Ben: Bernie Sanders and Elizabeth Warren spent much of last night’s debate defending their ambitious health-care plans, which call for Americans to transition from private to public insurance, as a field of moderates attacked them for being unrealistic and giving Republicans ready-made talking points. Both candidates were seen as turning in strong performances overall; do you think they effectively made their case that big, sweeping changes to the health-care system are the way to go over smaller, incremental ones?
Ed: I think they were able effectively to get across the simple points that in their proposals any higher middle-class taxes would be more than offset by the elimination of out-of-pocket costs, and that the current system is plenty disruptive.
That doesn’t mean the arguments will end, of course. The two big problems that “moderates” will continue to raise are that (1) lack of trust in government means voters may fear a bait-and-switch wherein taxes go up but out-of-pocket costs remain, and (2) there is no immediately foreseeable scenario where Congress passes Medicare for All, no matter how much a Democratic president pushes it.
Sarah: Yes, absolutely. Warren and Sanders are both very good at making the moral case for Medicare for All. Warren brought up the story of activist Ady Barkan, who spends thousands on the care he needs for his ALS despite having insurance; Sanders recently traveled to Canada with diabetes patients who have to cross the border to buy affordable insulin. Against such dramatic evidence, the assertion that incrementalism could sufficiently address the injustices inflicted on people by our current system really falls short.
Ben: Some liberals were not impressed with what they saw. Paul Krugman wrote on Twitter: “I had hoped that Warren would use the occasion to start climbing out of the hole she’s stumbled into on health care. Instead she dug it deeper.” He advocates a hybrid approach to getting everyone coverage, something like what Kamala Harris has proposed, instead of the all-or-nothing one favored by the structural-change candidates, which tends to be less popular in polling, since people generally don’t like the idea of disruption. Has Warren constrained herself by being relatively inflexible on this point?
Ed: I understand why Bernie is inflexible on this, since it’s a signature proposal (he did, as he pointed out last night, “write the damn bill”). I’m not sure it makes sense for Warren to refuse at least to embrace a way station to M4A in the extremely likely event it cannot get through Congress. The heavy investment of progressive activists in M4A as a — sorry to use the term, but in this case it’s accurate — litmus test may influence her course of action.
Sarah: Based on Warren’s polling numbers, which continue to rise, and the enthusiastic reaction to her performance last night, I don’t think her inflexibility harms her. I’d add that I think it’s meaningful that the two candidates who consistently defend M4A reliably rank second and third behind Biden in the polls. (I’m not convinced that Biden owes his top position to his centrism on issues like health-care reform rather than some combination of nostalgia and name recognition.)
Ed: I agree with Sarah’s point about public opinion, though I would also observe that even if you concede a long-term trend in favor of single-payer health care, it looks like the more voters learn about M4A, the less they like it. Additionally, Harris has had a bit of a moment, too, and the debate over M4A will at some point need to address her argument that the current Medicare model — you know, the one we are proposing to extend to “all” — is heavily dependent on private insurers via the Medicare Advantage program. You get the sense that M4A advocates hate private insurers so much that they cannot bring themselves to acknowledge that fact. Last night Warren occasionally seemed to suggest that punishing insurance companies and drug companies was in itself sufficient reason to go to M4A.
Ben: Many people have pointed this out, but the primary concern for a lot of Americans isn’t necessarily getting rid of their private insurance, but just the clear and present danger of spiraling costs — soaring premiums and drug prices. Has there been enough attention paid to getting those costs under control?
Sarah: Those transformative plans are designed to get costs under control, though.
Ben: Yes, but that’s a fix that won’t take effect for many years.
Ed: I think we all understand that rising costs have all but eclipsed lack of coverage as a problem. I wish there was more talk about blood-sucking providers and hospitals alongside the criticism of insurers and Pharma. It’s all part of the problem.
Sarah: I agree that even in the best-case scenario, M4A is years away, and that Congress has to take action in the short term to help bring costs down. I think all the candidates agree on that latter point, actually, even though I don’t personally think that the moderate solutions on the table will do much to get things where they ought to be. My point is just that I don’t think it’s either/or.
Ed: I’m old enough to remember the “managed care revolution” that gave more power to insurers to hold down costs because providers had zero incentive to do anything other than approve the most expensive (and sometimes unnecessary) tests and treatments. Obviously it all went far too far, but the underlying issues have not gone away. And M4A won’t magically solve them, unless something is done about hospitals and providers. Kinda wish one of the doomed candidates would come out for true socialized medicine. Then we’d have the full debate we need.
Ben: Then then there are the political obstacles. Any plan, including a relatively modest public option, will be difficult to pass through Congress. Medicare for All seems like, at best, a long shot, even with a Democratic trifecta post-2020. As part of the health care debate, should there be more discussion about the practicalities involved in getting this stuff implemented? And does it make sense to spend so much time debating the merits of a plan that is unlikely to happen soon?
Sarah: The Affordable Care Act once seemed like a long shot, too. I think there’s plenty of discussion about the obstacles to passing M4A. We’ve been talking about it for years at this point, since Sanders helped popularize the policy with his first primary race. But it should be increasingly apparent to everyone that the system we have is failing, even with the ACA in place, and dramatic reform is necessary. The fight for M4A will be a difficult one, but that difficulty isn’t a reason to spend less time on discussing its merits.
If anything, last night’s debate helped clarify the policy’s merits.
Ed: I don’t disagree with Sarah’s point about keeping one’s eyes on the prize, but I do have problems with Sanders’s claim that he will lead a “political revolution” that will make this more immediately feasible (that’s your basic magical thinking). And let’s remember the ACA required a Senate supermajority that is very unlikely to reappear any time soon.
Ben: Just another reason to get rid of the filibuster.
Ed: Absolutely. Not just on this subject, but on others, elimination of the filibuster is a condition precedent to taking advantage of the greater ideological unity Democrats have developed since the struggle to enact ACA.