Earlier this week, Senator Wyden (D-OR) laid out a marker on Medicaid for All:
Ron Wyden, who would be chairman of the Finance Committee w a Dem majority, says on m4a at axios event:
“My starting point when we’re in the majority” is “I’m going to support more Medicare-type choices.”
(ie not single payer)— Peter Sullivan (@PeterSullivan4) November 13, 2019
This is important.
Significant institutional elements of the Democratic Party including the Speaker of the House, the Senator who would be the relevant committee chair in any scenario that could see M4A advance, and the marginal votes in any Senate that could plausibly advance M4A are all laying down major markers that they don’t want to go down this route. Instead incremental change and build-out of the ACA is the approach that they are on board with.
Part of that is that Medicare for All is seen as a base argument and not a swing voter argument. Part of it is that the 2018 elections did not demonstrate that M4A advocacy improved Democratic electoral chances. Alan Abramowitz at the Crystal Ball is laying out that argument:
A regression analysis comparing the performance of 2018 Democratic House candidates shows that those who supported Medicare for All performed worse than those who did not, even when controlling for other factors. fully 73% of Democratic candidates in districts that Hillary Clinton won by a margin of at least 20 points supported Medicare for All. However, the data in Table 1 show that the lowest level of support for Medicare for All was not in strongly Republican districts but in districts that leaned Republican — those that voted narrowly for Donald Trump in 2016. These findings suggest that Democratic candidates were least likely to support Medicare for All in marginally Republican districts where it could reduce their chances of winning….
The results in Table 3 indicate that after controlling for all of the other variables affecting the outcomes of these contests, Democratic candidates who endorsed Medicare for All did significantly worse than those who did not. The estimated coefficient of -4.6 indicates that support for Medicare for All cost Democratic candidates in these competitive districts almost five points of vote margin — a substantial effect in a close election.
One of the key things that we need to remember is that the median House seat is several points more Republican leaning than the nation and the 51st Senate Seat is further to the right than the median House seat. The minimum winning Democratic coalition for Medicare for All or any other bill that is more ambitious than naming a post office requires a few dozen votes from people representing marginally Democratic turf to nominally lightly Republican districts. A 5 point penalty is a huge deficit to make-up elsewhere especially if there are other policy avenues that can accomplish most of the same goals at lower cost.
David ??Booooooo?? Koch
There aren’t 50 votes to force 200 million people from their current insurance into Medicare.
There are 50 votes that give people the option to voluntarily join Medicare.
David ??Booooooo?? Koch
Campaigning on forcing suburbanites from their current insurance into Medicare will only give Dump another term.
Chyron HR
Dare I suggest that the MFA candidates actually have to win the primary before demanding fealty from the rest of the party?
Baud
@David ??Booooooo?? Koch:
I actually had an outside the bubble real world conversation with a couple of Democrats yesterday who said something similar about scaring suburbanites who have insurance.
satby
@David ??Booooooo?? Koch:
@Baud: you both get bingo!
I have several good friends who are union families and pretty loyal Democratic voters, but they love their union insurance, which is far better than any employee thing I ever had, and would not like to lose it. Make a public option attractive enough to be competitive, and they probably would voluntarily switch at some point, but not before. And I sympathize with them, they have lots of health issues from working hard, physically demanding jobs.
Betty Cracker
People who propose overturning the current unequal, expensive and ineffective system are radicals, but those who want to keep a system where…
…are the nice, sane grownups and are never asked to explain why they find the current system tolerable. Only in America!
Baud
@Betty Cracker:
No one here called M4A radical, or is defending the current system or proposing to leave it as is.
Betty Cracker
@Baud: I wasn’t replying to someone else’s comment, merely making a general observation, as others in this thread have done.
topclimber
Wyden said what his starting point was, but what about his endpoint?
Let’s have the policy debate and voter education process during the primary, agree on a consensus starting point at the convention, and push the envelope as feasible if and when we have the Senate and Presidency for more than two years.
Baud
@Betty Cracker: Gotcha. You are correct as a general matter.
JPL
M4A is a worthy goal but not achievable with the current Congress. Count me in as not wanting to lose an election because of fighting for unattainable goals.
zzyzx
My arguments against M4A are mainly:
1) It’s not something that can get past any Congress in the immediate future so this is at most an Overton window type conversation, so why are we making it into a purity test?
2) Seeing how initiatives along these lines can’t pass in blue states, I don’t see how this is going to be a net winner in a world with the electoral college.
3) I don’t trust future governments to not get all austerity and cut M4A to the point where things are even worse than we have it now.
Reasons why I like it:
1) I spent hours looking at various health plans last week that my company provides to make sure I chose the right one. I’m still not sure.
2) I’m terrified about what happens if I lose my job.
3) I’m tired of seeing friends having to do gofundme’s to undergo surgery.
So yeah, if I can magically flip a switch and give us M4A, I do it. I just don’t see an electoral path and another term of Trump terrifies me, so right now my goal is to just stop the insanity.
Betty Cracker
@JPL: No one wants to lose the election, but it’s also important to factor in the galvanizing effect fighting for better policies can have on voters. We hear plenty about how M4A frightens suburbanites and gives union members the willies. That’s important, but so is the enthusiasm of M4A supporters.
