Why Sanders, Harris and Booker Compete for Medicare for All

The Democratic Party's 2020 primary began with a confused and confused debate over the details of Medicare-for-all – a debate that shows how much complexity lies behind a seemingly simple slogan.

Sen. Kamala Harris (D-CA) kicked off, Jake Tapper of CNN that she would "eliminate all this," where "this" was referring to private insurance. A few hours later, her staff softened the statement, telling reporters that if Harris's goal was to get single-payer health care, she also took out additional bills. ("I want a burrito", tweeted Harris communications director, in a mischievous clarification. "I would accept tacos meanwhile, but I want a burrito."

Sen. Cory Booker (D-NJ) took another tone after announcing his candidacy and was asked if he would "eliminate private health care," said Booker, "even countries with wide access to health care. health offered to the public still have private health care, so no. "

Within hours, Booker was besieged by angry tweets from the Liberals reminding him that he was one of the co-authors of Senator Bernie Sanders' (I-VT) Medicare for All bill and that it abolished private insurance. (In fact, this is not the case – more information on this subject in for a moment.) Thus, they thought he had proved to be a false progressive and a real hypocrite.

Sen. Elizabeth Warren (D-MA) quickly examined the wreckage and decided to get around all the mess. "We know where we are, and that every American is getting affordable health care," she told Bloomberg. "There are several bills in the US Senate. I have joined Medicare for all. I have signed another contract that offers an option to purchase in Medicaid.

Sanders, who deserves credit for making Medicare for all the defining policy of the 2020 Democratic primary, took the opportunity to double his bill. "I look at the polls and 70% of the population supports Medicare for All," he told the New York Times. "I think I would be foolish enough not to develop policies that capture what the American people want."

Justin Sullivan / Getty Images

At the same time, Senator Sherrod Brown (D-OH), another likely candidate for 2020, decided to play more moderate ground. "I know most of the Democratic primary candidates are all talking about Medicare-for-All," he told the Clear Lake Chamber of Commerce in Iowa. "I think we should be doing Medicare at 55". Brown, one of the most liberal members of the Senate, has presented his position as mere pragmatism. "I'm going to talk about what's practical and what we can do to get there," he said. "What if it makes me different from other candidates?"

Behind this debate lies the fact that Democrats have adopted a politically powerful but deliberately confusing slogan to describe their health goals. "Medicare-for-all" does not mean what it means. And so, what that means or should mean has become a decisive debate within the party.

What does "Medicare" mean in Medicare-for-all?

In the imaginary democrat, Medicare is a generous system, single payer insurance system that can be extended to the entire country.

In reality, Medicare is a special health insurance plan, specifically designed for the elderly and marked by decades of political conflict. It does not cover a host of conditions – like pregnancy, for example – that young people face. It does not cover vision or dental care. This includes a large share of the co-payers and no limit on the expenses to be borne, which is why three-quarters of the registrants use additional insurance to cover their expenses.

Medicare also makes extensive use of private insurance. All prescription drug coverage is provided by private insurers under the Medicare Part D program and approximately 34% of Medicare beneficiaries are enrolled in private Medicare Advantage plans rather than the traditional Medicare system.

None of the plans offered extends Medicare insurance to all Americans. , and for good reason. If Medicare-for-all meant that everyone had access to Medicare, the insurance itself would not cover what young people need, and much of the insurance would be private.

What many people seem to hear about Medicare-for-all is Sanders' Medicare for All bill. As Sarah Kliff's excellent explainer explains, Sanders' legislation introduces a much more generous system under the banner of Medicare and bans en route duplicate private insurance and sunsets from current programs. Medicaid and Medicare.

It's not entirely true to say that Sanders' plan completely removes private insurance – you can still buy private insurance without duplication – but that would mean that some 180 million Americans with private insurance would see their plans canceled.

Sanders' Bill boasts of co-owners Booker, Gillibrand, Harris, Merkley and Warren – after the 2016 elections, some hopeful candidates for 2020 wanted to let Sanders outperform them in health care – but that's not the case. is far from the consensual vision, in part because of Sanders' maximalist approach Medicare-for-all polls.

What does "everything" mean in Medicare-for-all?

People do not like health insurers in general, but they tend to like their own health insurance. Sixty-one percent of insured Americans under the age of 65 report that their insurance plan is "excellent" or "good". It is perhaps for this reason that the cancellation of individual private plans goes from health insurance for all to majority support (+14 in favor) to majority opposition (-21 unfavorable). Raising taxes and ending the current health insurance program is doing even more damage.

Kaiser Family Foundation

Sanders' plan removes most private insurance, raises taxes, and replaces current Medicare program. In addition, it is theoretically quite possible that its legislation, which reduces the tariffs of health care providers while giving all Americans free access to all health care services, results in supply constraints. , which is the most dangerous attack that can be opposed to the idea.

I think that no poll would be prophetic and Sanders has revealed a particularly effective health care messenger. Maybe his plan would be stronger to counter arguments with him on the path that defends him. But disrupting existing health care systems has been politically disastrous for anyone who has tried it.

The most-publicized announcement of the 2008 presidential campaign is Barack Obama's attack on John McCain's plan to tax employer-provided insurance. Care Act. Americans are very afraid of the risks in their health care.

