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.