“I’m not a big fan of Medicare-for-all,” Pelosi told Bloomberg TV on Friday. She cited the cost. She noted the “comfort level that some people have with their current private insurance.” And she cautioned, “Remember November.” Pushing Medicare-for-all “would increase the vote in my own district,” the California Democrat said, “but that’s not what we need to do in order to win the electoral college.”
Indeed. For years after passage of the Affordable Care Act, Democrats paid a steep, and unfair, political price for enacting the law. Then the electoral calculus flipped. Health care became a political winner for Democrats, and the Trump administration offered the party a gift with its continuing crusade against the ACA.
A smart party would seize this opening and go on the offensive against the Republican effort to take popular coverage away from millions. Instead, the Democratic presidential field is immersed in a destructive internecine battle over the wisdom of a massive entitlement expansion. Imagine President Trump hammering Democratic nominee Warren in a general-election campaign. He would accuse her of plotting to take away your private insurance, dangerously hiking federal spending and, citing Warren’s primary rivals, ultimately socking the middle class with a tax increase when she can’t raise enough otherwise.
The wonk in me wants to pause to give Warren credit for laying out what she thinks this overhaul would cost and how she plans to pay for it. The wonk in me also needs to point out that Warren’s numbers are fanciful. The Urban Institute, no conservative bastion, has pegged the added federal spending of Medicare-for-all at $34 trillion over 10 years, about 65 percent more than Warren’s $20.5 trillion price tag. By way of comparison: The total projected federal spending over the coming decade is $43 trillion, plus $14 trillion for Social Security.
Warren’s generous benefits make her chief rival in the Medicare-for-all sweepstakes, Sen. Bernie Sanders (I-Vt.), look miserly. No one, no matter how much they earn, would have to pay for health care, and they get long-term coverage, too. In Warren’s imagining, her plan is not just a middle-class tax increase, it would be, at least on paper, a huge gift to middle-class taxpayers. Health-care consumers would have no skin in the game: no premiums, no deductibles, no co-payments.
But the Warren plan is festooned with magic asterisks. Warren assumes she can wring enormous cost savings out of the system, lowering payments to doctors, hospitals and pharmaceutical companies far beyond what the Urban Institute considered feasible. And she imagines paying for it all not only by heaping new taxes on the ultrawealthy but also by beefing up tax enforcement. Great idea, but Warren assumes she could bring in another $2.3 trillion that way. The Congressional Budget Office projects that increasing Internal Revenue Service enforcement by one-third would reap just $35 billion over the next decade.
Is all this necessary — or are there other, far less disruptive ways to expand coverage and drag down costs? Yes: Let those 55 and older buy into Medicare; create a public option in the existing exchanges; reduce drug costs by letting Medicare negotiate prices. Do Americans want to have their existing insurance taken away? It doesn’t look that way. Recent polling by the Kaiser Family Foundation found that while a bare majority, 51 percent, said they supported a Medicare-for-all system — a number that is trending down — even more, 55 percent, thought that system would still allow them to keep their current insurance. What happens when Warren informs them — the 177 million who would lose their current insurance — otherwise?
Finally, even if all this were achievable, legislatively and practically — both highly doubtful — would no-cost, no-limits health coverage for all be the best way to use the massive sums Warren is proposing to spend? Or are there other worthy priorities that we should be debating — fixing crumbling infrastructure, improving public education, mitigating the impact of climate change?
But here we are. Warren took the bait from her Democratic rivals. She has a plan for that. Now she needs another one — how to get that hook out of her mouth if she becomes the Democratic nominee.