Tuesday, December 11, 2018

What Bothers People About Medicare-for-All, Really?

by Neil H. Buchanan

Now that the Democrats -- thanks to their historic trouncing of Republicans in the midterms -- are set to take back control of the House of Representatives next month, many in the party are talking excitedly about finally creating a universal single-payer health care system in the U.S.  Why not get this country at least into the Twentieth Century when it comes to health care, even if we stagger across the finish line five or six decades later than every other country that we think of as "civilized"?

Because the U.S. already has a non-universal single-payer system called Medicare, which happens to be quite popular even among the Republican base, Democrats are using the shorthand Medicare-for-All to describe a range of proposals, some of which would involve the total elimination of private insurance while others would provide public funding for universal care but allow private add-on insurance policies.  Those policy differences, though undeniably important, are not pertinent to the discussion here.

Instead, my question is why so many people disparage Medicare-for-All (or any kind of public health care financing system).  After all, we are not merely talking about a bunch of astroturf groups, funded by shadowy right-wing ideologues, spinning stories about death panels and Stalinist assaults on personal freedom.  Supposedly reasonable conservatives -- and even a lot of centrist and left-centrist Democrats -- become twitchy when anything like Medicare-for-All is on the table.

Why is there such widespread opposition to a system that is not only a proven success worldwide but that already exists here in the U S of A?  Why do even people of apparent good faith lose their marbles when we start to discuss treating health care as an American right rather than as a privilege of wealth?  I think the explanation can be broken into three categories.

Substantive Objections

One possibility, of course, is that Medicare-for-All is actually a bad idea on the merits.  Certainly some versions, especially if not well thought out in advance, would not be as good as others.  The transition would also be tricky, of course.  And no system is perfect, meaning that there would be meaningful policy challenges in running such a system, even after it was up and running.  If this were easy, even our political system could have done it by now.

But what exactly are the substantive concerns?  The complaint most often heard from the doubters is cost.  "Great idea, maybe, but what a huge price tag," is a common claim about single-payer.  This, however, is nonsense.  As I noted in a column this past summer, tut-tutting centrists like The Washington Post's editorial page frequently make a huge deal about the cost of such programs, trying to convince people that this is pie-in-the-sky thinking from muddle-headed people with no sense of fiscal discipline.

But as I pointed out in that column, saying that Medicare-for-All is expensive ignores the simple fact that the current system is more expensive.  One estimate of the cost of a single-payer system is $38 trillion in the first ten years, which sounds like a lot of money until one realizes that the money currently spent on insurance premiums, co-pays, coinsurance, and deductibles adds up to a lot of money, too.  In fact, it adds up to more money than Medicare-for-All would cost.

As one of The Post's own columnists, Paul Waldman, pointed out the month after the editorial board freaked out about the cost of universal care, the current system is hugely expensive, adding: "So let me suggest a different question that might be asked not to those advocating Medicare-for-all, but to those opposing it and those journalists assuming it is unrealistic: How do you propose to come up with the $50 trillion you want to spend on health care over the next 10 years?"

In other words, naysayers conveniently ignore the tradeoffs between the current system and the proposed alternative.  It is somewhat amusing (or, depending on one's mood, infuriating) that the people who condescendingly lecture liberals about clear financial thinking focus only on costs while studiously ignoring benefits.

The widely known fact is that the U.S. spends a much larger chunk of its national income on health care every year than any other country in the world -- on the order of half again more than even the next-most-expensive system.  Of course it is possible to make mistakes when switching to a different system, but we have an awful lot of slack to work with in a system that is so hugely wasteful.  Other countries still see much better health outcomes than the U.S. -- at 40-65 percent of the cost.

The evidence shows that it is possible to get more for less.  Substantively, there is nothing to fear from Medicare-for-All as a categorical matter.

Ideological Objections

With no basis in economic or policy reality for opposing Medicare-for-All, opponents fall back to ideological complaints.  The classic fetishization of the public/private distinction plays a central role in the rhetoric from the center and right.  The current system might cost $50 trillion over ten years, but that money is labeled premiums, co-pays, and so on.  The $38 trillion that would go to Medicare-for-All would be ... gasp! ... taxes.

