Tuesday, August 14, 2018

The Post Joins the Right-Wing Freakout Over Medicare for All

by Neil H. Buchanan

Republicans are understandably having fits about the increasing popularity of Democrats' plans to expand eligibility for Medicare to the entire U.S. population.  Should this popularity not also be great news for Democrats, as a matter of both politics and problem-solving policy?  Surprisingly, it turns out that there are some prominent liberal-ish voices that are freaking out about Medicare for All, and I do mean freaking out.

Until now, it has been possible to imagine that the Democrats and independents who opposed a single-payer system were doing so because they viewed it as political suicide or because it seemed too difficult to do as a matter of policy mechanics.  Are those excuses still viable?

The latter argument became untenable when it dawned on Democrats that there was already a popular single-payer system that serves 44 million Americans.  The worry about "scaling up" is usually reserved for cases in which a small pilot project in a few cities has proven useful and it is unclear whether a national system would be feasible.  Medicare, however, is already scaled up to an enormous size, and increasing its reach to the remainder of the population is not fundamentally daunting.

Setting that issue aside, the other excuse among non-Republicans who have long opposed single-payer plans -- the claim that the public would never support it -- is pretty obviously testable against the evidence of whether the public actually supports it.  And in pleasingly increasing numbers, they do.

This means that the non-Republicans who continue to be opposed must either have some variation on the scaling-up argument or some other substantive reason to oppose Medicare for All.  It turns out that they have neither.  Instead, they have resorted to anti-government rhetoric, and they sound no different from Republicans when they start warning darkly about how the government would "take over one-fifth of the economy" or impose a huge tax increase or whatever.

In short, those supposedly sober-minded non-Republicans are resorting to scare tactics, trying to get people to oppose Medicare for All simply by calling it a Big Government program.  It turns out that the editorial board of The Washington Post is among the purveyors of this nonsense, and now The Post's fact-checker has even gotten in on the act.

Before I go further, however, I should state quite clearly that although my criticisms here are aimed at the arguments of editorialists and journalists, I am most emphatically not attacking them as human beings or saying that they are the enemy of the American people.  As I emphasized in a column last week, Donald Trump's attacks on the media have made it important for responsible people to be especially clear in saying that criticism of content is not the same as criticism of the very existence of an independent press.  It is sad that we can no longer take that distinction for granted, but here we are.

With that said, what about Medicare for All scares people who are nominally non-conservative?  Surprisingly, many of them, to use a favorite term of academic-speak, fetishize the public/private distinction.  That is, they treat exactly the same activity as somehow different if it is being directly carried out by a government entity as opposed to a private entity.

For example, the national statistical accounts once treated the construction of a new runway at a major airport as "private investment" if the money for the runway was paid by a private company but "public consumption" if the money was paid by any level of government.  Because consumption is often deemed wasteful while investment is presumptively thought to be virtuous, this distinction mattered quite a bit politically.  Yet the bottom line was that, either way, there was a new airport runway.  Who should care if we call it government spending or private spending?

In the single-payer debate, fetishizing the public/private distinction is particularly pernicious, because people like The Post's editors focus on the arbitrary fact that the money that people pay into a public health insurance system like Medicare is called "taxes" (and the system's spending counts as "government spending"), whereas dollars spent to buy health insurance from companies like UnitedHealthcare are called premiums -- that is, not-taxes -- and the company's benefit payments are similarly deemed not-spending.

Why does this matter?  Republicans often talk about the U.S. being too heavily taxed, an argument they use to justify their obsession with cutting taxes for the wealthy and businesses.  Thus, when an op-ed in The New York Times summarized Trump's full list of lies in 2017, the author included Trump's claim on June 21 that "Right now, we are one of the highest-taxed nations in the world" and then linked to a PolitiFact analysis that showed that the claim is false.

The irony is that combining health care spending with taxes would actually show that U.S. citizens do pay larger amounts of money on the things that other countries' citizens receive by paying taxes.  And if we relieved people of the need to pay money to private insurance companies to receive their health care and instead pay something labeled "taxes," they would not care what it is called so long as they did not feel any difference in their bottom line.

