The Electoral Buzzsaw of ‘Medicare for All’ Editor’s Blog – Talking Points Memo / by Josh Marshall

The Electoral Buzzsaw of ‘Medicare for All’

Editor’s Blog – Talking Points Memo / by Josh Marshall / 5h

In Democratic policy debates since 2016 there’s been a widespread and sometimes near dominant narrative that Medicare for All is the way forward and actually surprisingly popular. You do away with all the rickety Tinker Toys complexity of Obamacare, SCHIP, Medicare, Medicaid, subsidies and exchanges and build out a single payer national health care plan out of the already popular Medicare program. It’s simpler and more coherent. It’s more efficient and thus cheaper. Critically, it’s actually quite popular: polls show that Medicare for All enjoys anything from substantial public support to overwhelming public support, with numbers usually hovering around 70% of the public backing the idea. This led most of the Senate Democrats with any interest in running for President to endorse the plan in 2017. Today all but one of the top tier of candidates are on record supporting the idea.

This also led to a corollary judgment: Democrats who didn’t support such a plan with strong and even bipartisan support must either be hopelessly ossified in old style incrementalist thinking or, more likely, in bed with the health insurance companies.

The problem is, the whole premise is false. A raft of public surveys show that Medicare for All has anything ranging from public support in the low 40s to dismal support down into the 20s. How is that reconcilable with all the polls showing that clear majorities support it? Like most political labels it’s not clear, beyond in an aspirational sense, what “Medicare for All” actually means. Survey after survey shows that when most people hear “Medicare for All” they assume something like a right for anyone who wanted it, regardless of age, to be able to get or buy into Medicare. Critically, most believe they and others would be able to keep their current private coverage if they chose to.

A new Marist poll illustrates the point, but it’s far from the only example. The poll asked Americans whether they supported “Medicare for all that want it, that is allow all Americans to choose between a national health insurance program or their own private health insurance.” 70% of adults thought that was a “good idea”.

When asked about “Medicare for all, that is a national health insurance program for all Americans that replaces private health insurance” the number fell to 41%. This isn’t an outlier. Numerous polls have shown roughly the same thing. A 2018 Reuters/Ipsos poll found 70.1% support and 51.9% support among self-identified Republicans. The numbers are actually remarkable consistent across many polls. Roughly 70% say they support Medicare for All, assuming that it means people can keep private policies. The numbers hover around 40% if they’re told that’s not true.

But just as consistently polls show that people assume Medicare for All means the option to opt into Medicare or keep their own private insurance. Much like the new Marist poll a January 2019 Kaiser Family Foundation pollfound that 55% of adults believed Medicare for All would allow people to retain their private coverage if they chose. When told it would “eliminate private health insurance companies” that support collapses, going from slightly more than 70% to just 37%.

There is an obvious logic to Medicare for All, not only substantively but politically. Democrats made herculean efforts and suffered massive political blowback for Obamacare, which was a framework first devised by Republicans as a way to oppose and counter a single payer type national plan. It was engineered specifically to preserve not only the existence but profitability of private carriers. But for all this, health insurance companies did no more than tolerate the effort at best and often actively worked against it, as did most of the rest of the health care industry, the entirety of the GOP and much of the federal judiciary.

Critically, the very complexity required to operate within the structure of the private health care system forced an often byzantine and regulation heavy approach that often frustrated the public and became a ready target for industry and political opponents. In other words, precisely the workarounds that were included to protect private insurers and make the plan more “market-friendly” ended up providing the cudgels those companies and their Republican allies used to make the argument against it. If industry will be at permanent war with any effort to provide universal coverage and fight plans designed to ensure their viability why not just go all the way, simplify the whole thing like most other countries do and gain the efficiencies which Medicare already provides to generations of seniors?

Why not indeed? The United States is burdened with a deep lock-in to private health insurance provision that most Americans don’t want to give up or at least don’t want to be forced to give up. This is the challenge universal coverage advocates have faced for decades. Indeed, it’s what got us to Obamacare in the first place.

The reaction to these stark numbers from Medicare for All advocates has been telling and instructive. Of course, if you focus on perceived negatives or scare tactics, support falls! But this makes no sense. You can’t understand the popularity or political viability of a policy without figuring in counter-arguments that will certainly be used in the political arena. This is especially the case with counter-arguments which are actually true!

The secondary response has settled down to daring people to find anyone who likes their insurance company. Nobody likes their insurance company ergo these numbers can’t be true or don’t mean anything or don’t matter. It’s a pretty effective dare. Who raises their hand at a town hall meeting to give a big thumbs up to their health insurance company? Unfortunately that doesn’t really prove anything or at least what advocates what it to prove.

Here we have the kernel of magical thinking inspiring this whole debate: advocates belief that if something doesn’t make sense, it actually can’t be true. It’s certainly true that more or less everyone has complaints about their insurance company. And it’s hard to find people who affirmatively like or have some devotion to their insurance company since the whole system is a mess. But it simply doesn’t flow from that that people support doing away with private insurance or being forced to give up their current insurance. To pretend otherwise ignores basically everything we know about public risk aversion, especially tied to health care, and people’s perception that while what they currently may not be ideal something else might be worse. Call it relative privilege or advantage and people’s resistance to losing it.

