vision 2020

Kamala Harris’s New ‘Medicare for All’ Plan Makes (Political) Sense

For the pragmatists? Photo: Gerald Herbert/AP/Shutterstock

Kamala Harris doesn’t want to “restructure society,” she just wants to “take care of the issues that wake people up” at night. She prefers “narrow, tactile proposals” to “grandly ambitious ones” –— because she wants to pass “relevant policy” not pen a “beautiful sonnet.” Thus, if Harris ever appears to be “wiffly-waffling” on a given issue position, that’s only because she’s in the process of thinking through “all the scenarios about how it would actually work.”

Or at least, that’s the California senator’s story. And she’s sticking to it (unless a careful consideration of alternative “scenarios” leads her in a different direction).

In a New York Times profile published over the weekend titled “What Kamala Harris Believes,” Harris and her aides recast her as the 2020 race’s most ruthlessly pragmatic progressive candidate. This branding makes some political sense.

At present, Harris and Elizabeth Warren are jockeying for the title of “most popular, hypercompetent female alternative to the septuagenarian white men in the Democratic primary fight.” Warren has defined herself as a (detail-oriented) adversary of American capitalism as we’ve known it. While the Massachusetts senator is hardly hurting for small-bore proposals, her plans for greening the Pentagon and insuring your Best Buy gift cards are linked to a broader vision of “structural economic change.”

Harris needs to draw some clear distinction between her pitch and Warren’s, and “I’m less mad Wall Street than she is” would be unsatisfying, even if Joe Biden hadn’t already laid claim to it. So, Harris has opted to define herself in opposition to Warren’s grand, ideological ambitions. Her bet is that a lot of Democratic primary voters don’t have very ideological worldviews, and do harbor suspicions of politicians who promise “too much.”  And there’s evidence to support both those propositions.

But if Harris’s claim to tough-minded pragmatism fits her political needs, it doesn’t really match her policy platform. The senator’s signature anti-poverty program is politically dicey (it has a price tag of about $3 trillion, gives no benefits to the upper-middle class, and punishes married couples) and substantively flawed (it would cut poverty by less than other, less expensive plans, while doing nothing for the poorest of the poor). And the same can be said of her proposal to grant large federal subsidies to cost-burdened renters, a policy that would arguably deliver many of its benefits to landlords, do nothing to address housing scarcity, and privilege the needs of low-income people in major cities over ones in rural areas — a feature that would almost certainly doom her plan in Congress. Meanwhile, Harris has spent the first months of her campaign intermittently championing a Medicare for All plan that would abolish private insurance (which is politically risky) but would spare middle-class households any tax increases (which is substantively dubious). All of which is to say: Harris hasn’t distinguished herself from the field by embracing ruthlessly practical policies so much as poorly designed ones.

Until Monday, anyway.

Harris’s new Medicare for All plan actually makes political sense.

After months of “wiffly-waffling” on the subject, Harris finally unveiled her definitive position on health care Monday morning — and while the plan is fuzzy and flawed in substantive terms, it appears savvy in political ones.

In her campaign’s own telling, Harris crafted her version of Medicare for All with an eye toward mollifying the electorate’s most prevalent anxieties about single-payer. Many voters who already have employer-provided insurance have a strong sense of loss aversion, which leads them to bristle at talk of rapid change, or the abolition of private insurance options. Others are wary of the middle-class tax increases that Bernie Sanders would enact to replace private insurance premiums. Finally, many seniors feel they have nothing to gain, and much to lose, from sharing their socialized medicine with younger generations.

Harris’s plan offers some form of reassurance to all these constituencies. To appease seniors, she promises to let existing Medicare and/or Medicare Advantage beneficiaries to keep their current coverage — only now, with dental, vision, and hearing-aid benefits to boot.

