Kamala Harris came face to face with the physics that have governed American health care politics for nearly thirty years.
Harris, a Democratic contender for the 2020 presidential nomination, is a co-sponsor of Senator Bernie Sanders’s Medicare for All bill. That bill would enroll all Americans in a single government-run insurance plan, abolishing private health insurance in the process. During a CNN town hall in Des Moines, Iowa, on Monday, Jake Tapper asked Harris if her plan would eliminate private health insurance. Harris answered unequivocally, “Let’s eliminate all of that. Let’s move on.”
The right pounced. The Republican National Committee said that Harris wants to “wants to eliminate private insurance even if you like your plan.” Conservative policy writer Philip Klein said Harris was “gambl[ing] that kicking 177 million people off of their private insurance is good politics.” Even coffee mogul Howard Schultz pounced, adding Harris’s health care plan to the growing list of things he has declared “un-American” during his fledgling pre-presidential campaign.
Of course, it’s a literal truism that Medicare for All would involve moving all Americans off of their current insurance plans and on to Medicare. But it’s also a somewhat disingenuous attack. Most people only have any particular attachment to their insurance plan because it unlocks access to a particular set of providers and benefits. They have loyalty to their physicians and hospitals, not to Aetna or UnitedHealth. Medicare for All might become the only game in town for insurance, but it would give everyone absolute choice of health care provider by getting rid of the networks that today limit which doctors and hospitals you can visit.
The best case for Medicare for All is that it would be liberating, providing truly universal access to health care, good anywhere for any physician you’d like to see. As Sanders colorfully explained, under Medicare for All, “You go to any damn doctor you want to go to. What’s going to change is the wording on the card that you have.” Harris too made this case on CNN, saying, “The idea is that everybody gets access to medical care,” she explained. “You don’t have to go through the process of going through an insurance company, having them give you approval, going through the paperwork, all of the delay that may require.”
But maybe that case isn’t enough to overcome the profound loss aversion people feel thanks to the health care status quo. Because our current private insurance plans all come with limited provider networks, changing plans right now really does threaten to throw a monkey wrench in your health care treatment by cutting your doctors out of your new network. It would be a tragic irony if the health insecurity of our current ramshackle system turns replacing that system into an inescapable catch-22.
But that’s the tightrope that several generations of progressive health reformers have walked: attempting to create a more sensible and universal health care system while inflicting as little disruption as possible on the already insured. Tumbling across that trip wire is what burned Bill Clinton’s health reform attempt in the early 1990s. The trauma of that failure is what led Barack Obama to over-promise: “If you like your plan, you can keep it.”
Current polling bears this out still. The topline popular support for Medicare for All quickly collapses when people are told that it would eliminate private insurance coverage. But what large majorities — to the tune of 70 percent of the country — do support Medicare for More: giving people the voluntary choice to opt into a Medicare-type public insurance program.
That might be a best-of-both-worlds approach. Progressives could take solace in having a strong public option to serve as default fallback health coverage for everyone, while those who like their current plans can keep them. Not to mention, in many other countries with “single payer” systems, private insurers still play an active role.
The Medicare for More public option seems to be the real health care plank among most of the Democrats’ 2020 field. After her town hall backlash, Harris noted that she has co-sponsored a number of bills providing public options through Medicare or Medicaid. So too have many other prospective Democratic candidates. Elizabeth Warren summed it up well when asked about her vision for American health care: “I’ve signed onto Medicare for All. I’ve signed onto another [bill] that gives an option for buying into Medicaid. There are different ways we can get there. But they key has to be always keep the center of the bulls eye in mind. And that is affordable health care for every American.”
So what role is Medicare for All playing in the progressive health care debate? Is it a serious proposal for an immediate social democratic revolution? Is it a long-term aspiration? A wistful ideal for a tabula rasa state? A way of meeting a perceived progressive litmus test in a crowded primary?
Or maybe it’s just marking out the left flank of the Overton Window. That’s what Bonnie Castillo, the executive director of National Nurses United, seemed to suggest when she criticized watered down versions of Medicare for All. “Don’t start bargaining with yourself and undermine yourself,” she told Politico. “The opposition, the insurance companies and pharma, they will come out against anything, whether it’s a half-measure or even a one-quarter measure. That’s why we have to aim high.”
Maybe Medicare for All will prove to be a useful negotiating tactic. But you can’t wish away loss aversion among the insured, or the elimination of millions of jobs for people employed in the health insurance industry and medical billing. The physics of American health care politics persist, like it or not. Kamala Harris was just the latest to learn that the hard way.