Medicare for All in an alternate universe

I would have preferred Medicare for All in an alternate universe where John Kerry or Al Franken were the individuals who were the last necessary vote instead of Ben Nelson or Joe Lieberman.  I would have preferred Medicare for All in a universe where the marginal coalition member in the 2009-2010 House was a member of the Progressive Caucus instead of either a New Dem or a Blue Dog.  But neither of those conditions were met, so we got the best that could be gotten plus or minus a little bit of wiggle room.

However, I want to carry out a thought experiment that assumed Medicare for All was rolling out Jan. 1 2014 and look at some of the headlines that would be on the major newspapers and op-ed pages:

Big City General is laying off 500 staffers

 Big City General Hospital has announced five hundred layoffs as reimbursement rates have declined dramatically as commercial insurance is being phased out.  Medicare pays significantly less than local insurers.. Big City General promises that patient care will not be compromised.


Local labor unions are furious

After spending seventy years negotiating an extensive benefits package for its members, Local 1982 of the IBEW is preparing to cancel its health insurance contracts and move all of its members to the govenrment run Medicare program effective 1/1/14.  Joe Roemer, 53 of North Nowheresville, a diebetic, is not looking forward to paying premiums or deductibles for the first time in his life.

What new taxes will you see soon

Medicare for All is going live in five weeks and that means we’ll have to pay for it too.  What new taxes can you expect to pay in the New Year — next on News Channel 8….

Any major system change in 17% or 18% of the economy is massively disruptive.  Handwaving that disruption away in the scenario that a favored hypothetical policy passed is infantile.

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62 replies
  1. MomSense says:

    What about all the newly unemployed insurance company workers and the people (teachers, union members) invested in insurance companies. There is no way that we could transition in just a few years.

  2. Ash Can says:

    Yep. Newsies have been apoplectic enough over a website crash. Imagine their reaction to a really big change.

  3. Betty Cracker says:

    @MomSense: True. I remember Hillary Clinton (as 1st Lady) doing some townhall type thingie on HillaryCare 20 years ago and taking a question from someone who worked for an insurance company who was worried that her job would be eliminated. HRC said something to the effect of, “A bright young woman like yourself can find work in another sector,” which caused all sorts of consternation.

  4. Ted of Baltimore says:

    Thank you, Richard. I’ve been wondering why this is has never been brought up in the never-ending public option/single payer debate. This is something I’ve been wondering about — has there been a society that overnight transitioned from employer-subsidized health insurance to single-payer? Has anybody proposed a mechanism for transitioning to single-payer where people with good employer-subsidized health insurance wouldn’t suddenly find themselves several thousand $ out-of-pocket?

  5. dr. bloor says:

    Point taken about the disruptions caused, but let’s be careful to distinguish between real disruptions caused by the shift and those “reported” in the press for the sake of selling newspapers. I can think of a couple of Big City Generals that have shut down all together in recent years because they were getting killed by decreasing reimbursements from insurers along with declines in state funds to cover care for the uninsured. Losing 500 workers looks pretty good by comparison. Also, the idea that Joe Roemer of North Nowheresville isn’t already paying premiums and deductibles with his union plan is…naive.

  6. HinTN says:

    Carry that argument to the dismantling of the Military Industrial Complex, which could be construed as white collar welfare. Unwinding that sucker without chaos in the employment markets will be tricky.

  7. MomSense says:

    @some guy:

    Really, do you not know that there are people who have been teachers and ministers and other obviously greedy 1% ers who have retirement funds that are in insurance companies. Do you really want them to get screwed over?

    It takes time to unwind almost 20% of the economy.

  8. Shrillhouse says:

    OK, how about these hypothetical headlines:

    “Medicare-for-all has dramatically cut costs and improved patient outcomes: study”

    “New study reveals a surge in entrepreneurship as workers no longer dependent on employer health plans”

    “Massive drop in personal bankruptcies linked to Medicare expansion”

    There’s another side to this (hypothetical) story….

