Whether you share Harris’s goal or not, it’s not actually a contradiction for her to say that she wants to get to a system of single-payer health care but to say she favors a series of incremental steps. In fact, no one who favors “Medicare-for-all” can honestly say it is going to happen anytime soon, given the Senate’s 60-vote requirement and the public resistance to cutting out private insurers. Any candidate who pretends such barriers don’t exist isn’t being any more honest with voters than Trump’s never-explained magical health-care system that was going to provide more choice, better care and cost less. So where does that leave voters and presidential contenders?
Virtually all elected Democrats want universal health-care coverage. However, most also recognize that eradicating private insurance is not feasible, at least in the short run. The problem is not that the system is “rigged” but rather that ordinary people don’t want such a drastic change.
“Whatever the actual merits of the switch away from private insurance, surveys suggest that many Americans who have decent coverage now are nervous about changes,” Jonathan Cohn writes. “Just last week, a poll from the Henry J. Kaiser Family Foundation found that support for a support for a Medicare-for-all system dropped dramatically when people learned that it would mean giving up existing insurance, although that was just one of several questions the pollsters tested.”
There are, as Cohn points out, oodles of proposals to expand coverage that don’t eliminate private insurance by fiat. (“An example is legislation co-sponsored by Democratic Sens. Sherrod Brown of Ohio and Debbie Stabenow of Michigan that would allow people 55 and older to sign up for Medicare,” he explains. “Other proposals envision creating a whole new government-run plan, more similar to the one in the [Bernie] Sanders bill, while still allowing employers to continue offering coverage to employees ― and then giving employees the option of sticking with the company plan or buying into the new public program.”) There are lots of ways to get closer to the goal Harris and others have — affordable, simple health care for everyone.
David Leonhardt argues that pushing the you-lose-the-insurance-you-like plan is an “unforced error” (or what comes from following Sen. Bernie Sanders (I-Vt.) over the political cliff). Instead, he says "a less problematic, but still bold, alternative exists: A vastly expanded version of Medicare that allows people to buy in voluntarily. That plan could also be called Medicare-for-all. And if it proved to be as popular as Democrats expect, advocating for the mandatory version would become much easier.” That’s the plan from the Center for American Progress.
Like all plans, this, too, has drawbacks, including funding and defining what exactly people would be buying into. To make things even more complicated, consider: “Within the current Medicare program, Medicare Advantage provides a choice of plans that deliver Medicare benefits to seniors.” CAP explains, “Currently, an estimated 20.4 million seniors are enrolled in Medicare Advantage, or 34 percent of total Medicare enrollment.” Any Medicare buy-in, CAP argues, would need to “reform Medicare Advantage and reconstitute the program as Medicare Choice.” No wonder candidates speak in shorthand; this is mind-numbing even for voters somewhat fluent in health-care policy.
In short, “Medicare-for-all” isn’t a meaningful phrase, both because it is not clear what specifics its proponents favor and because in its purest form it’s not going to happen anytime soon. How, then, do Democrats have an informed discussion that doesn’t split the party over a nonsensical argument between a plan they can’t have or define vs. something else?
New vocabulary would help. The “Medicare” part of “Medicare-for-all” is the root of the problem. Perhaps they should return to basics: “health care for all” or “universal coverage,” an old, familiar phrase that people like. (Yeah, everyone should have health-care coverage!)
You can then have a reasoned discussion about how to get there. One idea would be to complete Medicaid expansion and restore Obamacare subsidies; another might be to lower the Medicare age. However, whatever plans they discuss, Democrats should be honest that this is going to cost money — a lot of money. They should be candid about how they intend to pay for it (capping the exclusion of employer-provided health care is one approach) and how they control costs (not simply lower payments to providers, which creates provider shortages and skimpier care). They would do well to make the case that in an era of medical technology unimaginable even a decade ago and the potential to live much longer lives, we should pay more for health care. It’s what some might call a “pro-life” position.
Republicans' notion of dismantling Obamacare and letting people fend for themselves isn’t going to fly, but neither is an undefined, scary-sounding takeover of all health insurance. We should watch to see how Democratic candidates grapple with tough questions. We should see how flexible they are, how honest they are and how they balance competing priorities because — here’s the secret — none of what they present as their perfect plan is going to be the final product. It’s a starting point for a discussion about how to improve health care. The details will change, but what we will be electing is a person to wrestle with these hard questions for which there is no easy, magical fix. We want to see which candidates display the empathy, common sense, economic literacy and political smarts necessary for the job.