To comfort risk-averse fans of private insurance, meanwhile, Harris’s plan makes two revisions to Bernie Sanders’s model of Medicare for All: It replaces his four-year “transition period” to single-payer with a ten-year transition, and preserves a role for private insurers in her final (single-ish payer) system analogous to the role that such insurers currently play in the Medicare Advantage program. In other words, a decade after Harris’s plan is enacted — when all Americans are finally funneled into a single, national health-care plan — private insurers will still be able to offer alternative benefits packages that “compete” with the government plan, so long as those alternatives meet a long list of quality requirements, and are “reimbursed by Medicare for less than the cost of the public Medicare plan to ensure taxpayers aren’t subsidizing insurance company profits.” To give the risk averse further comfort, Harris also stipulates that the switchover, after ten years, would be conditional on the public plan working as promised:

Throughout this [transition] period, I would also ensure the new system of Medicare for All meets clear benchmarks before asking people to join the plan. Has the public Medicare plan fulfilled its promise of high-quality coverage without unaffordable cost sharing? Have we meaningfully expanded coverage to the uninsured? Have we reduced costs for middle class Americans and working people?

If you don’t like my Medicare for All, we won’t keep it.

In policy terms, these measures raise several questions: Wouldn’t a ten-year transition period give Republicans an excellent chance of nipping Medicare for All in the bud, especially if a GOP president could do so automatically by using administrative sabotage to ensure the program misses Harris’s benchmarks? And if private Medicare for All plans need to be even more cost-effective than the public one, how many would really exist? Further, since Harris’s plan immediately establishes a Medicare buy-in option available to all — and automatically enrolls all newborn babies and uninsured into that public option — there’s a high likelihood that many employers will switch from offering private insurance to offering the public plan. Which is fine from a progressive point of view, but this reality does mean that Harris’s approach wouldn’t necessarily let Americans who like their employer-provided coverage keep it, even in the short term.

Politically, however, Harris’s plan enables her to say that she has no intention of abolishing private insurance, or imminently forcing all Americans onto an unproven government plan. Given that “Medicare for All Who Want It (and the Status Quo for All Who Don’t)” polls better than single-payer, this seems like a politically sound gambit (even if Harris’s plan wouldn’t necessarily preserve the status quo for all who like it).

Harris promises to pay for her plan by soaking Wall Street and gaming the CBO.

Harris’s concession to those who fear middle-class tax increases is much simpler: Whereas Sanders’s has suggested his plan may include a 4 percent income-based premium for all households earning over $29,000 (by replacing private insurance premiums, this would still likely reduce middle-class families’ overall costs of living), Harris insists that she will provide tax- and premium-free, comprehensive health coverage to all households earning “below $100,000, along with a higher income threshold for middle-class families living in high-cost areas.” To make this possible, she calls for a tax on all financial transactions.

In policy terms, this is the opposite of hard-nosed realism. Very few left-wing economists — including those who contend that America’s fiscal deficit is too low — believe that the U.S. can afford to establish Medicare for All without charging families that earn $90,000 a year any premiums or new taxes. What’s more, Harris’s reference to high-cost areas suggests that she would like to exempt Manhattanites who earn six-figure salaries from having to pay into the health-care system, which is dubious in both fiscal and fairness terms.

But politically, Harris’s free lunch looks appetizing. “I admire many aspects of Senator Sanders’s health care plan, but I oppose raising a cent of taxes on working people until Wall Street pays its fair share” is a line tailor-made for a Democratic debate. What’s more, it will be hard for fact-checkers to definitively call Harris’s bluff for a couple of reasons. First, she does not specify the rates that those making over $100,000 will pay. Second, since the Congressional Budget Office typically “scores” policies by estimating their cost over their first decade in operation, Harris’s ten-year transition period would allow her to game the system.

And the senator signals her intention to do just that in the most misleading passage of her plan:

Right now, the US spends $3.5 trillion a year on health care. If we do nothing over the next decade, that number will skyrocket to an estimated $6 trillion a year. So the real question is: how can we afford not to act? 