But the ideological objection might not be merely a matter of labels.  Conservatives play word games all the time, and they are able to content themselves with convenient fictions when it suits them.  Just as one example, consider how Republican Senate leader Mitch McConnell has been able to sell his caucus (more than once) on plans to increase the debt ceiling -- which many Republicans vowed never to do -- by first suspending the debt ceiling and then reinstating it at a higher level.  Et voila!  We have an easy work-around to prevent a debt ceiling crisis.

The objection to Medicare-for-All thus could be about something that cannot be fixed with rhetorical sleight of hand.  Maybe the objection is that the private sector is simply superior to the public sector -- not in a substantive sense (see above), but in the sense that the private sector is presumptively better than the public sector, evidence to the contrary be damned.

The best that one can say about such an objection is that it might be based on a no-exceptions belief in the power of market competition.  Private companies compete and thus provide better outcomes, say the ideological purists.  Anything that seems to suggest otherwise must surely be liberal deviousness, misperception, or fake news.

But of course, even the most highly decorated economists have known all along not only that markets can often fail but that the health-care market is simply different.  Books and journals have been filled for more than a half-century with analyses showing that health care is an irreducibly noncompetitive environment.  Again, that is why the evidence shows so clearly that the U.S. system is more expensive and performs worse than countries that treat health care more like a regulated monopoly.

One twist on the ideological objection focuses not on economic competition per se but on the companies that would lose their position in a Medicare-for-All world.  Even though one of the founding tenets of antitrust law is that we should protect competition itself, not particular competitors, some opponents of change hide behind "the efficiency of the marketplace" when their real agenda is to protect hyper-profitable insurance companies like Cigna and UnitedHealthcare.

That objection then boils down to the claim that, as an abstract ideological matter, we should prefer a world where private oligopolists make lots of money while providing substandard care to a world in which governments fund more effective health care at a lower cost.  That is one strange ideology.

Political Objections

The final category of objections to Medicare-for-All is the claim that "this is politically nonviable, so you should just drop it."  This is, I think, what motivates people like The Post's Jennifer Rubin, who has become a broken record in repeating that Democrats should not "screw up" by nominating Bernie Sanders or someone like him.  Rubin is more open-minded than many on the center-right, but she truly does not understand economics beyond sound bites on the right about "fiscal responsibility" and the supposed dangers of, say, the minimum wage.

Perhaps Rubin thinks that there are substantive or ideological reasons to opposed Medicare-for-All, but if so, I have not seen anything from her (or people making similar arguments) that withstands even a moment's scrutiny.  The most generous reading of her argument is that other people will never be able to get past the Big Government and Socialist labels, so Democrats should simply give up and settle for center-right rearrangements of deck chairs on the sinking U.S.S. Health Care.

Although I am deliberately being sarcastic here, I do not mean to say that the political lift will be a small thing.  Waldman, who is generally supportive of Medicare-for-All, warned his readers just yesterday that this will be "a long and bloody fight" and that victory is far from assured.  He is absolutely right, and that is something that some giddy people on the left need to remember.

That is, however, not an argument for unilateral disarmament.  "People don't already agree with you, so give up trying to change their minds" was never a mantra for progress.  Yes, we might fall short, but that is not a reason to presume that there can never be any progress at all.

After all, the fight over the Affordable Care Act included a moment in which the Democrats got cold feet and dropped the so-called Public Option, which conservatives correctly perceived to be the possible beginning of a transition to full single-payer health insurance.  If the left now makes a big push for Medicare-for-All but ultimately must satisfy itself with a compromise that includes a robust public option, that would represent both immediate progress and a long-term victory.

Again, I am not saying that one need not worry about the details.  Even if some form of Medicare-for-All is eventually adopted, Republicans and many centrists will nonetheless try to undermine the program at every turn.  And even without sabotage, any system will be complicated enough to be attacked politically.

Nonetheless, it is important to remember that -- at least based on what has been offered publicly to date -- those who oppose Medicare-for-All have offered nothing as a matter of substance, ideology, or politics to undermine the case for Democrats trying to give Americans what they have said that they want.


Joe said...

Opposition is likely a mix of things that might not stand up to rational informed scrutiny but that is more ideal than reality in our political system in some ways.