If it were merely a matter of labeling, however, that would not be an argument for or against moving to Medicare for All.  The benefit of the new system is that it would be a net benefit to citizens, whose "taxes" would go up but whose taxes-plus-health spending would go down.  The government would not need to charge people as much in taxes as private companies charge in premiums (and co-pays, coinsurance, deductibles, and all the rest), because the evidence domestically and internationally overwhelmingly demonstrates that single-payer and national health care systems are much less expensive overall than the chaotic U.S. system for non-retirees.

And this is where the editors of The Post come in. They have long been vehemently opposed to anything resembling single-payer, and they reliably use the "but taxes will go up" scare tactic to try to persuade people to oppose it.  Last June, for example, they ran an editorial inveighing against the "astonishingly high cost" of a single-payer plan, snarking that Bernie Sanders's plan "would raise government spending by $32 trillion over 10 years, requiring a tax increase so huge that even the democratic socialist Mr. Sanders did not propose anything close to it."

The editorial board did not even bother to deal with the meaninglessness of the comparison, which amounts to the implicit assertion that people and their employers would somehow continue to pay exactly as much as they are now paying to private health insurers even after those companies are no longer insuring them.

The latest round of this silliness arose with the recent publication of a study of Medicare for All from a libertarian research center at George Mason University, written by a former member of George W. Bush's administration.  As a very good Post news article from two weeks ago explains, that study included a conclusion that the overall cost of U.S. health care would decline by $2 trillion under Medicare for All through 2031, but because the government would be the official provider of health insurance, $33 trillion of health care spending would newly be called "government spending."

I completely understand why Republicans would focus on the $33 trillion figure, because frightening people with big numbers is their only move when it comes to government finances.  But why would the editorial board of arguably America's most important newspaper then rush out a piece warning, in its first paragraph, "that the government would expand massively — by a whopping $32.6 trillion over 10 years, gobbling up an additional 12.7 percent of gross domestic product by 2031" under Medicare for All?

And why would that same piece end with a claim that Medicare for all "would require a national consensus to dramatically expand the government" without bothering to note that it would simultaneously allow Americans never again to have to deal with private health insurers or have to worry about onerous out-of-pocket costs that ration health care toward the wealthy?  Why indeed.

To be sure, The Post's board and others make additional arguments, parroting the author of the study in saying that the economic assumptions that Sanders makes (and which were built into the model) are unrealistic.  There is a robust debate about how well Medicare for All could eliminate the inefficiencies of the current system in order to save money, but even if Sanders's side were to lose some of those arguments, the correct way to describe the outcome of that debate would be to say, "Under Sanders's assumptions, the system would save $2 trillion dollars, but under what we have decided to call more realistic assumptions, the system would save only $1 trillion" or "... would actually cost $4 trillion more," or whatever the results of the revised forecast showed.

That the total cost would be $30 trillion, or $35 trillion, or whatever, over a multi-year period (during which the U.S. economy will produce something like $250 trillion of incomes) is entirely irrelevant to this debate, unless one fetishizes the public/private distinction.

Moreover, even if the net cost of health care in the U.S. were to rise rather than fall, the point is that we would actually be spending more but getting more, too, because the system would provide universal coverage, whereas even a smoothly functioning system under the Affordable Care Act (which, of course, Trump is dedicated to destroying) would still leave more than ten million people without insurance.

It is bad enough that The Post's editorial board has ignored its own reporters' clear writing on this topic and has even blithely set aside one of their own op-ed writer's accurate description of the Big Government scare tactic as "[t]he dumbest criticism of single payer health care."  If the editors want to ally with the scare-mongering right on this issue, that is unfortunate, but it is their right.  What is worse, however, is that The Post's fact-checker has actually said that Democrats who cite the libertarian's study are lying.