By extending the phase-in period to ten years, we will decrease the overall cost of the program compared to the Sanders proposal, and we can save additional money by accelerating delivery system reforms and value-based care that rewards meaningful outcomes.

In the first paragraph, Harris refers to the total, aggregate cost of private and public health care in the U.S. In the second, she suggests that a ten-year phase-in will bring down “the overall cost” of Medicare for All, implying that her approach is more cost-efficient than Sanders’s. But this is the opposite of the truth: The ten-year transition brings down the sticker price of Harris’s program, but the longer the government waits to impose Medicare’s (low) reimbursement rates on all providers, the higher America’s overall health-care spending will be.

The moral case for cynical pandering.

All that said, Harris’s subterfuge here might actually serve the cause of health-care justice by making universal coverage more legislatively viable: If moderate Democratic senators are willing to lie to themselves and their constituents, they may actually be able to pass a Medicare for All bill that neither raises taxes on the middle-class nor increases the deficit — within the CBO’s traditional budget window, anyway. And by the time this arrangement becomes unsustainable, perhaps Americans will be sufficiently attached to socialized medicine to prefer tax hikes to benefit cuts (the GOP’s perennial failure to slash Social Security and Medicare lends some credence to the view that it’s easier to keep tried-and-true welfare programs funded once they’re in place than it is to finance new ones).

So the cynicism of Harris’s plan isn’t necessarily all bad. And her plan isn’t necessarily all cynical. Although some aspects of her plan appear tailored narrowly to her personal political interests, there is a moral case for putting political palatability above substantive perfection on Medicare for All. Polls clearly show that a lot of voters are worried by the prospects of paying higher taxes, and losing their existing coverage. Progressives can credibly counter that the vast majority of Americans will enjoy cheaper, more stable coverage under a single-payer system. But progressives don’t control all mass media in the United States. Fox News, much of the mainstream political press, moderate Democrats, wide swathes the labor movement, and the entire health-care industry will work overtime to reinforce the public’s anxieties during both the 2020 campaign and any legislative fight that might follow it.

Insurance, hospital, pharmaceutical, and physician lobbies have already made it clear that they will wage a holy war against any proposal that significantly expands public health insurance — including public-option plans much less ambitious than Harris’s. No serious health-care reform will escape their opposition, because seriously reforming America’s health-care system requires not only eliminating wasteful private-insurance administration, but also bringing down the exceptionally generous payment rates that U.S. doctors, hospitals, and drug companies enjoy.

Given the immense power of their enemies — and the overrepresentation of conservatives in the House and Senate — there is simply no way for progressives to deliver universal health care unless their approach has overwhelming public support. After years of advocacy, Sanders’s plan — i.e., a single-payer bill that imminently abolishes duplicative private insurance and includes tax increases on middle-income households — currently doesn’t.

It’s far from clear that Harris’s plan will. But it is clear that, for all its substantive flaws, if Congress were to pass anything resembling the California senator’s policy, tens of thousands of premature deaths would be averted, and millions of lives would be improved. (The fact that the “third way” position on health care in the Democratic race is now a “glide-path to single-payer” public option, which automatically enrolls all newborns and uninsured in government coverage, is no small achievement for Sanders and his backers.)

And unlike most of Harris’s proposals thus far, her approach to Medicare for All plan at least has a coherent political logic. What’s more, the senator’s sales pitch for socialized medicine is as strong as any Sanders has articulated:

Imagine changing a job and not having to worry about your health care coverage. Imagine going to the pharmacy and not having to worry about an outrageous price increase on the prescription drug you need. Imagine walking through those sliding glass doors at the emergency room or doctor’s office or hospital knowing that the first card you pull out will be a Medicare card, not a credit card.

Harris’s plan won’t be mistaken for a beautiful sonnet (or an intellectually honest white paper). But it just might be a politically viable framework for dramatically improving the American health-care system.

Kamala Harris’s Medicare for All Plan Makes Political Sense