What Medicare-for-all skeptics are missing
It's health-care season in the Democratic presidential primary. Following Bernie Sanders' famous Medicare-for-all proposal, Joe Biden has since published his plan, a sort of upgraded version of ObamaCare. Kamala Harris just released her plan as well, which is roughly halfway between Sanders and Biden. Both Biden and Harris would preserve a role for private insurance, at least in the medium term.
Meanwhile, Vox's Ezra Klein argues that leftists (like myself) have deceived the public about what Medicare-for-all would entail, and suggests disruption would be an insurmountable political obstacle. But Klein gets both the policy details and the political terrain wrong. Passing Medicare-for-all would indeed be an enormous effort. But getting as close to it as possible will be key to passing any quality health care reform at all.
Let's start with some details. Biden would build out a public insurance option that would be sold on the rump ObamaCare exchanges. Existing subsidies would be increased for people making between 100 and 400 percent of the poverty line, and people who would have been eligible for Medicaid but live in states that rejected the Medicaid expansion could get the public option for free. Harris, meanwhile, proposes to gradually extend Medicare Advantage (traditional Medicare delivered through private insurance companies) to most people over 10 years.
Both options would include many more years of private coverage, at a minimum. There is one primary argument for doing so — it supposedly assuages people's anxiety about having to switch from their current private plan to a new government plan.
Leftists have developed a strong argument that actually, it should be the private system that must answer for switching anxiety, because it constantly throws people off their insurance. Every time someone gets laid off, switches jobs, or their employer changes plans, or they turn 26 or 65, they get thrown off their plan — sometimes onto a new one, sometimes not. Conversely, Medicare-for-all would get rid of switching forever after a big one-time switch while it was being implemented.
Klein claims that we are being slippery with definitions here, referring to losing insurance outright for maximum emotional impact when that is only part of the total. As Matt Bruenig (the main target of Klein's piece) writes, this just isn't true. I have clearly referred to all types of insurance changes in my articles on this — switching to another insurer, outright loss, aging into Medicare, and so on. Incidentally, while it is clearly worse to lose one's insurance than it is to just switch plans, it's often no joke either. For instance, the cost of our coverage at The Week went up by 40 percent this year (not the fault of anyone here, of course), and I opted for a less generous plan to save money.
Klein then argues that Medicare-for-all would have a problem with insurance loss too, because a future Republican government might cut the program. "The skepticism Bruenig brings to private insurance is the same skepticism many bring to single-payer insurance. You like your government-provided health plan? Better cross your fingers, because your side just lost the White House," he writes.
This is a very peculiar argument. Clearly any policy can be repealed at any time, which would indeed delete any benefits thereof (unless written into the Constitution, though then there is always the possibility of more radical action). But that is equally true of our current employer-based system, and my arguments didn't count the possibility of all 160 million people on that coverage losing it due to a change of government. When discussing the merits of various policies, clearly it makes most sense to compare their internal dynamics and logic instead of what happens if they vanish.
That brings me to the politics. It is true, as Klein writes, that people's attitudes in polling shift dramatically when they are primed against Medicare-for-all. On its own, support comes in at 56 percent in favor and 38 percent against — but if you tell respondents it will abolish private insurance, support falls to 37-58. Tell them more taxes are required, and it falls to 37-60.
On the other hand, it's also true that if you prime people in the opposite direction, support goes up. Tell respondents that Medicare-for-all will eliminate premiums and reduce out-of-pocket costs for most Americans, and support increases to 67-30. Tell them it will guarantee health care as a right for all Americans, and support goes to 71-27.
A plausible picture of what's going on here is not hard to imagine. Most people do not have have consistent, well-defined policy views, but they know that private insurance is a bit of a pain, and that it keeps getting worse year after year. Simple ideas to fix the problems sound good. But people also have generalized loss aversion — in addition to wariness about American reforms specifically, where the track record is not so great. Indeed, the last liberal attempt to fix the system (while it did a lot of decent things) manifestly failed to cover everyone or put American health care on a sustainable footing — in addition to introducing a janky health care "marketplace" that doesn't work at all how it was supposed to and is a giant pain in the neck to use. "Oh great, the freaking Democrats are going to 'help' us again," millions are probably thinking.
The political theory of Medicare-for-all is that if you just bite the bullet and go Full Socialism (or as close as you can get when it comes time to count votes), the overwhelming satisfaction that most experience afterwards will protect you against the backlash. And indeed, millions of people would certainly be pleasantly surprised by how good Medicare-for-all would be. For instance, in the Kaiser poll cited by Klein, 69 percent mistakenly say they think they would still have to pay deductibles and co-pays under Medicare-for-all, and 54 percent wrongly think they will still have to pay premiums.
Neither is true — under the Sanders bill (which covers all medical, dental, vision, nursing, and long-term care) there is no cost-sharing whatsoever except for prescription drugs, and that is capped at $200 per year. This plan is wildly better than virtually any private plan — and would be accepted at every medical provider in the land. People would be celebrating in the streets once they figured out it wasn't some scam. It's worth noting that while Republicans did nearly repeal ObamaCare, and have attacked Medicaid at the margins, they never tried to attack Medicare.
In fact, public attitudes are not even the biggest obstacle to Medicare-for-all. That's an argument that could be won over time. Instead it is the medical lobby that is dead set against any reform that cuts into their gargantuan profits (which any reform worthy of the name must do). Indeed, they are even against Biden's small-bore plan — why settle for half a loaf when you can have the whole thing? These are the people and interest groups who will cynically mobilize the public's cynicism and loss aversion to keep titanic rivers of cash flowing into their own pockets.
Conversely, this means the key political task for people who want to fix American health care (through Medicare-for-all, or any other method) is to build confidence, aggressiveness, and righteousness among Democrats, in addition to carrying out a broad educational campaign. Preemptive surrender, as centrists like Biden suggest, will activate the same resistance without providing much in the way of broadly popular benefits. The only way out of America's dystopian health care nightmare is through.
Editor's note: This article originally misstated Bernie Sanders' prescription drug cost-sharing cap as $250. We regret the error.