Predictably, much of the commentary about Hillary Clinton’s newly expressed interest in making a Medicare buy-in option available to people near retirement age is treating it as another calibrated “move to the left” to head off Bernie Sanders or placate his supporters. The unstated assumption is that anything other than a full-on single-payer system (the only creditable progressive proposal, you see) is a half measure reflecting either political cowardice or corrupt kowtowing to private insurance interests.
Here’s the thing, though. People who love to cite polls showing the popularity of “Medicare for all” (the favored buzz-phrase for single-payer) should be aware that the popularity of the venerable retirement program is based on its current characteristics as an “earned entitlement” program for which working Americans pay payroll taxes and then, after becoming beneficiaries, premiums. The “buy-in” proposal, by targeting people who have (a) presumably been paying those same payroll taxes and will continue to do so until retirement if they are employed, and (b) will immediately pay relatively steep premiums (though not as steep, in most cases, as private insurance premiums), does minimal violence to the structure, financing and original purpose of Medicare. “Medicare for all,” once it is a tangible proposal rather than a bumper-sticker slogan, changes Medicare in all these respects, and might make it unrecognizable. The financing challenge alone for a single-payer system — which never much gets mentioned in the polling — makes the incremental approach, via a combination of Medicare, “Obamacare”-subsidized private insurance, and Medicaid, a much easier reach financially and politically.
Perhaps I’m wrong and perhaps Hillary Clinton is wrong in feeling this way. But one thing’s for sure: Expanding Medicare and providing a “public option” under Obamacare are not popular ideas in the private insurance industry. That’s certainly not the constituency Clinton is representing here. And anyone who doubts the political courage it takes to achieve universal health coverage incrementally, instead of just intoning “Medicare for all” until the walls fall down like Jericho’s, hasn’t been paying much attention the last quarter-century.