Over the last two years, the idea of government-guaranteed universal health coverage, often shorthanded as Medicare-for-all (I’ll refer to it as M4A from here) has grown from a minority belief within the Democratic Party to a majority belief, and one that is on its way to becoming consensus. We are now entering a period of debate within the party about what universal coverage should look like and how to transition from the system we have now to the system we want.
This is an extremely complicated policy challenge, but it’s an even more difficult political challenge. And to be honest, I worry that many of the M4A advocates — whose basic principles I share — may not fully appreciate what they’re going to be up against.
Let’s look at this report from Politico’s Adam Cancryn on the forces gearing up to prevent M4A from ever happening, many of which were also staunchly opposed to the Republican effort to repeal the Affordable Care Act:
More than a dozen groups intend to press their point next year through The Partnership for America's Health Care Future, a vehicle to combat an expanded government role in health care.America's Health Insurance Plans and the BlueCross BlueShield Association helped found the coalition alongside the Federation of American Hospitals, the big drug lobby PhRMA and the American Medical Association.Since then, it’s added another 13 organizations — most representing companies with much to lose under a system that shrinks or in some cases eliminates private health care. [. . .]The Partnership, some of whose members began discussions within weeks of Senate Republicans' failed Obamacare repeal vote in July 2017, is planning to launch a campaign featuring ads, polling and white papers playing up the private sector’s role and warning against further disruptions to the health system, people involved with the group said. Avalere, a consulting firm Democrats often leaned on to highlight the dangers of GOP repeal bills, is producing research for the coalition.
That’s the tip of the iceberg. It doesn’t mean universal coverage shouldn’t be a critical goal, but it does mean that it’s going to be a struggle, and advocates need a plan to overcome the opposition from people with almost limitless resources and an intense interest in making sure M4A never comes to pass.
It is difficult to formulate such a plan at this stage because the internal policy debate is still ongoing. There are some on the left who say they will settle for nothing less than a full single-payer system with no role at all for private insurers. (Many of those people have a habit of lashing out at anyone who deviates even slightly from this vision as a neo-liberal shill and corporate sellout, but the people who do that are often those with the least understanding of the complexities of this issue.) Others are devising plans that retain some role for private insurers but boost the government’s role as a guarantor of coverage (here’s an example). My own preference is for a hybrid system like they have in France, where there is a basic universal system that covers everyone, and then people are free to buy additional private supplemental insurance to get more comprehensive benefits.
But Medicare-for-all is easy to understand, and benefits from the fact that so many people love Medicare. That branding will likely stick to whatever Democrats settle on, for better or worse. But no matter what we wind up calling it, the opposition is going to be fierce. And there a few things we need to understand about what will happen if there’s a time when a Democratic president and a Democrat-controlled Congress actually try to accomplish universal coverage.
Obviously, the opposition will be far, far better funded than the supporters are, simply because the ones who stand to benefit will be the public at large, while the ones who stand to lose will be a bunch of highly profitable industries. President Barack Obama managed to co-opt many of these opponents in 2009 and 2010 (though the cooperation was always tenuous), which helped make it possible to pass the ACA. But if we’re talking about M4A, there will be no co-opting. Insurers, doctors, pharmaceutical companies — they’re going to fight against it.
Some of the arguments they make will be legitimate, and some won’t. But the public will find it impossible to distinguish between the two when it is faced with a torrent of propaganda, all aided by the Republican Party. Last time we had “death panels”; who knows what we’ll have next time.
And supporters will be fighting against powerful status quo bias, no matter how many people tell pollsters right now that M4A sounds like a great idea. Consider what happened in November: A good deal of the success Democrats had in last month’s elections came because of the health care issue, but it was narrowly focused, in many cases on the single issue of preexisting conditions. But Democrats had the benefit of arguing against change — people have protections now, and Republicans wanted to take them away.
Arguing for change, especially radical change, is always more difficult. Even if people are unhappy with the status quo, they will be receptive to the argument that change will make things worse and cause them to lose what they do have.
I wish I had a magical solution to these political problems. But the first step is understanding that actually passing a universal system will take a huge amount of work, extremely friendly historical circumstances, and no small measure of luck. It will take years at least, and success is anything but assured. The fact that it’s right and necessary, or that the current system is still a nightmare in so many ways, doesn’t make it inevitable. No one should delude themselves into thinking otherwise.