Everything is awesome until there are trade-offs

Early this year, Kaiser Family Foundation released a poll showing Medicare Advantage was popular:

(56 percent) favor a national Medicare-for-all plan

There is a fairly typical partisan split on all of these proposals. Buy-ins are more popular than replace the entire system plans. Incidentally that is why I think a Medicare/Medicaid buy-in approach is what will be on a Democrat’s agenda if there is a blue trifecta.

However, Kaiser then did something interesting. They offered trade-offs and support for Medicare for all sank:

This is the political problem for Medicare for All proponents. It is a massive change to the system which will produce winners and losers. It upsets the status quo bias that worked against the ACA 2009-2016 and it upsets the status quo bias that worked for the ACA in 2017 to present.

Managing the transition so that there is no fear that anyone could, in anyway, be worse off or perceive themselves to be worse off is impossible. The challenge is minimizing both the number and the power of people who are worse off or perceive themselves to be worse off. And that is a tough challenge if one assumes that healthcare is, to some degree, a positional good.

Trade-offs are tough. Passing out free ice cream is easy.

25 replies
  1. 1
    jonas says:

    Good points, David. As we saw with the rollout of the ACA, the people who would probably be negatively impacted by a move to a single-payer system (higher taxes, longer wait times) have a lot of political power/voice and would be willing to use it, while the people who would benefit the most (minorities/poor) are also the least inclined to make political noise to protect their interests. Which is why I just don’t see MFA happening anytime soon. I think the best Dems can do in the short term is promise to continue pushing for Medicaid expansion and build the ACA out with better subsidies.

  2. 2
    BobbyK says:

    This is what pisses me off about these questions especially the one about higher taxes. Maybe someone should inform people they wouldn’t lose their health care if they lose their job with M4A, but that little nugget never seems to get communicated. Yes I have really good health insurance, however if I lose my job (entirely possible) I have no health insurance.

  3. 3
    Barbara says:

    If you read the comments yesterday about California you might be clued in to how deficient Medicare actually is as a benefit plan. What Medicare has is political commitment. I am convinced that “Medicare for All” is a slogan that evinces a desire for comparable commitment to universal care that goes beyond the elderly. Because if you actually understood how Medicare works, you would not be so keen to replicate it for everyone.

  4. 4
    Ohio Mom says:

    @BobbyK: My standard answer for when people (especially people I suspect have absorbed Republican talking points) complain about taxes is to agree with them, they do pay too much in taxes. Their faces relax, they feel heard.

    Then I follow up with, The reason you pay too much is that the wealthy pay way too little.

    Immediately, they are confused and boy, you can see it in their faces. I follow up with a short bit of some solid info, maybe a description of earned income vs. investment income (I like the Buffets story about paying a lower rate than his secretary) or the “death tax,” and they usually can’t absorb any of it.

    It’s just a game I play for my own amusement but I also keep in mind that people typically need to be exposed to information a number of times before it’s learned.

    The key is to start by empathizing with them.

  5. 5
    OzarkHillbilly says:

    Eliminate private health insurance companies

    Is this even a serious consideration? I mean, other than in Wilmer’s world?

    Threaten the current Medicare program

    How? How could expanding it threaten it?

    Lead to delays in getting some medical tests and treatments

    Sure, so will doing absolutely nothing.

    Require most Americans to pay more in taxes

    DUH! But consider that no one will have to pay the thousands of dollars they currently do for private insurance.

    These are all Republican shibboleths, each of them having some small nugget of truth behind them but blown way out of all proportion to what reality will actually look like.

  6. 6
    Starfish says:

    I am growing more skeptical of the delays in medical care being discussed. There were a lot of people fearmongering about delays in other countries making it seem like people were waiting months for essential surgeries. The delays to be seen by a specialist in the US if you are a new patient not in an urgent situation is usually months so we are living with delays in the current system. However, when you are a patient of those specialists, some of those clinics look positively sleepy.

  7. 7
    Spanky says:

    @OzarkHillbilly: Well, you saved me a lot of typing. No doubt Kaiser neglected to remind respondents that as a private insurance company they have a large vested interest in how (or if) Medicare For All is rolled out.

  8. 8
    Starfish says:

    @BobbyK: When given the option to pay for taxes, no one wants to pay, and everyone wants free ponies. Here in Colorado, over half the public schools are down to four-day school weeks rather than people paying their damn taxes and sending kids to school for five days a week. That expands the inequality. The poor may not be able to fork over that child care expense for that fifth day so they cannot take any jobs that require people to work five days.

  9. 9
    Spanky says:

    Also too, per one retirement/Medicare wonk:

    Run an internet search for “Medicare for All and seniors,” and you’ll see plenty of posts explaining just how harmful single payer health care would be for retirees.

    The Medicare for All debate is just starting, with many questions yet to be answered. But don’t be too quick to assume that Medicare for All would take away something that seniors enrolled in the current Medicare program now enjoy. Just the opposite: The proposals circulating in both the House and Senate would improve Medicare by eliminating the program’s most glaring coverage gaps for long-term care insurance, and for dental care, vision and hearing. The bills also would eliminate cost-sharing, meaning that one of traditional Medicare’s weakness would be gone–the absence of a cap on total out-of-pocket spending.

  10. 10
    Barbara says:

    @Spanky: KFF isn’t Kaiser Foundation Health Plan. It’s the Kaiser Family Foundation. It has nothing to do with the health plan. It’s probably the single most credible source of actual information about public and private health care programs that you can get without spending money. Its interactive presentations on how each proposed ACA repeal bill would affect individuals by age, income, and county of residence probably did more to inform average people and journalists than any other available resource.

    The only path to a result that looks like Medicare for All is through incremental change.

