Thursday, December 20, 2018

Details as Distractions in Medicare-for-All and Social Security Debates

by Neil H. Buchanan

As I noted in a column last week, conservative politicians and pundits are becoming increasingly frantic about the possibility of the U.S. actually moving to a single-payer health care system, the most likely version of which would be an expansion of the current Medicare system to cover people of all ages, not just those over 65 -- that is, Medicare-for-All.

Viewed as a political moment, this panic is important simply because it represents a return to form for those conservatives who have strayed from their lifelong paths by opposing Donald Trump and all that he represents.  One might have been forgiven for thinking that prominent NeverTrump pundits had become policy moderates -- people who, once hit with the bucket of ice cold water that is the combination of Trump and movement conservatism, suddenly woke up and realized that perhaps one's highest calling in life should not be to justify tax cuts for the wealthy or throwing tens of millions of people off of Medicaid.

But in the end, the people who had stuck with the Republican brand even after the madness of the Tea Party-fueled rage against Obama are not likely converts to centrism.  Thus, even the pundit who seemed to have made the most substantive progress in her views, The Washington Post's Jennifer Rubin, apparently was unembarrassed to ask earlier this week: "[W]hat’s the alternative to the left-wing infatuation with super-centralized government, anti-capitalism and retrenchment?"  Yes, she actually wrote that -- and she is supposed to be one of the reasonable ones.

Unless "super-centralized government" is merely a muscle-memory way to insult liberals that has no actual content (which is a very real possibility), this kind of comment must surely be of a piece with the fatuous claim that expanded Medicare is bad because it would mean higher taxes -- even though those taxes would replace health insurance premiums, co-pays, coinsurance, deductibles, and every other part of the clip-joint scheme that is the U.S. private health insurance system.

This return to form on the center-right suggests that there will be no kumbaya moment for the 60 to 70 percent of Americans who abhor Trump and his enablers.  If there is going to be progress on anything, most certainly including health care policy, there will have to be a real debate that includes dealing with red herrings and bad-faith objections.  It must also, however, deal with real concerns.  Here, I want to discuss how the fact that "it's complicated" plays out in good-faith policy discussions.

In that column last week, "What Bothers People About Medicare-for-All, Really?" I noted that the right-wing objections to a single-payer system amount to misunderstandings about health care economic reality, ideological objections, or appeals to political "reality."  But what about people who see the pluses but have genuine concerns about any minuses -- what we might call the Medicare-for-All Curious?

Some very good comments on my column echoed arguments made in the broader political discussion, raising some important questions.  One initial concern is that the current policy discussion among Democrats is more a matter of rhetoric than reality, that it is all too easy to be in favor of "Medicare for All" when there is no firm content to that phrase.  Is that a fair assessment?  Yes and no.

It is certainly true that Medicare-for-All became a buzzword among Democrats in 2018, and I have seen reports suggesting that some Democratic candidates claimed to be in favor of it even though they did not know what it meant.  Being in favor of a notion is easier than being in favor of something specific.

But that is always true in politics.  On both the left and the right, there are plenty of people who are absolutely certain that "deficits are bad," but when pressed, they could not explain why.  They just have a gut feeling that Shakespeare's admonition, "neither a borrower nor a lender be," is an eternal verity -- even though Shakespeare meant only that friends should not borrow from friends.  But when the time comes to do the things that are required to reduce deficits -- cut spending and/or increase tax revenue -- those same people lose enthusiasm.

Perhaps, then, the Medicare-for-All boomlet will be a passing thing, and people will lose interest once they start to think about fuller details.  Even so, it is surely not true that there are no detailed proposals on offer, nor is it true that even the vaguer plans are nothing but feel-good exercises.

The Center for American Progress, as close to representing the slightly left slice of "the Democratic Establishment" as one could find among think tanks, earlier this year published a nicely detailed description of what they call Medicare Extra, which does not fill in every policy detail but does do important things like explaining how the transition could work, how people with employer-provided health insurance would be affected (they could choose to stand pat), and other policy wonkery.

