on July 1, 2018 — preceding all this cautious uncertainty — newcomer Rachel Bitecofer, assistant director of the Judy Ford Wason Center for Public Policy at Christopher Newport University in Newport News, Virginia, released her prediction of a 42-seat “blue wave,” while also citing the Arizona and Texas U.S. Senate races as “toss-ups.” Her startling prediction was numerically close to perfect; Democrats will end up with a gain of 40 or 41 seats, depending how the re-run in North Carolina’s 9th district turns out. (Democrat Kyrsten Sinema won the Arizona Senate race, in a major historical shift, and Beto O’Rourke came close in Texas.) Furthermore, she even strutted a little, writing on Nov. 2 that she hadn’t adjusted her seat count, but that “the last few months have been about filling in the blanks on which specific seats will flip.” Her resulting list of those was also close to perfect.
With a record like that, you’d think that Bitecofer’s explanation of what happened would have drawn universal attention and become common sense — but you’d be sadly mistaken. She’s barely beginning to get the recognition she deserves, and more troubling for the country, the outdated assumptions her model dispensed with continue to cloud the thinking of pundits and Democratic Party leadership alike. (Follow her on Twitter here.)
This hampers efforts to counter Donald Trump’s destructive impact on a daily basis, and spreads confusion about both Democratic prospects and strategy in the 2020 election prospects. Above all, the mistaken belief that Democrats won in 2018 by gaining Republican support (aka winning back “Trump voters”) fuels an illusory search for an ill-defined middle ground that could actually demobilize the Democratic leaners and voters who actually drove last year’s blue wave….
The explanation, of course, is that it was this giant turnout of core constituencies, that either are Democrats or favor Democrats — they’re independents who favor Democrats — and they have a huge turnout explosion. So it’s not the same pool of voters changing their minds and voting Democrat after voting Republican because of the issue of health care. It’s a whole different pool of voters.
They might have many reasons that they cite, and probably this is not the reason they would cite. But what made them enraged and show up is Trump Inc., the negative partisanship. I don’t know why Nancy Pelosi, the DCCC or many of these moderate members are convinced that moderate Republicans crossed over and voted for them. I have the data for some of these districts and the data tells a very different, very clear story: If Republicans voted in huge numbers, they voted for Republicans.”
And take heart, the Professor predicts 2020:
“Rather than fearing Trump’s ability to repeat his 2016 upset, on July 1 of this year Bitecofer released her 2020 projection, which shows Democrats winning 278 electoral votes versus 197 for Trump, with several swing states too close to call. Bitecofer also isn’t worried about the Democrats losing their House majority. On Aug. 6, Bitecofer released a preliminary list of 18 House seats the Democrats could flip in 2020, nine of them in Texas. The most significant threats that concern Democrats are actually golden opportunities, according to her model.”
We can hope she is right, after we vote of course.
It is nice to see someone of status come out and say what I said a while ago. MI, PA, and WI were won by Trump. not because or Trump; but due to votes for the “other” candidates. Later on I picked up on the anyone but “Trump or Clinton” vote. Even showing the numbers, I was pummeled repeatedly on this “fact.” With the exception of WI, the turnout was higher in MI and PA. WI was down 3%.
Edit: White America should quit blaming Black America for the loss in 2016. We lost 2016 due to many being disgusted with the trump attacks on Clinton and doubts about Clinton by Dems. We did not trust our own candidate even though withstanding numerous investigations.
Michigan was up in 2016, but barely — 1.4% vs national +5.9%. It’s easy to conclude that MI and WI had not only a high level defectors to third parties, but also to the couch. Pennsylvania, who knows? since it was up more than the national increase, 6.3%.
No, the argument stands as it is. It is far easier to conclude the issue is people not going polls when it has been a problem for a long time. The vote for others was historical in size and 3-5 times as compared to other years. Of course we could blame Black America for not showing up; but then, historically they have had fewer voting stations in polling areas than white Americans and long lines to get in to the polling places. Since 1990 the Michigan legislature has been controlled by Repubs 100% in the Senate and 67% in the House, the governorship 2 of 3 times till Whitmer, and a trifecta 2 times. There goal is too block Detroit and other primarily black areas in whatever way they can.
Your argument is specious.