Did you know that if liberals get their way and pass Medicare-for-all, you’ll have to actually pay for health coverage for the first time, when obviously everyone now gets it for free?
That was what you would have thought if you knew nothing about health care and listened to the way Jake Tapper of CNN framed the question during the Democratic presidential candidate debate on Tuesday night. And it showed just how difficult it is to have a meaningful, informative debate about a complex policy issue when the media are so determined to focus on squabbling and “newsworthy” moments.
Those moments usually happen when a candidate says something that they’ll be criticized for, often when their comments are taken out of context. So in the debate, Tapper relentlessly demanded to know whether taxes could increase for the middle class if health-care reform was passed, as though that is the only real question worth considering. He asked Elizabeth Warren if she’d have to raise taxes, twice. He asked Pete Buttigieg, also twice. He asked Beto O’Rourke.
And he found the response that under reform, total costs for middle-class people would go down to be totally unacceptable. What mattered was getting the candidates to speak the words “Taxes will go up.” They refused.
But there were important differences between the candidates, differences that they managed to tease out only over the determined opposition of the moderators and the debate format itself.
First, let’s establish some key context. The United States now spends more than $10,000 per person per year on health care, dramatically more than any other country on Earth despite the fact that we leave millions of people with no coverage, which none of our other peer countries do. You absolutely cannot have an honest discussion of what we should do in the future and how we should pay for it without starting with that extraordinary and appalling fact.
Now if I said to you, “I’ll increase your taxes by $2,000 but cut your premiums by $5,000, leaving you $3,000 ahead,” and you replied, “That sounds terrible — I don’t want to pay higher taxes!” we’d all agree it would make you an idiot.
Under that logic, no one should ever want a raise, because earning more money means you’ll have to pay more in taxes, even if it’s only a fraction of your increase in salary. But that’s the implicit logic of all these “Are you gonna raise taxes? Are you? Are you?” questions.
The financing questions aren’t irrelevant, but how we’ll continue to generate the money we’re already spending is one of the less important questions when judging the value of these candidates’ plans. If you think it matters terribly whether a few years from now you’ll chip in your $10,000 via a line on your paycheck under health care or a line under federal taxes, you’re focused on the wrong thing.
So what matters more? Here are some questions to ask of every candidate’s ideas about reform:
- Would everyone get covered automatically, or through a process that takes time to play out and could leave significant numbers of people without insurance? There are single-payer plans that include everyone, public option plans that auto-enroll all newborns and everyone who’s uninsured, and public option plans that don’t auto-enroll people.
- Would we continue to organize the health insurance system through employers (an accident of history) or not?
- Would private insurance continue to exist as a supplement to government insurance, a provider of what is essentially government insurance (as with Medicare Advantage), or something like how it works now? Or would it no longer exist at all?
- Would the cost-sharing (co-pays, deductibles, co-insurance) that generates so much dissatisfaction be eliminated, limited or allowed to continue as it is now?
There’s a temptation to group what these candidates want to do into two boxes, one marked “Dramatic” and one marked “Incremental.” But the more you know about them, the more you see that’s an oversimplification.
For instance, the debate featured a lot of squabbling between former congressman John Delaney and more liberal candidates such as Bernie Sanders and Warren. But if you actually look at what Delaney wants to do, it’s more liberal than what many candidates have proposed, because it puts everyone under 65 into a Medicare-like plan (though you could opt out, and there would be private supplemental insurance). Instead of a public option, it’s more of a public default.
But since he’s at approximately zero percent in the polls and is a centrist in many ways, Delaney had an incentive to get attention by picking a fight with Warren and Sanders. Did that fight actually illuminate anything? Not really.
But here’s a final reality: Since Democrats are serious about health care, all of them are proposing things that would represent large change and a challenging transition. That’s even true of the more moderate candidates such as Joe Biden or Amy Klobuchar, who would still want to create new programs that would insure millions.
Meanwhile, as The Post reports, the White House is “scrambling to create a health-care agenda for President Trump to promote on the campaign trail.” I guess they just realized it might be something Americans care about.
So that’s the choice: essentially the status quo if Trump is reelected, and ambitious reform (with uncertain prospects for passage) if a Democrat wins. You just have to decide how ambitious, and in which ways, you think it should be.