By Ed
Kilgore MAR. 19, 2019
There’s
an ancient debate within the Democratic Party about how (and how quickly) to
move the country toward universal health coverage. The enactment of the
Affordable Care Act was the high point of one basic approach: incremental,
involving both public and private insurance, and minimally interfering with
existing arrangements. The many dissatisfactions, substantive and political,
with Obamacare have fed a revival of the other basic approach: a full leap into
a single-payer system operated by the federal government.
The
preeminent single-payer scheme of the moment is Bernie Sanders’s proposal, which he has wisely
dubbed Medicare for All, trading on the popularity of the Great Society–era
health insurance program for seniors. The title is a bit of a misnomer, in that it would change
Medicare itself in very significant ways. But once you get past that issue,
it’s pretty straightforward: private insurance would be abolished, as would
copays, deductibles, and premiums; Medicaid and Obamacare would be folded in;
and the cost of this massive new Medicare program would be fully socialized
through taxes. The basic appeal of the proposal is its simplicity and equality,
and the proposition that most people would pay less in higher taxes than they’d
save in premiums and out-of-pocket expenses.
The two
obvious problems with Medicare for All are those higher taxes (Sanders proposes a combination of new employee and
individual taxes and making existing federal income taxes more progressive),
and the disruption of existing insurance. That would include not only the
employer-sponsored insurance that covers roughly half the U.S. population, but the
Medicare Advantage plans offered by private insurance companies that cover a third of the Medicare population.
These are
pretty big problems, so unsurprisingly, the world of left-of-center think tanks
has generated a different initiative building off Medicare, called Medicare for America. That this initiative isn’t
some sort of timid Clintonian, incremental improvement of existing law is
signaled by the names of its two chief congressional sponsors, Rosa deLauro and
Jan Schakowsky, both stalwarts of the Congressional Progressive Caucus. It is
probably best understood as a “public option” on steroids: it would enroll
Medicaid and Obamacare participants in Medicare, while making it a voluntary
option for everyone else, regardless of age. Out-of-pocket expenses would be
capped, not abolished, and premiums would be maintained on a means-tested
sliding scale.
Because
the federal government would continue to obtain revenues from premiums, and
enrollment would presumably be less than universal, Medicare for America would
be less of a fiscal leap than Medicare for All. And no one would be forced to
give up her employer-sponsored insurance or Medicaid Advantage plan. The grand
idea is a gradual transition to the kind of single-payer system Sanders’s
proposal would initiate immediately.
These two
proposals aren’t just competing in the abstract world of health care wonks.
Sanders’s plan is at the center of his own presidential campaign, and has been
embraced to one degree or another by Cory Booker, Kamala Harris, and Elizabeth
Warren, among others. Medicaid for America has won an important new advocate in
Beto O’Rourke. And because so many Democratic politicians (not to mention
voters) are more than willing to support alternative plans that vary in cost,
scope, and ambition, it won’t be surprising if O’Rourke is joined by others,
regardless of their position on Medicare for All.
Even
though either proposal would represent a significant leftward move for the
Democratic Party and the country, and would also cast a large shadow over more
modest “centrist” proposals like a limited Medicare buy-inopportunity, the emergence of
Medicaid for America could collide with the determination of some progressives
to make Medicare for All a non-negotiable demand (or as detractors put it, a
“litmus test”). As Dylan Scott observes, it’s unclear how deeply that idea is
rooted in the opinion of rank-and-file Democrats:
I have wondered for some time how many
absolutist single-payer acolytes there really are within the Democratic
Party. A January poll by the Kaiser Family
Foundation found that 81 percent of Democrats support a single-payer
Medicare-for-all plan — but support for a plan like Medicare for America,
opening government coverage to everyone but allowing people to keep their
current plan if they so choose, was a little higher, at 91 percent. Like the
rest of the public, Democratic support for single-payer rose when they heard
out-of-pocket costs would be eliminated and every American would be guaranteed
coverage. But then support fell when they were told it would lead to higher
taxes or delays in medical treatment.
Another poll, taken by Democratic pollster
Michael Perry, found that just 11 percent of Democrats say they would support
only Medicare-for-all, because incremental reforms prop up a broken
system. The vast majority — 84 percent — said they support Medicare-for-all and more
gradual improvements to the Affordable Care Act.
So long
as the two big Medicare proposals are understood as two paths — one very simple
and equitable, one perhaps more feasible and less disruptive — to the same
goal, they may play a limited role in the 2020 Democratic primaries
(Republicans will, of course, savage both as “socialized medicine” and as an
effort to soak hard-working white taxpayers to provide still more benefits to
coddled and idle minorities). But the Beto-versus-Bernie dynamic could make a
lot of wonky health policy distinctions politically salient right away.
http://nymag.com/intelligencer/2019/03/beto-bernie-healthcare.html
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