Medicare for All meets health reform physics

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.

Kamala Harris & the progressive healthcare message, take 2

In May, Democratic Senator Kamala Harris sat down with the Pod Save America guys for and laid out a somewhat jumbled four-part message on healthcare, vowing to: (1) protect Obamacare from then-active Republican repeal efforts, (2) empower government to combat prescription price gouging, (3) “look at the Cadillac Tax and deal with that,” and finally, (4) pursue a Medicare-for-All-type system.

observed at the time that Harris’s rough-draft answer showed that there was work to be done on honing the affirmative message communicating the progressive vision for healthcare.  Burying a tepid endorsement of Medicare-for-All behind Cadillac Tax repeal left much to be desired.

Harris has significantly tightened up her healthcare message.  On Wednesday, she announced that she would co-sponsor Sen. Bernie Sanders’s upcoming single-payer bill.  “I intend to cosponsor the Medicare for All bill,” Harris tweeted.  “Health care is a right, not a privilege.”

Harris is a probable 2020 contender for the presidential nomination.  While others have expressed support for single-payer, she is the first establishment Democratic to put her name on actual legislation.

This is yet another indicator that the center of gravity within the Democratic Party is swarming to the left.  Harris took some flack from the left for allegedly lacking progressive bonafides.  I argued that Harris and other prominent center-left Democrats are actually testaments to the left’s success in reshaping the party’s agenda.  Her unequivocal embrace of single-payer now adds to that success.

She endorsed the view that healthcare is a fundamental right.  This is a common rhetorical assertion among progressives.  But it has the benefit of uniting the party’s supposed rift between those prioritizing economic issues and others prioritizing social and identity issues.  “Healthcare is a right” presents universal coverage as an issue of both economic and social justice.

Still, there is reason to slow down the Democratic rush to sign on to single-payer healthcare.  Democrats may quickly find themselves on the wrong side of the public’s deep status quo bias toward healthcare–the same fear of change that stymied Republicans’ Obamacare repeal efforts this year.  The public may express support for a single-payer system as a way of voicing dissatisfaction with our current healthcare system.  But when the rubber hits the road, for many people, there’s just too much at stake in healthcare to venture too far away from the system they already know.

There are always painful tradeoffs in healthcare.  There are transitions that must be navigated, revenues that must be raised, and industries that must be displaced or accommodated.  By putting their names to legislation, Harris and other Democrats will be taking sides in those tradeoffs.  Medicare-for-All will no longer be an abstract wishful preference.  It will be real dollars and cents, legislative carve-outs and burdens.

The progressive healthcare vision is coming together in refreshingly bold terms.  But Harris and other Democrats need to make sure that they are prepared to stand by all that this entails.

Kamala Harris & the progressive healthcare message

Sen. Kamala Harris is the newly-elected junior senator from California, and one of the Democratic Party’s rising stars.  She recently sat down for a live taping of the popular podcast Pod Save America in San Francisco.  Jon Favreau asked Harris about what the Democrats’ positive message on healthcare should be.  Her answer is worth exploring, for it gets at substantive decisions that Democrats must reckon with as they chart a path forward in both immediate resistance and future governance.

First, Harris said that “step number one is not to eliminate” Obamacare, reciting the Congressional Budget Office’s projection that the Republicans’ repeal bill will throw 24 million people off of their coverage.  So far, so good—but that’s not a positive message, it’s a defensive one.

Next, she pivoted to talking about ways to improve Obamacare.  But she only mentioned allowing the government to negotiate prescription drug costs “so these prescription drug companies aren’t just taking such advantage of us,” and pointed to the Epi-Pen price-gouging scandal.

Sensing that this was a pretty thin positive message, Jon Lovett pushed her to name more things that Democrats should do to improve healthcare.  And Harris responded by pointing to…the Cadillac Tax.  “I think we need to look at the Cadillac Tax and deal with that,” Harris said.

Harris continued, offering some prolonged word salad of stammering qualifiers before endorsing a Medicare for All single-payer system as the vision of progressive healthcare.  “And then there is what we need to do around really at some point figuring out how at some level we are going to have a policy that is Medicare for All.  That would be the ultimate and great place to be, Medicare for All.”  Her pitch for Medicare for All won much applause from the crowd.

Harris declined to formally endorse the single-payer bill winding its way through the California legislature, saying, “I like the concept but we need to work out the details.”  She concluded that as a country, “We need to get to a place where it is not a function of your income that you have access to healthcare.”

It’s worth unpacking that answer.  Leading off her “positive message” on healthcare by talking about the Cadillac Tax is baffling to say the least.   The Cadillac Tax is an Obamacare provision that imposes an excise tax on the most expensive — and generous — health insurance plans offered by employers.  This is meant to both generate revenue for Obamacare’s coverage expansion, and to steer employers away from uber-comprehensive insurance plans that help drive up healthcare costs.  The tax is unpopular—liberals like Bernie Sanders and Hillary Clinton have joined conservatives and labor groups in pushing for its repeal—and has been routinely delayed by Congress.  It isn’t scheduled to take effect until next year.

Presumably, when Harris says that we need to “deal with” the Cadillac Tax, she means we need to repeal it.  But endorsing a rollback of a subsidiary part of Obamacare that will help pay for its coverage expansions won’t exactly stir progressive ambitions.

Harris ultimately got around to re-iterating that guaranteed healthcare for all is the long-term progressive vision, backing a government-run system.  She stood up for the principle that healthcare is a right that should not be dependent on one’s income.  And letting Medicare negotiate drug prices is a fine idea—one that Trump himself might be amenable to working with Democrats on.

But there’s a lot to work through in Harris’s support for Medicare for All as the party’s positive vision.  As I have written, there is both significant apprehension and large institutional hurdles surrounding single-payer healthcare that won’t be easily overcome.  There are other progressive policies—like a Medicare buy-in, a public option, and expanded Medicaid eligibility—that would make progress toward government-provided healthcare for all, without crumbling under the weight of intense public and stakeholder opposition.

So is Harris endorsing Medicare for All as an imminent solution?  If so, is she throwing out Obamacare and starting from scratch, or building on it with incremental reforms?  What do those reforms look like?  Does that make Medicare for All in fact just a long-term aspiration that maybe just might eventually obtain “at some level”?

In Harris’s defense, a podcast interview probably isn’t the venue to suss out these nuances.  But without these details, “Medicare for All” becomes little more than a slogan—an applause line for liberal crowds.  Maybe that’s the future of progressive health policy: campaign on “Medicare for All”, but enact “Medicare for More.”

Harris is also far from the only prominent Democrat to fumble a progressive healthcare message.  Sen. Cory Booker (another potential 2020 contender) recently gave a similarly mealy-mouthed answer on Medicare for All, which his office cleaned up as “one of those ideas that must be considered.”

Like Booker, Harris is a compelling and engaging politician, and has an exciting future as a Democratic leader.  Like many other prominent procedural or “rights-oriented” liberals, she seems much more at ease standing up for social justice than for economic justice.  And she’s hardly the first upcoming Democratic politician to give a jumbled answer on healthcare—Barack Obama famously fell flat at a healthcare forum early in his 2008 campaign for president.

But Harris’s answer is illustrative of a bigger problem for the Democratic Party.  Maybe Democrats have been too consumed with the fate to save what they’ve already accomplish to flesh out just exactly what comes next.  But in resisting Republican efforts to tear down Obamacare, it’s essential to explain just what exactly the Democratic alternative looks like.  If Harris’s positive message on healthcare is any indication, there’s more work to be done on figuring out just what the alternative will be.