Intelligencer staffers Benjamin Hart, Ed Kilgore, and Eric Levitz discuss.
Ben: Today, Democratic still-front-runner Joe Biden revealed his campaign’s health-care plan. As many of his rivals endorse transformative changes to the system, mostly under the banner of “Medicare for All,” Biden is keeping things more modest, expressly building on his old boss’s biggest achievement, the Affordable Care Act. The central plank of Biden’s proposal is a government-managed public-insurance option; Politico reports that the plan “would also empower Medicare to directly negotiate drug prices, allow the importation of prescription drugs from abroad, and extend tax credits to help tens of millions of Americans buy lower-priced health insurance.” Polls show that most Americans like their private health insurance, and Biden clearly doesn’t want to rock the boat that much. What do you make of this proposal?
Ed: Well, it’s perfectly in accord with the overall Biden message of returning America to its positive Obama-era trajectory, and it’s certainly “realistic” in terms of having a better chance of enactment in a Congress controlled by Republicans or narrowly controlled by Democrats.
But it’s pretty far away from the prevailing Democratic Zeitgeist. In a party where “Medicare for All” and “Medicare for Most” are the two main options, a “Medicare for the same people who get Medicare now” menu item isn’t going to be very satisfying.
Eric: The strangest thing about the proposal is that it explicitly aspires to cover 97 percent of Americans. Surely, there’s a way to tweak it that gets to universal coverage under a reasonable model. Or else the campaign could simply round up in its messaging. It’s baffling to me that they’d stake out the position of “almost everyone should be covered.”
Ed: That was indeed the sort of thing considered “probably good enough” in 2008. Biden’s general calculation is that people would be happy to return to that situation now.
Ben: Can you explain that? The 97 percent thing?
Eric: Not really! Haha, it’s just what Biden’s people are saying. I guess people won’t be automatically enrolled in the public option, and undocumented immigrants won’t be eligible for subsidies. I think in practice, 97 percent coverage would be an incredible accomplishment (particularly if that coverage were genuinely affordable and comprehensive). But it’s just weird to own it politically. That said, I think some people are exaggerating the modesty of Biden’s proposal.
Larry Levitt of the Kaiser Family Foundation told Politico, “Building on the ACA is the quickest way to get more people insured and improve affordability, while not taking on any powerful health-industry group.” That strikes me as patently false. Health-care lobbies are already publicly advocating against a public option. Opposing the government’s right to negotiate drug prices is one of Big Pharma’s top priorities. It is not going to be easy to pass Biden’s plan. And it would represent a major (and positive) change to the U.S. health-care system if it did make it into law. (Though how major depends on the details of the public option.)
Ed: It’s important to understand that some of Biden’s critics are people who pretty much thought Obamacare was a corporate-whore sellout program.
Ben: Bernie Sanders has been clear and unapologetic that his version of Medicare for All would mean abolishing private insurance altogether — an enormous disruption to the system but one he thinks will be worth it. Some other candidates have not been as forthright about how, exactly, they would get to universal coverage. Do you think Biden’s plan is really much different from what a non-Bernie candidate would end up putting on the table if they were to become president?
Ed: Not sure what the next president “puts on the table” is the right yardstick. It’s what the next president is willing to go to the mat to enact that matters. And whether she or he has a strategy to do that.
Eric: I think Bernie and Warren would feel compelled to put single payer on the table
Ed: Yes, but then what?
Eric: Joe Manchin and Jon Tester move it into the dog bowl.
Ed: Single payer is not going to be enacted by any foreseeably possible 2021 Congress.
Eric: Agreed. And it seems wildly optimistic to think Biden’s plan would be. America cannot afford universal coverage without eventually coming for the health-care industry’s rents, and the industry knows it.
Ed: So I guess the question is why Biden doesn’t say, which others have, that single payer is the ultimate goal but here’s something we can do in the meantime.
Eric: I think it makes plenty of political sense for him. He’s running as the electable moderate. A lot of Democratic primary voters are looking for that.
Ben: Yeah, to me it seems like a pretty sensible move. Sure, lefties will be annoyed, but they weren’t gonna vote for him anyway.
Eric: He’s never going to be accepted as a progressive champion or even a consensus candidate, so he should own his brand.
Ed: It does put opponents in the uncomfortable position of openly trashing Obamacare, which might even tempt Obama himself to say something.
Eric: Biden did try to play the “M4A is a rejection of Obama’s legacy angle” in his rollout, saying, “I understand the appeal of Medicare for All. But folks supporting it should be clear that it means getting rid of Obamacare. And I’m not for that.” But Obama just last year praised Democrats for not “just running on good old ideas like a higher minimum wage but on good new ideas like Medicare for All,” which suggests that he doesn’t actually take personal offense at the concept of Democrats running on single payer.
Ben: And of course that’s a little misleading. Medicare for All has become a nebulous term that does not automatically imply wholesale rejection of Obamacare.
Ed: In any event, the bigger question, which Eric raised a minute ago in the “his own brand” comment, is whether Biden can no longer position himself as a unity candidate and is instead a factional candidate — much like Sanders — with an electability argument. If so, yeah, grab that moderate lane on this and other issues!
Eric: By his own word, if Obama were emperor, he would establish single payer.
Ed: As I said earlier, it would be easy enough for Biden to say the same thing as Obama, with the emphasis on the “in the meantime” alternative. Must be some reason he chose not to.
To me, Biden’s attempt to promote the idea that Obama’s highest goal in life was for the U.S. to have a universal health-care system built on subsidized insurance exchanges reveals his low opinion of the Democratic electorate’s intelligence.
Ben: You’re saying he’s taking Obama’s favorite maxim, “Don’t let the perfect be the enemy of the good,” a little too seriously?
Eric: I’m saying his implication is that Medicare for All is not desirable, because that would mean repealing the program that bears Obama’s name in popular discourse.
Ed: In reality, a majority of Americans probably really wish they could have private health insurance with no premiums, copays, or conditions. So everyone in both parties is trying to figure out a way to scratch that impossible itch. I agree that Biden’s formulation won’t satisfy much of anybody, but it’s not as easy as it sounds.
Eric: I think “I’m going to take what already exists and make it better” is a very popular line to draw. The question is exactly how much Biden’s plan would actually do to increase affordability for people who already have insurance.
Ed: I personally wish we could find a way to stop talking so endlessly and redundantly about health insurance and focus on price-fixing by providers.
Eric: Yes. The public is pissed about prices.
Ed: We’ll need to do that anyway to make single payer feasible.
Eric: The voting public likes universal coverage as an abstract principle. That’s not a personal issue for the vast majority, but ever-rising premiums and deductibles are.
Ben: A topic for another day …
Eric: “All-Payer Rate Setting for All” just rolls off the tongue.