Thursday, March 21, 2019
Health care FTW
This piece by Paul Waldman about where the Democrats are heading on health care is very good news, as far as I'm concerned.
Something quite remarkable is happening right now among Democrats on the issue of health care: After an intense period in which rhetoric, policy and politics were all seemingly in flux, the party is rapidly moving toward something like consensus on where it ought to go next on its most critical domestic priority.
As you may know, almost every Democrat running for president has said he or she supports Medicare-for-all, but most of them (with the exception of Sen. Bernie Sanders, who has been proposing a single-payer plan for years) have been vague about what that might mean. Maybe private insurance will be eliminated, or maybe not; maybe people will continue to get coverage through their employers, or maybe not. They will all presumably present specific plans eventually, but they haven’t yet.
What they are doing is circling closer and closer to something that doesn’t yet have a name, but which I’ll call “Medicare For Anyone.” The fundamental difference between that and Medicare-for-all is that instead of eliminating (or minimizing) private insurance and putting everyone into the same pool, it would open up Medicare or something like it to anyone who wants it.
In most of the variations that have been proposed, large numbers of Americans (newborns, people with low incomes, the uninsured) are automatically enrolled to make sure they’re covered. Employers can choose to stay with the insurance they have, or put their employees into the government plan. It’s paid for through a combination of taxes and premiums, with low-income people paying nothing and premiums rising with income.
For the moment I won’t get too deep into the policy details. But if you’re looking for a full version of it, there’s a proposal from Reps. Rosa DeLauro and Jan Schakowsky called “Medicare for America” that is probably what most Democratic candidates will either specifically endorse or which will be very similar to what they present.
But if you want to sum it up in the most simplified form, this kind of proposal is like Medicare-for-all, except instead of everyone being put into Medicare, there will still be private insurance plans that people can stay with if they want to. If the policy heart of it is that everyone gets insured, the political heart is that it’s voluntary.
Beto O’Rourke is already saying that the DeLauro-Schakowsky plan is what he wants. Pete Buttigieg says he supports Medicare-for-all either actually for all or “as a public option to buy in,” but either way with private insurance remaining involved as it is in the current Medicare program.
And Sen. Kirsten Gillibrand said at an MSNBC town hall on Monday night that she wants to “allow anyone to buy into Medicare at a price they can afford. Something like 4-5 percent of income. They buy in, so it’s an earned benefit, and they are qualified automatically for Medicare.” She concluded, “Let’s have a not-for-profit public option compete for the business. I think over a couple years, you’re going to transition to single payer.”
That’s also something you’ll hear from multiple candidates, not just because it’s a reasonable prediction of what would happen, but also because it’s a way of appealing to strong single-payer supporters. But not necessarily from all of them. In fact, a public option or a Medicare buy-in or Medicare For Anyone could encompass a wide variety of plans, some more sweeping than others, depending on how it’s designed.
Not every non-Sanders candidate is endorsing Medicare For Anyone. Elizabeth Warren’s position at the moment is essentially that we’ll get everyone together and work it out, so long as we find a way to cover everyone at lower cost. But I can confidently predict that in the coming days, candidates who have also been vague on the question are going to be drawn to this idea like iron filings to a magnet.
Why is this where the party is arriving? There are three main reasons. First, this kind of plan satisfies, at least for the most part, the progressive desire to insure everyone and eliminate the pathological features of the current system. Second, it addresses what is probably the greatest vulnerability of single-payer plans: the fear of change. It’s foolish to think that fear can be eliminated through sufficient logical persuasion, and Republicans will absolutely exploit it when they fight against whatever Democrats propose. So the fact that joining Medicare would be voluntary is essential to these proposals.
And finally, it’s easy to explain. I cannot stress enough how important this is. The ACA was an absolute nightmare to explain to people, which left it vulnerable to all the demagoguery and lies Republicans could muster. Like Medicare-for-all, Medicare For Anyone is just three words, and it requires no explanation at all. You know what Medicare is, right? It’s the program your grandmother is on, the one she loves. Now anyone can join. That’s it.
To be clear, there won’t be complete consensus, since many Democrats still favor an immediate move to single-payer, like the one Sanders has proposed, or the one offered by Rep. Pramila Jayapal. And there are others who have proposed more modest expansions of Medicare. But if and when the presidential candidates come together around a basic idea, that becomes the party’s position — and the one the next Democratic president will have to pursue.
That’s what happened the last time we went through this. After Bill Clinton’s health reform failed in 1994, Democratic politicians and policy wonks spent a decade and a half working to devise a health-care reform they thought would be effective and politically possible. The result was a combination of expanded Medicaid, subsidies for those with low incomes, individual and employer mandates, and stronger regulation of insurers to protect patients.
In the 2008 primaries, all the leading candidates proposed something like that, and it eventually became the ACA. But now, instead of spending 15 years working it out, Democrats are trying to do it in just a couple of years. And just as they were then, they’re trying to adjust based on what went wrong on both policy and politics in the last reform.
There are going to be a lot of details to debate. But this is where Democrats are heading.
This makes sense. I don't know whether we will end up with single payer in the long run. But we do have a large number of people already in government-guaranteed health care: Medicare, Medicaid and the VA. The idea here is to take the ACA one step further and add the Medicare opt-in to the menu for people who aren't covered by any of those or their employers. I suspect that this will end up being part of the menu for employers as well, making Medicare buy-in a benefit that employers pay for their employees. Over time most people will probably gravitate to the program because of the affordability and seamlessness of it.
This is a big step that the Democrats can get done right away if they win a majority.
digby 3/21/2019 01:30:00 PM