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.
Joe Biden is offering a return to normalcy. Elizabeth Warren aims to bring big corporations to heel and prop up the working class. Bernie Sanders wants a political revolution.
Kamala Harris’ one-sentence rationale for wanting the presidency is less clear.
Harris, who has now begun fleshing out her policy agenda, told POLITICO in an interview that she’s looking to offer something tangible to voters. She’s pitching herself as the kitchen-table realist of the field, the candidate who eschews lofty speeches and understands the day-to-day financial struggles of regular Americans and, bottom line, wants to put more money in their pockets.
Harris’ plans include big raises for public school teachers, a proposal to pay women equally to men and a tax plan that calls for a $500 monthly credit for families earning less than $100,000 a year. Her paycheck agenda, which one adviser described as a platform of “big tangible solutions,” centers on how Americans are experiencing the economy and is aimed at people whose wages aren’t keeping pace with the cost of living. She’s trying to reach voters who are too often left out of the conversation, with an emphasis on women — and women of color.
Harris said she thinks about the issues she’s taking on in the context of “literally looking at people through the prism of their lives—not some plate glass windows.”
“It’s about solving the problems that keep people up at night,” she said.
“It’s about the value of work and dignity of work and paying people their value — understanding that people are working hard, but they still aren’t able to get through the month and make it with dignity,” Harris added. “And it’s about meeting people where they are.”
Another adviser compared her positioning with the other Democratic candidates more bluntly: Harris is calling for direct payments to families to ease their paycheck-to-paycheck burdens. It’s a simple message they hope will set her apart as a proactive “doer” focused more on delivering immediate results than waiting around for broad, systemic overhauls. “She’s not creating liberal trickle-down policy,” the adviser said. “She’s focused on bottom-line economics, not abstract economics.”
Harris’ big challenge will be breaking through on policy in a way that captivates voters and tells a broader story — about herself, but also what she’s trying to accomplish. Ben LaBolt, a veteran of Barack Obama’s presidential campaigns, credited Harris’ tough stance against Trump, calling it smart. “Democratic voters are looking for a candidate that can take the fight to Trump and win,” LaBolt said.
He noted that Harris had breakout moments during Judiciary Committee hearings when she grilled then-Supreme Court nominee Brett Kavanaugh and Attorney General William Barr to the point that they appeared to trip over their answers.
But LaBolt suggested it won’t be as easy for Harris to stand out on policy. “As the Clinton campaign learned, it is difficult for pragmatism to match or drown out Trump’s provocation in the headlines — and driving powerful and memorable moments to communicate our message will be more powerful than white papers this cycle,” he said.
Harris is betting that her focus on issues people worry about at “3 a.m.” — “when you wake up in a cold sweat”— will pierce the noise. Her next opportunity in front of a national TV audience comes Tuesday night in an MSNBC town hall in South Carolina. Her faith that the approach will catch on is based partly on her own experience and partly on what she’s heard over and over on the campaign trail.
The teacher pay idea, for example, wasn’t planned as a standalone proposal but turned into one because Harris heard from so many educators.
Harris’ platform has taken shape over several months. She laces her stump speech with statistics and anecdotes diagnosing economic disparities: Nearly half of American families are one unexpected $400 expense away from financial distress, she often says, and in 99 percent of the counties in America, a minimum-wage worker can’t afford market rate price of a one-bedroom apartment.
She describes how her late mother, a breast cancer researcher, sat at the kitchen table and shuffled through bills after Harris and her sister had gone to bed. “She was focused on the demands of what it means to keep all the trains moving on time,” Harris said of her mother, who split with her husband early in her daughters’ lives and took charge of raising the children.
Harris’ policy remedies take a page from Democrats who ran during the 2018 midterm election cylce, when pocketbook issues such as jobs, health care, prescription drug costs and infrastructure resonated with voters in swing districts. Her pitch aims to strike at primary voters who want direct action more than changes that could take generations to bear fruit. She’s keeping it simple and avoiding talk of radical change even when the plans include significant changes to government.
In the interview, Harris sought to ground her policies in a broader governing philosophy. She stressed that Americans’ hardships are largely the result of policies written over many decades and designed to favor the wealthy at the expense of working people. She blamed those in power for the lack of meaningful commitments on more affordable childcare, universal pre-K and paid family leave. Even the tax overhaul Trump signed, Harris said, was pushed by Republican lawmakers and interest groups that long pre-dated Trump.
“The spirit behind the tax bill—that is not new. It’s not an aberration,” Harris said.
“A large part of what I do, and I try to do, is to actually see people,” she added, turning her attention to Trump. “And that requires having some curiosity and concern about the condition of the lives of people other than one’s self. And then when you ask the questions and you hear the stories, seeing what the opportunities are to actually bring solutions.”
Democrats mislead voters by appropriating the name of a popular program they actually seek to abolish.
While most of Washington has been obsessed with the Mueller report, serious foreign policy issues are coming to the forefront in these two countries. WSJ’s Gerald F. Seib explains. Photos: Getty
More than 100 House Democrats have endorsed Rep. Pramila Jayapal’s Medicare for All Act of 2019. Fourteen Democratic senators have co-sponsored a similar bill from Sen. Bernie Sanders.