  9. pluege says:

    so we got the best that could be gotten plus or minus a little bit of wiggle room

    this is wrong. it was obama that killed the public option without pressure from anyone except his corporate overseers from the insurance industry and Big Pharma

  10. Suffern ACE says:

    But people in the individual market would be happy not to have choices. And everybody was so mad at Kaiser and Humana they would be glad to make these changes.

  11. jon says:

    All the people whose employers pay large amounts of their premiums would not like to see what would happen if Medicare E(veryone) came on board. Companies would be unlikely to immediately give that entire amount to the employees, because why would they? Yes, some would. But the individual tax structure and corporate tax structure could very well be from different nations (and states, localities, and cetera.) The whining from all sides would be tremendous. It wouldn’t be entirely a bad thing, but there would be enough bad things involved in such a change to make headlines until people actually have a chance to decide for themselves whether they do or don’t like the change.

    I want Medicare for All, but there’s enough inertia in both the old status quo and the new status quo to make that change, as logical as it is, difficult. And that’s the understatement of the year.

    But since a website isn’t ready, some pretend the difficult is impossible. The Moon Landing didn’t take a website to work. The Civil War wasn’t won by the side with the better website. Paul Revere didn’t even have a tumblr or twitter page. Next time you hear someone cry that the website isn’t working, send them a pdf of the 12-page application form (available on the website.) Or use Benjamin Franklin’s Postal Service.

  12. MomSense says:


    Why would big pharma want to kill the public option? Even the version of the public option that passed the house was problematic because it did not tie reimbursement to Medicare – meaning the public option insurance would have to reimburse at higher rates. That combined with the income restrictions made it a really weak option. But I know for a fact that it was Max Baucus who did not want the public option. When the Senate Finance committee was working through it, Olympia Snowe was trying to keep the public option–although her version was so convoluted that it really wasn’t a public option anymore.

  13. Davis X. Machina says:

    As long as we’re doing purely hypothetical headlines:

    Average American liberal finally figures out differences between Medicare for all, single payer, public option

  14. Davis X. Machina says:

    @MomSense: That combined with the income restrictions made it a really weak option.

    Little-known fun fact… ‘Shibboleth’ is actually the ancient Hebrew word for ‘public option’…

  15. different-church-lady says:

    OK, here’s a question: am I right or wrong to think that it’s insane 17-18% of our economy is health related?

    One the one hand I look at my own income stream and think, “Shit, close to 20% of my income is supposed to go to medical expenses? That’s crazy.” Especially since I am on the relatively healthy end of the scale.

    On the other hand, I think, “Health is pretty fundamental, maybe it ought to account for a large percentage.”

    Maybe we’re caught in a temporal dilemma: 100 years ago it wouldn’t have made sense to spend that much on your healthcare because medical technology couldn’t actually do that much for you.

  16. japa21 says:

    Yes, there would be major disruption, but not all the disruption referred to. Yes, some insurance companies would suffer, but many would go along just fine. Currently, the number of Medicare Supplemental plans out there would probably increase. Also, Medicare Advantage plans would still exist and probably increase in number. So insurance companies would still exist and do fairly well.

    But other things are also important to notice:

    1) Car insurance rates would go down drastically.
    2) Homeowners and renters insurance rates would also go down.
    3) Workers’ Compensation rates would decrease significantly.
    4) Companies would have more cash and they would have to increase employees’ salaries as a result or there would major labor force upheaval.
    5) Overall health care costs would decrease significantly.
    60 Not sure just how badly hospitals would suffer. Yes to some degree, but they would be receiving compensation on a higher percent of their patients with reduced accounts receivable and increased cash flow.

    But there is little doubt that the media would focus on everything bad and none of the good outcome aspects of it.

    Regarding the public option. Obama stayed with that as long as he could. When it was obvious that it wasn’t going anywhere and continued pushing for it jeopardized anything being passed at all, it was dropped.