Don’t believe me? Simply look at every survey of public opinion to see what people support once they hear people who currently have private health care insurance would be forced to give that up in favor of the new system. The fact that that doesn’t make sense to you doesn’t matter. The fact that many countries have systems like single payer (Canada) or public/private hybrid systems (Germany) that ensure universal coverage and it works well and those publics wouldn’t think of switching to our system doesn’t matter either. Fundamentally changing our system of national health care provision requires first accepting the massive resistance to the most logical paths to doing so. And that is popular resistance, what people actually think and their basic attitudes toward change. We’re not even talking about the avalanche of scare tactics and lies that would certainly rush forth like a tsunami from all the corporations (health care insurers, hospitals, pharmaceutical companies and more) which would fight such plans as an existential threat.

One of the advantages of the Medicare brand is that everyone knows relatives who are on it, know that people can’t wait to get on it and that it’s both metaphorically and literally a lifesaver. Retirees know it’s not some dystopian hellscape because they have it and know it’s awesome. But actually seniors are the demographic most opposed to Medicare for All. Some of this is due to the fact that in our current politics, seniors trend to the right. But it’s also because liking what they have a lot they fear that Medicare for All would take something away from what they currently have.

Medicare for All advocates have responded to these dismal surveys by citing a small number of polls that suggest that losing access to private care is acceptable if people are promised they can keep their doctor. But the difference is limited and it assumes the ability to shape the political question without counterclaims.

It’s worth noting that there are other aspects of Medicare for All that are less clear cut, more intermingled with scare tactics, but also drive down support sharply. Private carriers reimburse at higher rates than Medicare. (That’s the cost savings we want from Medicare!) But a significant amount of our health care system is financed by those more generous reimbursements. Take away those rates and some significant numbers of hospitals really would have to retrench or close. It wouldn’t be the dystopian nightmare the lobbyists and 30 second commercials will portray. But it won’t all be propaganda.

The more realistic approaches to implementation would have Medicare for All reimbursements pushed up closer to current private insurance rates at the outsets and then gain the Medicare cost savings over time with Medicare’s bargaining power. That would work. But it means that a lot of the savings from Medicare for All don’t show up at the outset. They come from Medicare’s assumed and probably real ability to bend the cost curve over time.

Taxes are of course the other big cudgels for industry opponents. Medicare for All would involve a huge amount of new taxes. And simply presented as big new taxes that makes public support drop markedly too. But as advocates rightly explain you can’t really capture what that means without also noting that no one would pay health insurance premiums any more. If I pay $800 a month in new taxes who cares if I’m no longer paying $800 a month to my insurance company? Even more so if the new system has no copays or deductibles and exclusions. If it’s better, more reliable care with the same amount of money going to taxes as went to Aetna. This is a solid and good and perhaps viable political response. My own concern, both political and substantive is that it won’t be this simple.

New taxes will be to individuals. But most private health care premiums (for most of the population) are paid by employers. (Roughly 2/3s of Americans have private coverage; just over half of Americans get that through an employer.) It’s textbook economics that costs paid in benefits are de facto income to the employee, even though they don’t show up in the bottom line of your paycheck. Economists will tell you that workers pay roughly 15% in payroll taxes on the first $125,000 or so of income, for instance, even though technically you pay half and your employer pays half. But it doesn’t necessarily work this way in the wild.

If in 2022, we switch to a Medicare for All system and private insurance disappears do you really think that most or all employers will give their employees a raise on a dollar for dollar basis to what the company had been paying in health care premiums? Over time something like that probably (maybe?) will happen. Certainly some employers will do just that either to maintain employee morale or retention. But the baseline reality of our economy is limited power for workers vis a vis employers in most sectors of the economy. So it’s not clear to me why most or at least a substantial percentage of employers won’t pocket some or all of that windfall and leave employees with a very real and pretty big tax increase.

I don’t argue that any of these issues are insurmountable. The point of advocacy is to advocate and change minds. My point is that beyond the abolition of private insurance for all but supplemental policies (which is the real achilles heel politically) there are a number of political and substantive road blocks which most polls don’t get into until the secondary or tertiary questions which lead advocates and many Democrats to greatly overstate the popularity of this approach underestimate the steep political peril for any candidate – like a presidential candidate running nationally – not running in a pretty liberal district or state.

Of course, none of this means that people shouldn’t support Medicare for All or other comparable single player plans on the merits. A substantial minority of Americans do support it. Indeed, more practically, without a vibrant left supporting such a model the public debate is inevitably skewed to the right. A decade ago the legislative debate on Capitol Hill largely focused on whether or not what we now call Obamacare would include a “public option.” It failed because of stiff opposition from insurers and opposition from centrist Senate Democrats. Now that’s basically the centrist fallback position and Republicans running for office, as opposed to working the courts, have basically given up on gutting Obamacare. Indeed, ‘Medicare for America’, one of the major Medicare buy-in style plans proposed by wonks at the Center for American Progress, is as the name implies in large measure a reaction to the Medicare for All push. But that’s not what the proposal entitled “Medicare for All” actually does. It’s a single payer plan in which private health care plans would be prohibited except for supplemental plans which covers services or deductibles not covered by the standard plan.

There is every reason to believe that Medicare for All would be a major electoral liability for a Democratic presidential candidate in a general election – just on the basis of what the plan actually does, let alone the way the GOP and the health care industry writ large would pile on to that with a campaign of lies, horror stories and propaganda. It could well mean the difference between Trump’s defeat or reelection by effectively nullifying the Democrats big advantage on health care and giving the GOP a cudgel to sour a significant amount of the electorate on the Democratic candidate.

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