So, the immediate cost thing will be cited.

Then, the problem will be how it is paid for. It will be seen as some big government nightmare. In time, government programs seem natural and in effect "rights" -- hands off my Medicare! Medicare once upon a time was controversial too.

This might help explain the cost thing -- yes, the current system costs more, but the devil you know and all that. Thus, the apparent horror at requiring people to buy health insurance -- or horrors, a public option -- as compared to government supplied fire insurance (that is, fire departments). Once upon a time, fire departments were often private affairs. Not any more (except in rare cases; one horror story was mentioned during the ACA debates of someone refused service out of failure to pay) and it seems natural really to get it. Ditto Medicare.

Well accepted government programs also have various nuances and complexities, just as ACA does, and they are not generally latched upon to call the whole system bad. Well, we do have calls to privatize Social Security. It's harder to start things out there, especially without it being the Great Depression or a united government ala the 1960s with years of acceptance of "big government."

A big obstacle here is likely overall acceptance of the general idea. It helps that even the Republicans have seen how unpopular ending the Affordable Care Act is, though they are doing their damnest to chip it to death. The taint of Republicans in general will help here, perhaps.

DAngler said...

I am very liberal in my political outlook, but I have been opposed to a single payer system like Canada and Great Britain have, because of lack of choice. If Medicare for All preserved the right for me to choose my doctor, then I would be much more pre-disposed to entertain it. The converse situation would be more like the VA's medical program, where you take what the government provides -- often not the doctor you would wish for.

Bass Around the World said...

Dangler, you might want to do more research:

"atients have free choice of primary care doctor. The requirement for patient registration varies.17 Clinical fee-for-service payments to primary care physicians in Canada averaged CAD271,417 (USD217,134) in 2014–2015.18 In several provinces, networks of GPs work together and share resources, with variations across provinces in the composition and size of teams."


Also, as of right now, I DO NOT have free choice of doctor. I had to leave my preferred primary care provider as well as specialists because I could no longer afford my previous insurance provider and had to switch to Kaiser. I like my new doctor OK, but a 10 year relationship, along with the fact that my previous doctors guided me out of dangerous medical situations, is completely aggravating.

It seems to me that a system could easily be devised whereby people can see the doctor of choice and save enough money in premiums, copays, etc., to see whoever they want, even if it costs out of pocket and still come out ahead financially.

We don't have to use the same exact plan other countries use and it's worth noting that other countries often have better outcomes with much lower costs and also have higher happiness quotients. Essentially, we are killing ourselves to keep insurance company executives rich. The added stress from the financial burden alone is a major factor in our unhealthiness.

My guess is that your objections are more ideological since they aren't based in fact or logic.

True freedom in healthcare isn't the choice of which insurance company you use to rip you off, its the freedom of knowing that getting sick won't ruin your life and your family's lives. During my son's birth he aspirated meconium, his lungs shredded and collapsed, and his heart stopped twice, leaving him with a significant brain injury. Flight for Life took him to Children's where they cooled his brain for three days, followed by various treatment and two years of intensive therapies. Now he's an amazing, brilliant 6 year old, sharp as a tack, thanks to the treatment we got, instead of in a $100k wheelchair unable to communicate. At the time, we were on Medicaid here in Colorado and had we not been, we would have lost the house and everything else. Medicaid was great. Sure, there was some bureaucracy, but if we lived in a different state, we would have been ruined financially, and maybe not able to access some of the treatment which ensured his complete recovery, which is no way to start a family.

DAngler said...

Edwin, I don't think I'm as opposed to single payer as you read into my comments. I am not ignorant of Canadian healthcare. We have many Canadian friends, and they say there is a very serious doctor shortage. The consequences is that the best doctors have so many patients that they no longer accept new patients, so new patients get the "choice" of the lesser doctors. The shortage creates a very serious lack of real choice, no matter what the claims.

Furthermore, I'm not sure Obama's original plan -- to give every American the same kind of coverage as Federal Employees and Congress have -- wouldn't be a better alternative, both in terms of outcomes and in terms of economics. What was passed is far from what was asked for. Instead of a national scope, every State implemented independent plans, reducing bargaining power hugely. Failure to control pharma costs is egregious.