  17. different-church-lady says:

    @Shrillhouse: I think that what Richard is saying is that in his alternate reality the headlines we’d see would focus on the negative just as much as today’s real reality.

  18. cleek says:


    obama that killed the public option

    prove it.

    and then prove the 60 Senate votes were there for the public option. show us the names of the Senators who would have voted for it.

  19. Citizen_X says:

    Thank you. There’s been entirely too much glibness from many on the left as well. “Simple answer: single payer for all. Done!” Way too cheap a response for something that would change the way the majority of Americans get their healthcare.

    Yes, “Clap louder” is not a good response to Obamacare’s problems. But I fail to see how “boo louder” will do anything but aid the Republican saboteurs.

  20. Davis X. Machina says:


    But I fail to see how “boo louder” will do anything but aid the Republican saboteurs.

    It will boost my progressive cred, and impress the people I hang with. It’s not much, sure, but it’s something

  21. Suffern ACE says:

    @different-church-lady: It is crazy to spend that much. But when no one on our side bothers to write about that craziness, it’s not too hard to understand why people aren’t aware of the looting.

    #100 dailyhowler postings from 2008-2012.

  22. Shakezula says:

    Medicare pays significantly less than local insurers.

    I assume you mean private (not local) and this is becoming less and less true as time goes on. Medicare doesn’t pay significantly less on average and many private payers set their rates based on what Medicare pays.

    @MomSense: Medicare contracts out its claims handling, provider/patient communication, everything else insurance companies do to … private insurers. For example one of the Blues has the Medicare contract out in my neck of the woods. You’d likely see an increase in employment at private insurers since every single American would now have health care coverage.

  23. Lawrence says:

    One way to avoid the system shock described is to temporarily transition claims processing and administration to existing private carriers. That’s how Medicaid is run in Arizona. There would be a ramp up of capacity in the Medicare system, and drawdown of capacity in private insurance, which could be managed by a transfer of existing workers. The “your taxws are going up” could be offset by “your employer stops taking money from your check to buy insurance”.

  24. FlipYrWhig says:

    @Suffern ACE: I wish Bob Somerby had kept chewing on that bone instead of whatever the fuck he turned into where his incessant complaint is that liberals in the media call racists racists.

  25. MomSense says:


    There’s another side to this (hypothetical) story….

    …that will never be covered by our failed media experiment in this or any other universe.

    @Davis X. Machina:

    You are killing me this morning! Now I have to figure out how to get coffee with cream out of my keyboard.

  26. Richard Mayhew says:

    @Shrillhouse: Those may be real benefits, but will they get on the news as the benefits are extraordinarily diffused while costs are concentrated in a demographics that have media access.

  27. Richard Mayhew says:

    @cleek: hell prove there were 218 solid yes’es in the House for the public option at any point as that should be an easier task given there was some wiggle room in the House.

    Push come to shove, I don’t think those votes were there. I think there may have been a solid 185 to 195 but not 218

  28. Shakezula says:

    @Lawrence: This is how Medicare & Medicaid are run all over. This work is all contracted out to private insurers.

    I’m not saying that Medicare For All was going to happen, but objecting to it on the grounds it would put insurance companies out of business and result in people losing their jobs is not a fact based objection.

  29. DanF says:

    This was my thinking as well. The economy was in the shitter – the last thing you want to do is put 10% of your workforce on pins-and-needles. We can agree that they are parasitic, but they need to be detached slowly so as not to shock the patient. I expect we’ll move slowly to a medicare option or some form of a national, not-for-profit insurance entity.

  30. MomSense says:


    It is not all contracted out to private insurers. I am in regular contact with state employees who administer Medicaid. Some is contracted out and some isn’t.

  31. ruemara says:

    Thanks, Richard. This was the inherently unworkable aspect to Medicare for all. I like it, but I wondered how the loss of such a massive shift would be handled with the legislatures we have.