For this reason, other Democrats and Liberal organizations have developed Medicare plans for all that allow people to subscribe to the new Medicare program rather than being forced. above, which reduces the total costs.

Reps. Rosa DeLauro (D-CT) and Jan Schakowsky (D-IL), for example, have just published their Medicare for America bill, which lists uninsured people, as well as all people living under Obamacare and Medicaid, in an expanded Medicare plan. and then let individuals and employers join if they wish, with income-based grants. Jacob Hacker of Yale, who was involved in the drafting of the legislation, explained the thought to Vox:

Health care plans collapsed every time we looked for where to find the money. For me, this is in some ways the biggest argument for a Medicare expansion that is not a single payer. Where do you find money if you are trying to socialize essentially the costs of the world's most expensive medical system?

Bernie Sanders' own team said their plan would cost 9 to 10 percent of GDP. I pointed out that the tax increase to finance the Second World War was about 5%. It's a lot. They are right in saying that you are only converting private premiums into public taxes. But I am incredulous at the idea that you can really implement this type of new tax funding as quickly as it would be necessary to have a universal health insurance system.

Other ideas are even more progressive. Meaning. Chris Murphy (D-CT) and Jeff Merkley (Medicare Act) would add an expanded Medicare option to the Obamacare exchanges and give employers the opportunity to purchase it.

All of these plans define the "everything" in Medicare-for-all differently. Sanders' plan states that everyone gets health insurance, whether they like it or not. The DeLauro and Schakowsky plan states that everyone can have access to Medicare, but private insureds can keep what they have if they prefer. Murphy's and Merkley's bill allows anyone to buy Medicare, to the extent that they can afford it.

Incrementalists (a strange word to use for plans that are still incredibly ambitious, but support me) argue that their proposals are safer "slippery tracks" for all people benefiting from Medicare .

The argument is that the size of Medicare allows it to negotiate better prices with doctors and hospitals, resulting in reductions of about 20% in private insurance. If Medicare is cheaper and better than private insurance, everyone will eventually switch. What is the purpose of forcing people to join the program and risk a backlash that could wipe out the entire project? After all, President Obama has been criticized for canceling nearly 3 million so shabby plans that they did not meet the relatively lenient standards of the Affordable Care Act; Is the cancellation of orders of magnitude of several insurance plans and much better insurance plans really the lesson to be learned from this debacle?

The counter-argument is that hospitals and doctors may decide that they do not want a world-wide Medicare and that they could stop taking Medicare to encourage individuals and employers to continue buying private insurance plans that offer them higher rates. A world where there is no private insurance scheme makes this fundamentally impossible.

The counter-argument is that if doctors and hospitals fear a world in which all insurances pay Medicare rates, they would abolish the plan even before it is enacted or force any plan to pay higher rates. and politicians have less confidence than medical providers, and it is unlikely that a plan will overcome all the objections of the medical industry.

Needless to say, I'm not going to settle this argument here, and I'm not even sure who's the best. But that shows how much the debate around Medicare-for-all really concerns your theory of politics, not just your theory of politics.

The Political Conservatism of Medicare-for-All

Scott Olson / Getty Images

The Medicare-for-all brand is attractive precisely because it's not threatening. People have a risk aversion to their health insurance. They want something that they know will work.

Medicare works, and Americans know it. This is a political advantage for Democrats. But it carries an implicit threat: if the Democrats' Medicare for All Bill is risky for citizens, the same forces that support the poll's results will sink the policy later. As a concrete example, it is very difficult for me to imagine that Democrats are withdrawing Medicare Advantage from older people on the pretext of expanding Medicare. If your bill is based on the idea that people like the current health insurance plan, taking away something that they are passionate about will seem like a deep betrayal.

When judging candidates for the presidency, there may be a tendency to let ambition act as a sign of commitment. From this point of view, if Harris wants to abolish all private insurance, she is more committed than Booker in Medicare for all, and both are more committed than Brown, who simply wants to extend the program to 55 years.

But this is an imperfect way of thinking about policy making. The point here is to extend the coverage to a larger number of people, so the issue needs to be broadened to include political strategy. A health insurance plan that enacts a law and successfully extends coverage to 40 million people brings the country much closer to Medicare for all than anyone who plans to expand the health insurance plan. 39; Medicare to everyone, but will fail in Congress and will cost the House of Democrats in 2022.

] I do not think DeLauro and Schakowsky engage less in the development of Medicare than Sanders or Harris. Instead, I think they think that Sanders' approach could trigger a reaction that would discredit the entire project and that their bill is more likely to be passed. Whether this is true or not is the real debate that Democrats must have.

It's not just the inside of the plane. The process matters too. None of these plans will literally pass as long as they reach the threshold of 60 votes in the Senate. In the absence of a plan to eliminate the obstruction, or in the absence of a bill that can fully integrate into the process of budgetary reconciliation, all this is theoretical. In this world, Brown's plan to open Medicare to 55- to 64-year-olds is probably the best you can do.

The Democratic Party has become much more ambitious in its political ideas in recent years and I think it's a change for the better. . But even in this case, the history of health care reform is primarily a story of failure and backlash. This is because American political institutions make big bills difficult to pass because financial interests are fiercely opposed to their adoption and because people do not trust the government to spoil themselves with their health care. The way in which the various Democrats running for president propose to navigate or defuse these threats should be an integral part of this debate.