Every society needs its public rituals to punctuate the national calendar, and during the Obama administration, one of the most regular was the symbolic repeal of the Affordable Care Act by House Republicans. By the end of 2016, they had already performed this elaborate ceremony more than 50 times to retain the devotion of their base.
Then Donald Trump surprised everyone by getting elected. Republicans had the Senate, they had the House, they had the presidency, and they had a whole lot of experience repealing Obamacare. Yet Obamacare is still with us, and come November, the Republican House majority may not be.
It turned out that actually repealing Obamacare was a much less appealing project than the ritualistic simulation. The law itself was unpopular throughout the Obama administration, but bits of it had broad support, which materialized into rising popularity when Republicans threatened to take those bits away. Republicans were realizing what health-care wonks already knew: Obamacare was already too deeply entrenched to be easily banished.
So the Republicans gave up, leaving something of a hole in the ceremonial legislative calendar. Now Democrats from the Bernie Sanders wing of the party may be coming to the rescue with incantations about “Medicare for all.” Amid reports of a blue wave rising for the midterms, taking over the House may offer Democrats the sort of health-care ritual fulfillment opportunities, and practical difficulties, that Republicans encountered with “repeal and replace.”
For starters, Democrats who pray at the altar of single-payer (government) health insurance will run into public opinion, just as Republicans did. Most Americans are generally satisfied with their own health-care coverage. Oh, they complain about the cost, but according to Gallup, more than three-quarters of Americans regularly rate their plans as “excellent” or “good.” They are much more likely to worry about the health-care system itself than about their own coverage — perhaps because they worry about losing what they have.
That’s why President Barack Obama promised: “If you like your doctor, you will be able to keep your doctor, period. If you like your health-care plan, you’ll be able to keep your health-care plan, period. No one will take it away, no matter what.” Remember the firestorm when that turned out to be false and a few million people stood to lose their policies? Now imagine trying to take away all the employer-sponsored plans enjoyed by half of the population. Better also imagine yourself wearing earplugs and an asbestos suit.
You can imagine, of course, that you’d sway them by pointing out how much better their new coverage will be. But that’s exactly what the Obama administration tried to do in 2013, and it turned out this only made people madder. People are extraordinarily risk-averse when it comes to their health insurance; that’s why they’d like a public safety net, but also why they don’t want anyone to touch their current coverage. And why officials at the Department of Health and Human Services raced to grandfather in the policies of all the folks who had received cancellation letters.
Some Democrats are hoping to inch toward Medicare for all by letting people “buy in” to Medicare — call it Medicare for some. That’s less likely to run into problems with voters, but it would still face strong opposition from others with stakes in the current system: doctors, hospitals, insurers, pharmaceutical companies and medical device manufacturers. Their lobbyists are already organizing a united front in anticipation of Democrats possibly controlling Congress next year.
Medicare for all and Medicare for some both depend on lower reimbursement rates to make the budget math even remotely feasible. Medicare rates are already substantially lower than those paid by private insurers — estimates vary, but it’s reasonable to say that Medicare pays somewhere between 20 percent and 40 percent less than the private sector.
Physician practices and hospitals have budgets, too. Those budgets support good salaries for employees — not just for six-figure administrators and orthopedic surgeons, but the vast army of phlebotomists, radiation techs and other workers one finds in a hospital or medical practice. They make up almost 10 percent of the workforce, and when their incomes are threatened, they will vote accordingly.
Then there’s the effect on patient care. Surveys from the Physicians Foundation find that medical practices increasingly are either refusing to accept Medicare patients or limiting their numbers. In 2008, 6.2 percent of physicians surveyed had closed their practices to Medicare patients. By 2016, 13.7 percent were saying they didn’t take Medicare patients and a further 13.2 percent limited those they would see.
And that’s when Medicare patients make up only 15 percent of the population. If more Medicare patients flooded the market, providers would probably further restrict their Medicare caseloads to keep the lower reimbursements from pushing them into the red. Retirees would probably not enjoy competing with younger folks for a limited number of Medicare slots at doctors’ offices, so AARP, the most powerful lobby in American politics, could be expected to join the battle against Medicare for all.
None of this will matter as long as Trump remains in the White House. Democrats can form Medicare-for-all caucuses and mark each turning of the seasons with a procession down Constitution Avenue and a solemn passing-of-the-bill ceremony before a hushed crowd.
But if Democrats are ever faced with having to move from Medicare ritual to reality, don’t be surprised if they suddenly break faith. The health-care gods are jealous ones. And those whom they would destroy, they first give power.