  32. Matt McIrvin says:

    Here’s an actually pretty good article from Ezra Klein, exploring a different alternate universe: the one in which Paul Ryan’s 2009 health-reform proposal was enacted instead.

    He points out that the things that are getting the most heat about the ACA (the exchanges, the disruption to existing health plans) are also present to an even greater degree in Ryan’s plan, whereas the things that are actually working great in the ACA are aspects that Republicans would never countenance.

  33. TriassicSands says:

    @Betty Cracker:

    “A bright young woman like yourself can find work in another sector,” which caused all sorts of consternation.

    And that statement is much less true today than it was in the nineties.


    There’s another side to this (hypothetical) story…

    I think there is some truth to that, but the problem would be that Richard’s headlines would almost certainly precede yours by quite a bit. There are short-term consequences and long and with the fickleness of Americans and the general operating principle that it would be a disaster if ten million new insured came at the cost of an 2% increase in my monthly premiums, even if my insurance was 25% better, the disruption Richard predicts would not be prevented by the promise of future benefits. Americans aren’t good at waiting for good things to happen; they’re much better at wailing about something bad happening, even if relatively minor, today.

  34. Yatsuno says:

    @Ted of Baltimore:

    This is something I’ve been wondering about — has there been a society that overnight transitioned from employer-subsidized health insurance to single-payer?

    No. Never. Canada took over 20 years before the Health Act passed. South Korea (which is an 80/20 cost split) took 15, and that was considered miraculous. No country ever has because it’s such a huge change. There is always a transition law. ACA, for all its quirks, is that transition law.

  35. Matt McIrvin says:

    …in fact, Ryan’s Republican alternative would have very likely eliminated employer-based insurance plans by removing their favorable tax treatment, and kicked everyone with employer-based health insurance onto the exchanges! I can only imagine the chaos.

    He’s still trying to replace Medicare with an exchange-based private system. Yeah, that’ll fly.

  36. Richard Mayhew says:

    @dr. bloor:

    Dr. Bloor — there are some very, very nice union plans out there. I know UPS national insurance has a $5 co-pay and no deductible and no premium share (all hidden from the worker). I know the insurance that my parents have had for 30 years had no deductible for in-network care (they’re both union).

    These are the Cadillac plans. Are they extraordinarly common for union workers? No, but they exist and they provide one hell of a news hook.

  37. mclaren says:

    But neither of those conditions were met, so we got the best that could be gotten plus or minus a little bit of wiggle room.

    “We got the best that could be gotten” because Democrats and president Obama lacked basic negotiating skills and a spine.

    Here’s how you get the public option:

    [Step 1] The president of the united states goes on national TV to declare a national emergency. He says he’s nationalizing the U.S. health care system by executive order to prevent the holocaust of 45,000 people per year dying from lack of insurance and to regain economic competitiveness to overcome the 2008 economic meltdown.

    [Step 2] Republicans and the AMA and every nurse and medical devicemaker in America go berserk. They threaten Obama, give hysterical interviews, scream for impeachment, and call for a mass armed uprising.

    [Step 3] Obama announces that he’s willing to compromise. Instead of nationalizing the entire U.S. health care industry and pressing all doctors and nurses into compulsory military service at milnimum wage by executive order, he thinks it might be possible to work out an alternative: single-payer public option.

    [Step 4] The Republicans foam and froth at the mouth, introduce impeachment resolutions, doctors burn Obama in effigy, nurses show up with AK-47s at hospitals and placards reading WE ARE ARMED AND DANGEROUS. Medical devicemakers and hospitals and doctors’ groups blanket the airwaves with smear campaigns screaming SO-SHUL-IZM!
    The Democrats express incredulity. How can the Republicans and the doctors possibly object? After all, we’re being reasonable — we’ve offered a compromise.