Although some liberals might be hiding behind vagueness, therefore, others are certainly not.  Moreover, if Medicare-for-All were truly a content-free label, then there would be no reason for people on the right to oppose it.  After all, soon-to-be-blessedly-former House Speaker Paul Ryan proposed gutting the actual Medicare program and replacing it with a fully privatized voucher program (where the vouchers would become increasingly inadequate over time), but he called his system Medicare.

If conservatives can get excited about a plan that is not Medicare but that is still called Medicare, then obviously they are not scared off by that word.  Yet they (including, as above, supposed apostates like Rubin) are freaking out about Medicare-for-All.  They have reasons -- bad reasons, indefensible reasons, but reasons nonetheless -- for opposing something that is still mostly a general idea rather than a specific and enactable legislative proposal.

They know, in other words, that Medicare-for-All means something, and they hate it.  Similarly, the people who are in favor of one or more versions of Medicare-for-All are in favor of something identifiable and appealing: universal health care coverage, at least in part provided by a government entity.  This is not an imaginary difference between left and right.  Both sides know what is at stake.

But of course, the details matter, and soft support can evaporate when some details are filled in.  Even there, however, it is important to understand that part of the strategy for opposing Medicare-for-All is to invoke detailed questions as if they are an essential part of the story.  Often, however, those details are mere distractions.

One concern, which has been given heightened political salience because of Barack Obama's fateful claim that "you can keep your doctor" under the Affordable Care Act, is whether any particular health care system would limit (or eliminate) people's choices of doctors and other providers.  Would Medicare-for-All "take my doctor away from me"?

The answer is not merely that we cannot know until we fill in the policy details, although that is true.  The larger point is that there is simply no connection between a health care system's financing mechanism and whether that system will preserve patient choice.  After all, when HMO's became a big deal in the 1990's, one of the complaints was that they were requiring people to use only "in network" doctors and hospitals.

More simply, single-payer systems and fully private systems (and everything in between) could all limit patients' choices.  Or not.  There is no inherent link between the type of system and this very personal matter.  But because opponents of Medicare-for-All know that this is politically salient, they will stoke the fear that any change in the system will take away what people care about.  In turn, people of good faith can be distracted by such sub-issues and oppose a new system for no good reason.  The fight for such people should be to enact Medicare-for-All with patient choice.

There is a similar dynamic in debates about Social Security.  Having been studying and writing about Social Security for decades now, I have noticed how easy it is to distract people with non-issues.  "You could do better investing your money in the stock market, so Social Security is a rip-off!"  "Social Security allows old people to steal money from younger people, because there is nothing real in the Trust Fund!"  And so on.

For each of those claims, there is a complete response.  From a political standpoint, however, what matters is only whether the intended audience can be scared into focusing on a sub-issue (or a complete fabrication).  The long-term strategy on the right has been to win over younger people by convincing them that Social Security is rigged against them, a strategy that involves throwing out claims about "rates of return" and other sophisticated-sounding issues that people do not truly understand but think should worry them.

Interestingly, the process of throwing out those talking points to confuse voters serves a concurrent purpose in occupying the minds of the policy wonks.  Whenever I present my work on Social Security to tax law scholars, for example, I am constantly amazed by how many of the questions relate to little policy puzzles that the questioner is interested in.  What would it take to replicate Social Security as a private annuity?  Is the Trust Fund technically solvent?  How much could you save by taxing benefits above $x?

As a policy wonk myself, I sincerely understand the joy of diving into those questions.  Doing so, however, inadvertently serves the purpose of muddying the waters with a bunch of technical questions that convince people that "this is all so complicated, and even the experts can't agree."

Again, moving to a system that deserves the Medicare-for-All label will involve many choices, some of which will be hugely consequential while others are simply decisions that must be made in order to have a working system.  But we -- both the voting public and, perhaps more importantly, policy analysts -- must simultaneously sweat the details while not allowing them to consume the debate.