I will stipulate that Glenn Kessler, who runs the fact-checking unit for The Post, has performed an enormous public service by keeping a constantly updated list of all of President Trump's lies since taking office.  Even so, Kessler is human and does make big errors, as I discussed recently regarding his badly-off-the-mark analysis of Mitch McConnell's lies about stealing a Supreme Court seat.  On Medicare for All, Kessler is almost as wrong.

Kessler's piece claims that Democrats are "cherry-picking" the claim that Medicare for All would save $2 trillion dollars.  Astonishingly, he concludes by giving the Democrats' claims "three Pinocchios," the second-worst ranking under his system.  How did he get there?  He notes the controversy over assumptions, but there is certainly no objective "fact" to check as to whether or not Sanders's assumptions are correct.  The author of the study prefers pessimistic assumptions, but that does not make his assumptions correct.

Moreover, Kessler tells us that the study's author thinks the big takeaway from the study is the $33 trillion of Big Government spending.  But so what?  If Democrats are saying, "This guy demonstrated that, under our assumptions, the country would spend two trillion fewer dollars over the relevant time period than otherwise," I suppose that  one might call that cherry-picking, but it is not lying.  And it is of absolutely no significance that the Bush appointee who wrote the study wants people to focus on something else.  He is not lying either, even though he is being more politically manipulative in focusing on something that is absolutely unimportant.

Even more surprisingly, Kessler credits the author's denial of Democrats' claims that the funding of his research institute by the Koch brothers should be expected to cause the author to reach conservative results.  I have no doubt that the author said that the funding did not affect him, and he might even be telling the truth (or, perhaps, might not be aware that he was biased by the funding).  But again, how does it lead to a three-Pinocchios rating for the Democrats to say, "Even a Koch-funded study concluded that our numbers add up, based on our assumptions"?

And even if they do not articulate the words "based on our assumptions," that does not make them liars.  The author says, "I used Sanders's assumptions and found results that you like, but I don't agree with your assumptions and I'd rather not discuss overall savings, anyway."  That does not make his ideological opponents liars.  They are simply disagreeing about assumptions and emphasis.

In the end, I suppose that I should not find it all that surprising that the editors of a mainstream newspaper would panic about a big policy change.  I am, however, surprised that they persist in using an easily and frequently discredited scare tactic to make their case.

What I do find surprising is that any fact-checking journalist would give credence to that tactic as part of a piece that describes supporters of Medicare for All as liars for simply making accurate statements along with contestable political arguments.  The fact-checker went from objective assessment to full-on editorializing.  He is allowed to do that, but he should at least admit that he is no longer acting as a fact-checker.

The good news is that the public does not seem to be buying this nonsense.  There will always be Republicans and curmudgeons yelling "socialist takeover," but with a health care system as dysfunctional and expensive as ours, more and more people are willing to say, "Whatever, dude.  I don't want people to die because they can't see a doctor.  Call it whatever you want, I don't care.  People deserve to live."


PDiddie said...

Cogent. Thank you for it.

Michael C. Dorf said...

A rational conversation would take account of costs and benefits of Medicare for All versus the status quo.

1) Numbers are disputed, but it's fair to say that the combined cost of on the one hand, fraud, waste, and abuse, and, on the other hand, administrative expenses, are lower (probably on the order of half the total cost) in Medicare than in the private health insurance market. Here are a couple of links to Politifact stories. Bottom Line: Admin costs in private health care dwarf the costs in Medicare; fraud, waste, and abuse are roughly comparable. https://www.politifact.com/truth-o-meter/statements/2013/jun/17/peter-roskam/rep-roskam-says-medicare-fraud-rate-8-10-percent/

So far, Medicare for All is a big winner.

2) Maybe all of those higher administrative costs in the private system are having a beneficial effect by preventing unnecessary care? I think that's probably wrong, because "unnecessary" care would fall within "waste and abuse." So counting the high administrative costs in the private health insurance market as helping by keeping down abuse would be double counting.