    [Step 5] Public pressure and beltway media pressure builds for the “grand bargain,” the great compromise — single-payer national health care. Relucantly, doctors and hospitals and nurses’ groups and medical devicemakers and insurers and the AMA and Republicans find themselves forced to accept the “grand bargain” of single-payer national healthcare in preference to the executive order nationalizing all U.S. health care and impressing all health care workers into the military at minimum wage.

    This is how it becomes “politically possible.”

    But you can’t make single-payer national health care “politically possible” by starting out your health care negotiations with the insurers and hospitals and AMA and nurses and doctors’ groups and Republicans by saying, “Okay, single-payer is off the table.” That’s not a negotiation. That’s giving in to your opponent’s every demand. Obviously if you give in to your opponent’s every demand, single-payer is not “politically possible.” But if you give in to your opponent’s every demand, nothing is politically possible.

  38. Fair Economist says:

    Touche, Richard.

    Here’s how you get the public option:

    [Step 1] The president of the united states goes on national TV to declare a national emergency. He says he’s nationalizing the U.S. health care system by executive order to prevent the holocaust of 45,000 people per year dying from lack of insurance and to regain economic competitiveness to overcome the 2008 economic meltdown.

    mclaren, you’re as out of touch with reality as the Republicans are. The President can’t do anything like that.

  39. JMG says:

    Americans hate and fear change (all people do, but we do more than others). A country violently opposed to the metric system is never going to institute reforms except in the most halting and sporadic way even in the face of catastrophe, as with financial reform.
    When it comes to medical care, a subject which evokes the most primal of fears for damn good reason, that goes times zillions. Add to that the widespread belief that government action to help others must of necessity screw me, and it’s a miracle Obamacare or any health care reform polls at better than single digits. It’s a tribute to the dysfunction of the current system.

  40. Tissue Thin Pseudonym (JMN) says:

    @mclaren: Obama would be impeached because he really had done something that is legitimately impeachable. Making the threat to nationalize the health care system would not be credible, because it would be very, very illegal. So your entire fantasy falls apart at the first step.

  41. Sherparick says:

    @mclaren: Yes, I like this idea. It avoids 40 years of grassroots activism and the tedium of endless hours going door to door and endless meetings with boring people complaining about all the aches and pains in their livesand allows me to promptly get back to reading Game of Thrones and playing Madden NFL on my smartphone since I have contracted out all the political work the Green Lantern, a/k/a Barack Obama. Great idea. To bad you didn’t send it to Obama 5 years ago.

  42. mere mortal says:

    Decrease the Medicare eligibility age by one year, every year.

    Almost zero disruption, takes the least attractive risk pool out of the private insurance market every year, and gives health insurance companies more than two decades to figure out something socially productive to do with their capital.

    Not as good as single payer off the bat, but it gets there.

  43. different-church-lady says:


    A country violently opposed to the metric system is never going to institute reforms except in the most halting and sporadic way even in the face of catastrophe…

    I know what you’re saying, but you shouldn’t poo-poo the idea of how strongly people will react when you screw with their frame of reference on things as basic and frequent as common measurements.

  44. Steve Crickmore says:

    Because of blue dog, red state and Republican federal intransigence, a national single payer healthcare system will always face insurmountable political obstacles at the national level. However, the way to influence and move national public opinión is, by example, that is from the three states that have heavy majority Democratic state legislatures with Democratic governors. Although there are 14 states in the US in 2013, both with Democratic governors and Democrat State Houses, only three, Rhode Island, 69 Dems, & 6 Republicans. Hawaii 44 Dems 7 Republicans and Massachusettes, 130 Democrats and 30 Republicans which have huge the state houses, that are practically electorally-proof from the Republicans. Each of these states also have huge majorities in the Senate. These three states, if they enact single payer as an effective model, plus Vermont who don ‘t have a whopping Democratic majority in the House but are already committed to single payer, could make single payer or medicare in ten to fifeeen years, seem like the unforseen acceptance gay marriage now in 2014, a favorable public policy issue, in all but the most extreme parts of wingnut America.

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