Medium-size reform creates the conditions for bigger things.
Recent state elections — the Democratic landslide in Virginia, followed by Democratic gubernatorial victories in Kentucky and Louisiana — have been bad news for Donald Trump.
Among other things, the election results vindicate polls indicating that Trump is historically unpopular. All of these races were in part referendums on Trump, who put a lot of effort into backing his preferred candidates. And in each case voters gave him a clear thumbs down.
Beyond offering a verdict on Trump, however, I’d argue that the state elections offered some guidance on an issue that has divided Democrats, namely health care. What the results suggested to me was the virtue of medium-size reform: incremental enough to have a good chance of being enacted, big enough to provide tangible benefits that voters don’t want taken away.
Remember, there was a third governor’s race, in Mississippi, in which the G.O.P. held on. True, Mississippi is a very red state, which Trump won by 18 points in 2016. But Louisiana and Kentucky are or were, if anything, even redder, with Trump margins of 20 and 30 points respectively. So what made the difference?
Personalities surely mattered. Louisiana’s re-elected John Bel Edwards was widely liked, Kentucky’s defeated Matt Bevin widely disliked. Demography probably also mattered. Urban and especially suburban voters have turned hard against Trump, but rural voters haven’t, at least so far — and Mississippi is one of the few states left with a majority-rural population.
But there’s another difference among the three states. Kentucky and Louisiana took advantage of the Affordable Care Act to expand Medicaid, leading to steep drops in the number of uninsured residents; Mississippi hasn’t. This meant that voting Democratic in Kentucky and Louisiana meant voting to preserve past policy success, while the same vote in Mississippi was at best about hope for future reform — a much less powerful motivator.
Back in 2010, as Obamacare was about to squeak through Congress, Nancy Pelosi famously declared, “We have to pass the bill so that you can find out what is in it.” This line was willfully misrepresented by Republicans (and some reporters who should have known better) as an admission that there was something underhanded about the way the legislation was enacted. What she meant, however, was that voters wouldn’t fully appreciate the A.C.A. until they experienced its benefits in real life.
It took years to get there, but in the end Pelosi was proved right, as health care became a winning issue for Democrats. In the 2018 midterms and in subsequent state elections, voters punished politicians whom they suspected of wanting to undermine key achievements like protection for pre-existing conditions and, yes, Medicaid expansion.
And this political reality has arguably set the stage for further action. At this point, as far as I can tell, all of the contenders for the Democratic presidential nomination are calling for a significant expansion of the government’s role in health care, although they differ about how far and how fast to go.
Which brings me to the latest development in intra-Democratic policy disputes: Elizabeth Warren’s proposal for a two-step approach to health reform. Her idea is to start with actions — some requiring no legislation at all, others requiring only a simple Senate majority — that would greatly expand health insurance coverage. These actions would, if successful, deliver tangible benefits to millions.
They would not, however, amount to the full Bernie, eliminating private insurance and going full single-payer. Warren still says that this is her eventual intention, and has laid out a plan to pay for such a system. But any legislative push would wait three years, giving time for voters to see the benefits of the initial changes.
Sanders supporters are, predictably, crying betrayal. For them it’s all or nothing: a commitment to single-payer has to be in the legislation from Day 1.
The trouble with such demands, aside from the strong probability that proposing elimination of private insurance would be a liability in the general election, is that such legislation would almost certainly fail to pass even a Democratic Senate. So all or nothing would, in practice, mean nothing.
But is Warren giving up on Medicare for All? After all, what she’s offering isn’t really a transition plan in the usual sense, since there’s no guarantee that Step 2 would ever happen.
The lesson I take from the politics of Obamacare, however, is that successful health reform, even if incomplete, creates the preconditions for further reform. What looks impossible now might look very different once tens of millions of additional people have actual experience with expanded Medicare, and can compare it with private insurance.
Although I’ve long argued against making Medicare for All a purity test, there is a good case for eventually going single-payer. But the only way that’s going to happen is via something like Warren’s approach: initial reforms that deliver concrete benefits, and maybe provide a steppingstone to something even bigger.