I guess my ultimate concern is that I don't trust Congress to give us any single payer system that hasn't been tweaked and torqued until it is worse than what could be had if we had a real nationwide system of competitive insurance like Congress and Federal employees have. We saw how that plan got torqued. Care to bet that a revised Medicare for All would not be?

David Ricardo said...

Mr. Buchanan answers the titular question of his post in his first paragraph

“Democrats are using the shorthand Medicare-for-All to describe a range of proposals “

which illustrates the point that Medicare-for-All is currently just a slogan, not policy. As for a more detailed explanation of why Americans have not bought into Medicare-for-All, in addition to what Mr. Buchanan has said here, there is this.

1. There is a deep distrust of the federal government, indeed of all government in the American psyche. The nation is not willing to trust the Feds at this point in time, and given the politics of government hatred they may never do so.

2. Most Americans get their health care insurance via employer sponsored and subsidized plans. They may not like that, but for most of them it works. No one will want to replace that system with something that they do not understand and do not know how will work.

3. Medicare is not comprehensive, and try and explain Medicare Advantage vs Medicare Supplemental Insurance to the typical American. Go ahead, we dare you.

4. The anecdotal horror stories about Medicare, while not representative, capture many people's imagination.

Finally there is this, it is in the political interest of conservatives to fight Medicare-for-All with lies, distortions, and misinformation, and the media is more than happy to go along with them.

Greg said...

To express a few liberal fears for implementing Medicare-for-All:

1.) It won't cover abortion. No way, no how.

2.) It might not cover contraception.

3.) I don't trust Republicans not to gut the taxes, and thus indirectly gut the program as a whole. At that point, we're back where we started, but with a lot of the existing structures that support the current private health insurance market dismantled.

I would love a robust single payer option, or at least a viable public option. I viewed the lack of a public option as a fundamental failing of the ACA. Unfortunately, in the current political environment I don't trust any fundamental structural redesign of the American health care system like true single payer to survive a change in the governing party.

Joe said...

Medicaid covers a limited number of abortions, some states having allowing more than others. I would think Medicare for All would just apply the same rules.

As to contraceptives, not sure how different that is from the current rules under government funded/secured health care at this time. If anything, in both cases, an individual based system might be better since we can avoid complicated/convoluted debates involving employers with conscientious objections providing insurance.

Not trusting Republicans is a good policy but that would entail some discussion of the specifics of the new policy. Republicans have harmed the application of ACA too. It is very unclear to me however we would have been better if it did not pass. For instance, lawsuits let to Medicaid expansion being voluntary. But, a majority of the states ultimately accepted it anyway.

The lack of a public option was unfortunate but various social welfare programs we have now came over time. The 1960s followed the 1930s there in multiple ways. As to gutting taxes, in time, things become well accepted. We are starting to be there even on ACA as seen by the problems Republicans had with ending it even with united government control.

But, wariness is not a bad policy.

James said...

Medicare for All's proponents are so consumed with policy details that they're incapable to presenting a strong but simple description of their proposal. Here's how I would describe a single-payer, universal, health care system, what I would call American Care:

An everyone covered for everything, zero copay, federal single-payer health care system financed by fair taxes. That clearly eliminates the need for private health insurance and the need to pay private health insurance premiums. American Care would be better than any health care insurance now available — better than Medicare, better than Medicaid, better than Tri-Care, better than employer paid private insurance — and it would provide equal protection under the law, something we don't now have. The public will support a better system.

The first decision the nation must make is whether it wants a health care system with American Care's features. Only after that decision is made should we discuss what to tax. If issues of cost must be settled before a decision on the system is rendered, every single-payer system will fail. There should be no argument over whether we can afford it. We're a rich nation. The question isn't whether we have enough money: it's whether we have the wisdom to replace our expensive, inefficient, unjust, system that doesn't cover everyone with an efficient system that does.

Joe said...

I think the current trend is that "Medicare for all" is in effect a 2020 campaign slogan with details to come later. Potential presidential nominees etc. might want to add details but as with Obama/Clinton doing that in 2008, it will be subject to events.

James comment is appreciated all the same.