Creating ‘Medicare for All’ Isn’t As Easy As It Sounds

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Bernie Sanders Holds Campaign Rally In Pittsburgh
Have we mentioned the problems yet?Photo: Jeff Swensen/2016 Getty Images

Among Republicans, every discussion of health policy in this presidential-election year has begun with the assumption that the Affordable Care Act is a disaster that must immediately repealed and replaced by some “market-oriented” system that turns back the clock to 2009 or perhaps to an even-much-earlier era when people paid for health care out-of-pocket. 

Among Democrats, instead of a corresponding discussion of how to defend and improve Obamacare, there’s been a back-to-the-basics argument about whether the ACA was an unfortunate detour on what should have been the high road to a single-payer system. This is, of course, Bernie Sanders’s position, and he’s suggested on occasion that an endorsement of single-payer in the party platform may be one of his demands at the convention in exchange for the gestures of party unity Hillary Clinton needs and wants. 

To many Sanders supporters (and others) the substantive and political advantages of single-payer are almost so obvious as to be self-evident: It’s what most other countries have (that is an over-generalization, but not entirely wrong); it puts government in a position to control costs (true in theory); it gets rid of a profit motive that’s inappropriate for what should be a basic human right (also true in theory); and it builds on the tremendous popularity of an existing single-payer program currently available only to retirees, Medicare. This last claim is why single-payer is often marketed and almost always tested in polls as “Medicare for all.”

The flip-side of the strong self-confidence of single-payer health-care advocates in its feasibility, fairness, and political salience is the suspicion (or accusation) that progressive opponents of “Medicare for all” must be motivated by the corrupt influence of private insurers or drug companies, or by cowardice and timidity in fighting for their convictions. In the context of the Sanders-Clinton presidential nomination battle, it’s easy for some partisans of the former to believe the worst of the latter’s motives, just as they believe she has compromised herself on financial regulation and foreign policy by unsavory associations and “centrist” political thinking. 

So far, Clinton’s counterattacks on single-payer have pointed to high estimates of its costs, and the risk of abandoning a solid accomplishment like Obamacare for something new and politically shaky. Proponents counter with high estimates of the private health-insurance premiums obviated by single-payer, and high poll numbers for “Medicare for all.”  There hasn’t been a great deal of dialogue beyond these dueling assertions, unfortunately. 

That intra-progressive gridlock should end with an important piece at Vox by the University of Chicago’s Harold Pollack, who raises ten questions about the implementation of a single-payer system while taking for granted its ultimate desirability. One whole set of questions involves the Medicare model: Will the existing Medicare financing model of payroll taxes and premiums and deductibles (supplemented by general revenues) be extended to people who aren’t working, or haven’t worked for long, or don’t earn very much? If not, will some “Medicare for all” beneficiaries have a much sweeter deal than others, or will the whole system, including the current vast Medicare program, be financed by income or value-added taxes? The fiscal and political implications of that kind of step are enormous, and no one has really been polled on it. When it comes to people currently on Medicaid, will their benefits be federalized and standardized across state lines, or will the current significant state variations be baked into the single-payer cake?

Beyond these structural issues, Pollack has some sharp questions about the political pushback that would ensue if Medicare’s controversial and not-always-effective cost-containment measures were extended to the entire health-care sector:

[I]f government squeezes too hard or too indiscriminately, it could cause serious harm. It might also provoke a punishing political backlash from virtually the entire supply side of the medical economy. Rural hospitals on thin margins would be one obvious vulnerable constituency. Veterans, current Medicare recipients, and unionized workers with generous tax-subsidized health plans are three others.

Yes, and if a single-payer system is enacted you can add doctors and hospitals to the list of arguably overcompensated interests that will have the incentives and the means to interfere politically with cost containment. 

Pollack mentions other problems, including the application of single-payer health care to undocumented immigrants, and the certainty that fights over reproductive services in public-sector programs will get larger and more bitter. The bottom line is that the arguments over single-payer need to become more practical:

[W]e need a realistic road map that does not merely describe a sound single-payer system but that also describes how we might get there from here. It’s telling that no detailed single-payer legislative proposal has been advanced that provides a realistic transition plan.

One such transition plan might begin by adding a “public option” to the existing Obamacare program. That’s what most progressives wanted from the beginning, and Hillary Clinton has reiterated her support for the public option (along with a Medicare “buy-in” for near-seniors) as an Obamacare improvement now. If Sanders and other single-payer advocates met her on that ground without abandoning the goal of “Medicare for all,” some more fruitful discussions might well ensue.