The title is deeply misleading. It implies that the current Medicare system would be extended to all Americans. In fact, Medicare for All differs from Medicare in fundamental ways—with much broader coverage, no cost sharing, and fewer choices of health-care plans. While America needs a debate about health care, it should be based on an accurate description of the alternatives.
Medicare for All would cover a panoply of dental, vision and mental-health services not covered by Medicare. Under the latest version of the House bill, the federal government would also pay for all long-term nursing and home care—estimated by the Urban Institute to cost roughly $3 trillion over the next decade.
The program would replace Medicare, Medicaid and the Children’s Health Insurance Program, as well as all employer-sponsored insurance and direct individual insurance (including the ObamaCare exchanges). It would cover not only uninsured American citizens but every U.S. resident—potentially including illegal as well as legal immigrants.
Despite this substantial expansion of coverage, Medicare for All would not require beneficiaries to contribute premiums, deductibles or copayments. By contrast, most parts of Medicare require some form of cost sharing by patients. Medicare Part B, for outpatient medical expenses, has a standard premium of $1,626 a year with an annual deductible of $185, plus a 20% copayment, according to the official Medicare website.
Because of the broad coverage of services and patients without cost sharing, Medicare for All would entail dramatically higher federal spending on health care than Medicare and other programs. There have been several estimates of the incremental cost over 10 years of Mr. Sanders’s 2016 proposal, which did not include long-term care—$27.3 trillion by the Center for Health and Economy, $28 trillion to $32 trillion by former Social Security and Medicare trustee Charles Blahous, and $24.7 trillion by Emory Professor Kenneth Thorpe. The Urban Institute estimate, which included long-term care, was $32 trillion over 10 years.
Proponents counter that the proposal would reduce federal health-care spending in three main ways—lower drug prices through government negotiations, lower reimbursement rates for medical services, and lower administrative costs by eliminating insurance companies. They also argue the proposal would increase federal tax revenue by repealing the deduction for employer-provided insurance. But these four factors are already built into the previous estimates. However you cut it, Medicare for All would inevitably lead to massive tax increases.
Neither the House nor the Senate bill includes much detail on financing higher federal spending. Mr. Sanders’s staff released a paper in April with revenue options—imposing a premium tax on employers and employees, increasing the top income-tax rate, imposing a wealth tax, closing tax loopholes and so on. But the paper does not address the budget implications of these options or the challenges of getting them through Congress.
Medicare for All would also replace Medicare’s current method of paying fees for services to every hospital, nursing home and other institutional provider. Instead, a new federal board would set an annual budget for each provider, which would receive one lump sum for current operations and another for capital expenditures. That board would be expressly forbidden by current Medicare for All bills from using quality metrics—which would be necessary to prevent providers from skimping on quality with lump-sum payments.
All this would force a radical change in the current business models of most hospitals and other Medicare providers. Although they would generally have discretion over how to spend their lump-sum payments, they could not use them to make “profit or net revenues.” Yet each provider would bear the risk if these payments were insufficient to cover actual costs. Many hospitals would limit the volume or scope of their services until they were sure they would break even for the year.
Finally, Medicare for All would eliminate the plan choices Medicare now allows. Elderly Americans don’t have to get outpatient or drug coverage from the government. Some opt to stay with their employer plans and others choose private providers through Medicare Advantage. Medicare for All would prohibit any insurer or employer from privately offering any services covered by this legislation—which means essentially all medical services.
Medicare for All allows even less in the way of plan choice than other single-payer systems. In the United Kingdom, patients may purchase private insurance for medical services even if they are available through the National Health Service. Canada does not cover dental, vision or long-term care, so two-thirds of Canadians purchase these services through private health insurance.
In the coming debate over health care, the label “Medicare” should be reserved for proposals that are built on the existing structure of this successful program. Whatever else “Medicare for All” may be, it isn’t Medicare.
Various proposals are floating around, each of which would change the health care system in distinct ways. Some, like one from Senator Bernie Sanders, would do away with all private health insurance. Some would make small expansions in existing public programs. Some would try to cover all Americans through a mix of different insurance types.
It can be mystifying when people call all of these ideas “Medicare for all,” as some in the debate have been doing.
.. Private plans handle Medicare drug coverage, and you can choose among options. You pay premiums each year, and you pay deductibles and co-payments when you use medical services.
Because the program’s out-of-pocket spending has no limits, most Medicare beneficiaries also buy private supplemental insurance to limit those costs. That insurance doesn’t cover medical services outside the Medicare system, but it helps pay the patient’s share of the bill when a person goes to the doctor or hospital.
.. Mr. Sanders, who prominently featured such a plan in his 2016 presidential platform and just announced he has joined the 2020 race, uses this term a lot. His plan would both expand traditional Medicare to cover all Americans, and change the structure of the program, to cover more services and eliminate most deductibles and co-payments. So the Medicare everyone would be getting would differ in crucial ways from the Medicare older people get now.