Senator Elizabeth Warren, D-Mass., released her plan for transitioning the country to a Medicare For All health care system Friday, splitting the effort into two legislative pushes that would happen over her first term in office, but holding off — at first — on ending the role of private insurance companies.
Instead, she would pass legislation to offer new Medicare benefits to everyone first and then follow up with legislation to end existing employer plans by her third year in office, once the new system has a foothold.”
Hosts: Mark Thompson, Ana Kasparian, Michael Brooks
Her plan is serious, even if it probably won’t happen.
Last week I worried that Elizabeth Warren had painted herself into a corner by endorsing the Sanders Medicare-for-all plan. It was becoming obvious that she couldn’t stay vague about the details, especially how to pay for it; and some studies, even by center-left think tanks, suggested that any plan along these lines would require large tax hikes on the middle class. So what would she come up with?
Well, the Warren plan is now out. And I’d say that she passed the test. Experts will argue for months whether she’s being too optimistic — whether her cost estimates are too low and her revenue estimates too high, whether we can really do this without middle-class tax hikes. You might say that time will tell, but it probably won’t: Even if Warren becomes president, and Dems take the Senate too, it’s very unlikely that Medicare for all will happen any time soon.
Nonetheless, Warren needed to show that she was working the problem. And she did. She brought in real experts like Donald Berwick, who ran Medicare during the Obama years, and Betsey Stevenson, former chief economist at the Labor Department. And they have produced a serious plan. As I said, experts will argue with the numbers, but this is the real thing — not some left-leaning version of voodoo economics.
How does the Warren plan expand Medicare to cover everyone without raising taxes on the middle class? There are four main components.
First, the Warren team argues that a single-payer system would provide significant savings in overall medical costs — more than other studies are assuming. Some of these would come from bargaining down prices, especially on drugs. Others would come from a reduction in administrative costs.
Are these savings plausible? Well, America does pay incredibly high prices for drugs compared with other countries, and the complexity of our system imposes a huge administrative burden — not just the overhead of insurance companies, but the sheer number of people doctors and hospitals have to employ to deal with multiple insurers. I’ve been puzzled at the reluctance of other studies to credit Medicare for all with big savings on these fronts.
And we should note that even with these assumed cost savings, U.S. health spending per capita would remain far above that of other advanced countries. So there’s a case — not an open-and-shut case, but a reasonable one — for optimism here.
Second — and the cleverest item in the plan — the Warren team would basically require employers who are now offering health insurance to their employees to pay the cost of that insurance to the government instead. Bear in mind that large employers are already required by law (specifically, the Affordable Care Act) to provide insurance. So this would just redirect those funds.
Third, state and local governments currently spend a lot on health care, mainly but not only through their share of Medicaid spending. The Warren plan would require “maintenance of effort,” basically requiring that states continue to spend that money, but on supporting a national plan.
Finally, even with all this there’s a significant budget hole. Warren’s team argues that this can be closed in two ways: some further taxes on corporations and large fortunes, and — an important point — strengthening the I.R.S., which we know fails to collect large amounts of legally owed taxes, principally from people with high incomes, because Republicans have starved the agency of resources.
Am I enthusiastically endorsing this plan? No. I still think that a public-option-type plan, which lets people buy into Medicare, would have a better chance of actually becoming reality — and may well be where a President Warren actually ends up if she gets to the White House. And the plan’s optimism on costs and revenues could be wrong.
But this is a serious plan that reflects hard thinking. In particular, it’s nothing like the snake oil that passes for policy analysis on the right, whether it’s the continual insistence that tax cuts pay for themselves or Paul Ryan budgets that assumed that discretionary spending could be cut to Calvin Coolidge levels.
So what has Warren achieved here? Realistically, her health care plan is more aspirational than her other plans. Enhanced financial regulation and universal child care are things she might well be able to accomplish if she not only wins, but wins big, next year. Medicare for All, not so much. And may I say, it would serve the public well if these topics — plus climate change! — got more attention in future debates, and health care a bit less.
Warren’s task was, instead, to counter criticism that she was being evasive on a big issue. I think she has met that challenge.
Kamala Harris proposes a 10-year phase-in for Medicare-for-all.