  11. 11
    Barbara says:

    @Spanky: Eliminating all cost sharing would be tough, but putting a cap in place to limit total annual out of pocket spending is definitely overdue.

  12. 12
    Betty Cracker says:

    I get what you’re saying, and it’s true that trade-offs are difficult and no one should minimize the scope of the challenge to reform or remake a system as complex as healthcare funding and delivery. At the same time, maybe dismissing a movement to address the inequities of that system as so much clamoring for “free ice cream” is a tad condescending?

  13. 13
    TomatoQueen says:

    Medicare can go fuck itself. My father (frail, 88) is caught in a Medicare trap (3 days observation status, NOT admitted status, so Medicare won’t cover his needed short stay in a rehab facility, even at lower rates, and of course I can pay the daily rate of $300 to $500 at two weeks’ payment upfront) of their own making, he’s well enough not to need admission but not to be released from the hospital because he needs 24 hour care. It makes no sense. I’ve told the hospital they can whistle. Medicare can go fuck itself.q

  14. 14
    Ruckus says:


    Because if you actually understood how Medicare works, you would not be so keen to replicate it for everyone.

    I start from the point that Medicare is far, far better than nothing, which is what seniors had and what they would still have. It also worked better when medicine was simpler. No heart transplants, no pacemakers, no……. Medicine in my youth was far simpler, far cheaper. It also didn’t have the outcomes that it now has. Think joint replacements. They are a common thing nowadays. Seemingly half the people I know have them. How long ago was it that almost no on got them? Pacemakers. My friend who passed away 2 yrs ago had one. In 1972. The first successful pacemaker implant was 1968. My friend was an experiment because they didn’t expect her to live. She didn’t mind it gave her decades.
    So today medicine is much more than it was for the first half of my life. It is also dramatically more expensive.

  15. 15
    Barbara says:

    @Ruckus: Well of course it is better than nothing. But the way Medicare fee for service is organized now reflects the way Blue Cross plans were organized in 1965. Medicare is one of the main reasons why there has been runaway inflation in the U.S. health system, because it is siloed, normalized fee for service medicine and defies efforts at rationalizing utilization and payment models. It has very good beneficiary protections and those are worth importing into other models (e.g., no outrageous balance billing). 40% of Medicare beneficiaries receive care through private Medicare Advantage plans. Most of the rest buy private insurance through Medicare supplemental plans.

  16. 16
    Barbara says:

    ETA: Its way of paying physicians has singlehandedly devalued primary care physicians and fast tracked the desire to specialize. Medicare is deeply embedded into the fabric of our health care system in ways that most people do not understand.

  17. 17
    taumaturgo says:

    America has become the preeminent unenlightened self-interest country of the world. What I read in the majority of the post here is “I have mine, fuck the rest.” No so different from the right wing troglodytes. For those who wish to see and understand, there is plenty of evidence and data of how to run a decent, humane, not for profit national healthcare system. Shit, if the tiny island of Taiwan did it, why can’t we do it? Well, there is the middle of the road, wait not so fast crowd that would have us believe that the private insurers are the best we can do and nothing else is remotely possible even though the changes would save lives, be less expensive and render better overall healthcare outcomes. We rather argue about the minutia, be driven to bankruptcy, lower our life expectancy, enjoy the merciless gouging of big pharma, all because we fear to pay taxes and in all honesty, we begrudge extending benefits to the “underserved.” We call ourselves “progressive”?

  18. 18
    New Deal democrat says:

    This is why I have advocated for a FICA-based Medicare for all system, where the premium is a tax withholding line on your paycheck, with an exemption for anyone whose paycheck already includes withholding for an employer based plan:

  19. 19
    Panurge says:

    Well, “if you heard”. Obviously the Republicans will make sure everyone hears, no matter the prposal. “Pay more in taxes”–well, of course pay more in taxes, but more than offset by lower premiums. “Winners and losers”–well, who needs to lose besides the people on top who’d never miss the extra money? This is more a set of Republican rhetorical points or leading questions than actual policy implications.

  20. 20
    Panurge says:

    One more thing: What exactly does “pay more in taxes” really mean? “Pay more in taxes than you pay in premiums for the same coverage”? “Higher tax bill, even if offset by lower premiums”? They’re not the same thing, and a phrase like “pay more in taxes” is really good at obscuring that.

  21. 21
    panurge says:


    If we had the wealth distribution we had in the ’70s, we’d be able to pay the taxes. But huh huh huh ’70s huh huh huh.

  22. 22
    TomatoQueen says:

    Daddy has been changed to ADMITTED status, due to changes noted on testing that was done on the first day, then followed-up. Medicare will now be billed again and a short-term rehab visit will be covered. Either this is entirely a charade or someone understood me the eighth time I said you can whistle for your $178/hourly rate.

  23. 23
    Marcus says:

    Somehow Kaiser missed the questions about not going bankrupt due to medical bills, or not delaying treatment due to fear of the costs. I’ve seen folks skip medications they need because of the cost – even with health insurance.

  24. 24
    misterpuff says:

    The problem is so much of the current system is not visible to the healthcare consumers. Yes, there is some money taken out of your check for premiums, but much is paid for by the company.

    Can we get Business to agree to up base pay by the amount of their current HC Ins spend, because if the shifting of responsibility from the employer to the govt for M4A brings that figure down to the bottom line …virtually free money…well that ain’t gonna fly.

  25. 25
    taumaturgo says:

    @misterpuff: Free money? Not so fast. Wages have been stagnant since the late ’70s and besides the investors and CEO’s greed, the other culprit is the unstoppable health care cost increases. The employer can shift the responsibility to the employee and the insurance companies and big pharma will continue to plunder the folks at the point of heightening vulnerability. They will gladly sell you a zero coverage cheap policy, which should include a tidy note, “Enjoy your false choice.”

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