Sen. Bernie Sanders (I-Vt.) introduced the latest iteration of his Medicare-for-all health-care plan this week, and as it happens, four of Sanders’s 2020 Democratic rivals are co-sponsors of his bill. But as we’ve learned, that doesn’t mean it’s actually their preferred health care solution. Many of them seem more inclined to support plans that I’ve termed “Medicare For Anyone,” the difference being whether the government plan covers everyone or covers anyone who wants to join.
As the person who has been advocating more radical health-care reform for longer than the other contenders, Sanders is anchoring the debate, and his plan raises questions about both policy and politics that every candidate will have to grapple with.
Among other things, Sanders’s single-payer plan has the virtue of simplicity. Here are the basics:
- Everyone in the country would be enrolled in a government health insurance plan akin to Medicare — but better.
- There would be no premiums, co-pays, deductibles or other cost-sharing (with some small exceptions).
- It would cover pretty much everything, including things such as vision and dental care that are now excluded from many insurance plans.
- You wouldn't have to worry about losing your doctor, because with the possible exception of "concierge" practices serving the rich, every doctor would accept it; there would be no more networks that don't include the doctors you want to see.
- Private insurance wouldn't be outlawed, but it would become mostly unnecessary.
- The government plan would negotiate lower prices for prescription drugs.
- It would be funded with some combination of new taxes, but since you won't be paying premiums or any other costs, most people will pay less than they do now.
Now let’s consider the policy and political questions. Barack Obama used to say that, if we were starting from scratch, he’d favor a single-payer plan, but since we aren’t, he didn’t. Sanders essentially argues that if you believe a single-payer plan would be superior, then that’s what we should shoot for, whatever the obstacles. And there are reasonable arguments for why it would be superior just from a policy perspective.
Some of the most compelling have to do with simplicity and cost. We pay far more for health care than those in any other high-income country in the world, in part precisely because we have a decentralized system with lots of middle men extracting money while costs just get passed down the line. A centralized system would eliminate a lot of the bureaucracy associated with having all those complicated insurance plans.
But the most important reason we pay so much is prices. Why does an MRI cost more than $1,000 in the United States, but only around $200 in Australia? The short answer is regulation: If the government can say, “This is what we’ll pay and no more,” then providers have to accommodate themselves to that, and it turns out they figure out how to do it. There aren’t a zillion imaging centers making doctors rich in the U.S. because we just need more scans than Europeans or Asians do. They’re there because in our system, there’s so much money to be made.
Which of course means that there are a lot of wealthy, powerful interests who will do anything to prevent stricter regulation, whether through a single-payer plan or something else. So, as the other candidates consider precisely what they want to advocate, they’re wondering about potential opposition both from interest groups and from ordinary people afraid of rapid change. One reason some gravitate toward Medicare For Anyone plans is that, while they would constitute a significant change, they wouldn’t be as sweepingly disruptive to the entire system as a single-payer plan would. There could be a slower transition, and the opposition might — might — be less intense.
The advocates of Medicare For Anyone believe that because it would be voluntary, it would be less susceptible to the “Democrats are gonna take away your coverage!” attack that will inevitably come from Republicans. That might or might not be true in the end, but it’s certainly possible. Sanders’s counter is that nobody really likes their insurance; what they like is their doctors. He may be right about that, but it doesn’t mean people aren’t still powerfully afraid of losing what they have, even for something that promises to be better.
That brings us to a final political question. Sanders wants to keep the filibuster, which would make passing any of his ambitious legislation impossible. There is zero chance Democrats will have 60 seats in the Senate in 2021, and Sanders has expressed the bizarre belief that numerous Republicans will vote for a policy they despise because a president they despise got elected advocating for it. This flies in the face of everything we know about the Republican Party and contemporary American politics.
After being ridiculed about that for a while, Sanders now says he’ll just have his vice president, presiding over the Senate, rule that anything he wants can be passed under reconciliation rules that require only 50 votes, a highly questionable strategy.
So all the candidates are going to have to answer these questions: What's the best system? What's the best system we can reach given how the current system works? What's the plan to get it passed through Congress with a Republican Party and a group of powerful interests that will fight it with all their might?
None of those questions have easy answers. But Sanders has put down his marker. Now it’s time for the other candidates to respond.