3 things Joe Biden is still getting wrong about Medicare-for-all

The top 10 remaining candidates for the 2020 Democratic nomination debated each other Thursday night. As previously, health care was a major topic of discussion, and as previously, the entire discussion revolved around the ideas of Bernie Sanders — namely, his Medicare-for-all plan.

Former Vice President Joe Biden attacked Sanders' plan on several points. The arguments were bad and wrong, but usefully so — providing an excellent brief in favor of Medicare-for-all, once one understands they are the opposite of truth.

Falsehood 1: Medicare-for-all is going to be more expensive. Biden claimed that universal Medicare would simply be unaffordable: "I think we should be in a position of taking a look at what costs are. My plan for health care costs a lot of money. It costs $740 billion. It doesn't cost $30 trillion, $3.4 trillion a year, it turns out, is twice what the entire federal budget is."

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So for one thing, the federal budget is not $1.7 trillion, it is about $4.6 trillion. But more importantly, while Medicare-for-all would very likely mean a large increase in the federal budget, it is critical to remember that there is also a great deal of private spending in the status quo system, and all that is ultimately paid by individuals. What matters for individual budgets is not just taxes, but all health-care payments in general.

If one counts mandatory insurance premiums as akin to taxes, then it turns out that U.S. workers are the second-most heavily taxed out of all the countries in the OECD. That's partly why even a study from the libertarian Mercatus Center found that Medicare-for-all would reduce total health-care spending over the next 10 years by $2 trillion. On the other end of the social ladder, Matt Bruenig calculates that by abolishing out-of-pocket expenses, Medicare-for-all "would reduce headcount poverty by 19 percent, reduce the overall poverty gap by 22 percent, and increase poor people’s incomes by 29 percent."

Ultimately, the budgetary price of Medicare-for-all will depend very heavily on how much we want to squeeze administrative costs, drug prices, and payments to providers. Indeed, we already pay enough in tax to finance Medicare-for-all at Canadian prices. But even short of that, it would be logistically simple to create a universal Medicare program that was very generous and relatively cheap.

Falsehood 2: Medicare-for-all will mean lots of people losing their health insurance. Biden claimed that either 160 or 149 million people would lose their coverage under universal Medicare. Now, it is narrowly true that there would be a one-time situation for about half the population where they were switched from the current system onto Medicare ahead of the current 65-years-old schedule (after which they would be insured for the rest of their lives).

But more importantly, as I have argued before on many occasions, the deeper reality is that the status quo system is constantly throwing people off their insurance. One study demonstrates that about 28 percent of people with employer-sponsored insurance are not on the same plan after a year — implying about 45 million insurance loss events every single year. Indeed, if we followed the Sanders plan to roll everyone onto Medicare over a period of four years, it would still cause fewer insurance loss events than the current jalopy system would over the same period — after which there would be no such thing as losing coverage, forever.

Falsehood 3: Medicare-for-all will take too long. Biden: "we're talking four, six, eight, ten years, depending on who you talk about, before we get to Medicare-for-all. Come on." This isn't even an argument. It may be the case that it is politically difficult to pass a good health-care reform. But that has nothing to do with the merits of universal Medicare, it's just to say a handful of Democratic members of Congress are too corrupt or ideologically blinkered to do the right thing. In that case one may well have to take half a loaf in the negotiations — but if so, one might as well start with Medicare-for-all as an opening bid.

Incidentally, when designing the Affordable Care Act the Obama administration deliberately delayed most of its provisions so they could game the 10-year budget window and make the program appear cheaper than it really was. Centrist hesitation — not Sanders-style radicalism — is what delays life-saving reforms.

Then again, this may simply be an instance of Biden just losing the thread entirely. At certain points in the debate he went completely off the rails — most notably, answering a question about his racist school segregation record with a non sequitur about Venezuela and Nicolás Maduro.

At any rate, Medicare-for-all remains the lodestar of the Democratic Party policy debate. Actually passing it would be a huge political challenge, to be sure. But in terms of policy soundness, it is far superior to any other more moderate proposal on offer.