Elizabeth Warren and Bernie Sanders have made “Medicare for All” a centerpiece of their campaigns. Pete Buttigieg has offered “Medicare for All Who Want It.” Both proposals have generated criticism, and in my opinion, most criticism of both is misplaced, because the discussion fails to distinguish between two very separate issues: 1) what would a sensible system look like, and 2) how do we get there?
I was prompted to revisit the issue because my cousin–the cardiologist I often cite on this blog–has done his own analysis of the current state of healthcare in this country, and concluded that a single-payer system is both preferable and inevitable. (Those who want to get “into the weeds” of that analysis should follow the link.)
In my most recent book, I also make the case for single-payer–and point out that a fully-implemented single-payer system would be much less costly than our current patchwork, dysfunctional approach. Virtually every economist who has analyzed the situation agrees. That doesn’t necessarily mean that taxes wouldn’t go up, but any increase would be more than offset by savings on premiums, co-pays and other costs currently borne by individuals and employers.
At any rate–I’m in full agreement that a single-payer system is needed. I depart from the “vote for me and I’ll change the system” approach being taken by Warren and Sanders because there is an enormous mountain to climb between where we are and where we need to be, and the suggestion that all we have to do to get a single-payer system is elect a Democratic president (or perhaps a Democratic president and Senate) is ludicrous.
It isn’t simply that politically powerful insurance and pharmaceutical companies would throw everything they have into that debate. Voters rebel when they are told they will be forced into a new system, no matter how demonstrably better off they would be. Just getting the Affordable Care Act through Congress took enormous political capital, and that was after numerous (unfortunate but necessary) concessions.
In a recent column for the New York Times, political scientist Jacob Hatcher writes that we shouldn’t lose sight of what Ms. Warren is trying to do.
She’s making an evidence-based case for shifting the debate away from the perilous place it’s now in. Rather than “Will taxes go up?” or “Will private insurance be eliminated?” she wants us to ask a more basic question: How can we move from a broken system — a system that bankrupts even families who have insurance and produces subpar health outcomes despite exorbitant prices — to one that covers everyone, restrains prices and improves results?
I actually don’t see Warren asking (or answering) that very important question–she seems to be making the case for an immediate change that would eliminate all private insurers, and if my impression is correct, it is a politically fraught case.
Nevertheless, “how” is the most important question. As Hacker writes,
Getting to affordable universal care has always been a problem of politics, not economics. Given that the United States spends much more for much less complete coverage than any other rich democracy, it’s easy to come up with a health care design that’s much better than what we have. The problem is figuring out how to overcome three big political hurdles: financing a new system, reducing disruptions as you displace the old system and overcoming the backlash from those the old system makes rich.
Yep. And that brings me to an interesting paragraph in my cousin’s post. Dismissing the “public option” (which is what “Medicare for All Who Want It” really is), he writes,
Even now, given our current healthcare pricing, a medicare type program, operating with lower administrative costs, would be far cheaper than those offered by their private counterparts. This would allow employers to willingly relinquish expensive private plans in favor of the cheaper public option that would reduce the cost burden of extra employee benefits. This means that the public option would likely supplant the present private plans completely in short order. (Emphasis mine.)
Yes. That’s the point.
“Medicare for All Who Want It ‘ isn’t the answer to the “what” question. It’s the answer to the “how” question.