3) Medicare constrains costs partly through its lower overhead but also partly by scheduling payments. Consequently, some doctors under the current system don't accept Medicare. In a world of Medicare for all, that would continue to be the case, as some doctors would offer "concierge" and other high-end services to wealthy patients. Others might divert to specialties -- like elective cosmetic surgery -- that are wholly outside the public system. It's impossible to say with precision what the overall impact of availability would be, but the increase in the number of patients covered, combined with what we know about the existing Medicare system and single-payer systems in other countries, strongly suggests that the overall impact would be greater access to needed health care.

4) The real objections therefore fall into two categories: a) As Neil explains, just anti-government ideology; and b) distributional. Funding the system as a whole chiefly through taxes would mean that some number of wealthy and upper-middle-classe people who now pay $X for their own health insurance premiums plus out-of-pocket expenses would end up paying some number $Y in the combination of taxes and payments for private health care services, where Y>X. But if the objection to Medicare for All is that the relatively well off and very well off don't want to shell out any money for health care for others, they ought to state it that way.

Joe said...

Thanks for that summary.

CJColucci said...

There are a lot of acceptable ways to skin the health care cat, and I'll support any one that can get the votes. Although I am not married to it, I'll gladly support Medicare for All if the votes are there. As for anyone who is against it, which alternative do you support? If you don't have one, go away.

David Ricardo said...

The number of practices that would opt out of Medicare if it were 'for all' is miniscule and a non factor. The reason is that the market would be too large, and while there would be a few practices that would go independent they would not impact access to any measurable degree.

One reason for this is that the health care system is rapidly consolidating, with large medical centers purchasing private practices and becoming full service provders. This may be a problem down the road with respect to competition, but these large entities would have no choice but to accept Medicare, as they do today.

Hashim said...

At least Mike was honest about this. Neil's refusal to fetishize the public-private distinction completely ignored the obvious and massive distributional consequences of shifting from a private system to a public system. It's not as if the govt is just a group purchaser who takes each person's own private premiums and then negotiates lower costs pro rata for everyone through leverage and supposed efficiencies. Rather, the govt will collect massively more in "premiums" from the subset of the population that pays the disproportionate share of taxes, and then use that to cross-subsidize everyone else. No wonder the post fetishizes the public-private distinction. They somehow figured out the subtle difference between people paying for their own health insurance and people forcing other people to pay for their health insurance.

Hashim said...

Ps. Neil, since you don't fetishize the public private distinction, how about this: Medicare for all, but funded exclusively through imposition of sales taxes on grocery purchases. Sound good to you? No difference at all between private and public, right, other than the sweet efficiencies the govt can bring to bear.

Joe said...

I'm not sure what a "disproportionate share" means exactly, especially taking everything into consideration here. There is a "subtle" difference here between just what is being "paid" for here, including all the benefits the wealthy get from society.

Insurance as a general concept involves a wide group of people adding to the pool and then later on getting benefits when necessary. In the area of health care, society overall doesn't deny benefits -- it being seen as cruel and generally not in society's best interests -- to a range of people, even if they can't pay. People are in that sense "forced" to pay for other people's health insurance in various ways. The situation is present now. It is a matter of expanding of a situation already in place.

The use of sales taxes of food and the other usual "grocery" products has various problems but the comment has a near trolling quality to it, so don't know how much to take it seriously. Anyway, I am glad H. is taking time off from his busy job -- he has gone up in the world -- to give his .02.

David Ricardo said...

Comments on the concept of subsidies in health insurance and a massive government program don't understand insurance, or Medicare.

Insurance consists of subsidies. The healthy subsidize the sick. The young subsidize the old. And higher income people subsidize lower income people, as well they should as otherwise we have a health care system where people suffer and die, or don't, based on income.

As for expanding Medicare creating a huge government program and making private health care public, well again a lack of understanding here. Medicare is not a health care provider program, it is a payments system. Under existing Medicare health care is provided by the private sector, both profit and not for profit. Expanding Medicare would simply substitute public expenditures for private expenditures. The system would stay the same except it would be more efficient and save money.

Arguments can be made against expanding Medicare, but they need to be fact based, not based on an incorrect view of how Medicare works.