Juice Box
I used to be a firm single-payer advocate, but now I don’t care. Other countries have lower-cost, comprehensive health care systems that are not single-payer and which function equally well. Underfunded single-payer plans can also be a problem. Just looking at a well-funded, well-run single-payer plan and attributing all of its success to the “single-payer” aspect is a mistake.
JGabriel
@satby:
Yep. I support some version of M4A myself, but I suspect that making it an ACA public option rather than the only option may be a better electoral choice.
That said, I do have concerns that going for a public option – Medicare for those who want it instead of M4A – leaves it more subject to the kind of Republican sabotage and undermining that we’ve seen, and continue to see, with the ACA.
In other words, I think Republicans are a lot less likely to fuck with an M4A program when everyone has to rely on it, not just those who want or need it.
It really isn’t obvious to me which is the better choice overall. So, that’s why I’m not making it a first tier priority for the primaries. As long as the ultimate nominee is supportive of some path that gets us to universal coverage with no (or at least significantly reduced) co-pays then I’ll be happy.
Baud
@Betty Cracker: Yeah, it’s a tough calculation. I’m general, though, people tend to react more strongly to risk of loss than promise of benefits.
Sab
Yay! My party leaders agree with me!
Another Scott
@satby: “”¿Porque no los dos?”
I think Warren’s “plan” made it clear that M4A (or Universal Coverage by any other name) is a long-term goal, not something that the next Congress is going to implement. Immediate progress can be made on expanding Medicaid and fixing issues with Obamacare, while we lay the groundwork in moving toward a more Universal system. I wish our candidates would talk about it that way…
Drum has some numbers on how the M4A candidates did in the 2018 elections, but of course that was a long time ago.
I can’t find it now, but someone (Drum? Krugman?) had post in the last couple of days showing a graph of union labor percentage over time and made the point that the GOP has been strangling labor for decades and are now holding the economy captive while the loot it with no other power center to oppose them now. The economy isn’t doing well because, as Atrios likes to say, the people got no money. Only the plutocrats are doing well, but they have too much power over everything else.
Union health care isn’t safe, just as union wages are no longer safe (two-tier systems at automakers, etc.). We have to look forward.
How do we get there, and how “pure” should the new system be? Dunno. Who’s oxen should be spared while others are sacrificed? Dunno. It’s a tough problem, but the status quo is not sustainable.
Cheers,
Scott.
Baud
@Another Scott:
Do you think either M4A proponents or opponents or other voters currently see it that way?
I don’t recall if Warren put out her timeline yet, but I believe Bernie’s plan calls for a 4 year transition.
low-tech cyclist
My basic position is, we need a health care system that:
1) Covers everyone for all the health care they need
2) Is easily affordable for everyone
3) Is easy to navigate
Other advanced nations have achieved these goals by a number of different paths. I’m good with any system that gets us there.
Right now, I agree that M4A is a political loser, and since I like Warren pretty much across the board aside from this, I can only hope she backs off from it.
Kay
My private health insurers latest innovation is an incredibly clunky and difficult to use website where I punch in vast amounts of personal information on endless pages and get bland, generic “good health” advice in return. I have to do this or I get charged an extra $100.00 a month for not complying.
The company offering the “service” is a contractor, so the insurer purchased this crap and I paid for it with premium hikes. It’s a scam- they’re skimming off the top and it offers no value to anyone, and one of the largest health insurers in the country bought it hook, line and sinker.
Just think of the hours of unpaid work millions of people are doing just so they aren’t charged a penalty. Completely unproductive work, millions of hours, unpaid. And we paid for the privilege of having it.
satby
@Another Scott: I think both is the correct short term approach. We urgently need ACA expanded and applied to all states to get the uninsured covered, and to protect it from Republican fuckery.
Then we can start moving to a better universal coverage system (IDGAF what name it’s called) and possibly include private insurance for those who want more. It’s not that my friends are opposed to expanding coverage, they’re rightfully terrified of losing theirs: one family is fighting cancer, diabetes, and congenital heart disease, and the other diabetes and a work injury that resulted in TBI. And they’re older, but not on Medicare yet.
JMG
Medicare was passed into law in 1965. The ACA became law in 2010. That’s 45 years between major changes to the health care system. I would expect Medicare for All to become reality in maybe twice that time, barring catastrophic failure of the current system, which is always possible.
Kay
A lot of people won’t be able to get through the 30 minute process to successfully sign up for this program and complete the initial elaborate information demand, then continue to update the program with health stats, so I suspect Blue Cross/Anthem in Ohio will be collecting a LOT of $100.00 monthly penalties to tack onto premiums.
Which may have been the actual goal. What do you think the perfect compliance rate is? Maybe 40%? It’s a back door premium hike.
burnspbesq
A very long time ago, when I was a Friday night relief blogger, I wrote that the road to universal health coverage ran through a VAT. I still believe that. I also believe that the United States will never have a VAT. That’s why I think that systems like the Dutch and Swiss are more likely to work here than any variation on M4A or anything NHS-like.
Betty Cracker
@Kay: My sister, who is a skilled clinician, has a similarly stupid and pointless set of hoops she has to jump through to avoid a gigantic surcharge on her already overpriced health insurance. She was just complaining about it the other day. No doubt it’s also a monstrosity built by contractors.
One way or another, we’ve got to get the rent-seekers like that out of the system. They extract a huge amount of labor and revenue and deliver nothing of value.
I’d prefer a single-payer system to get rid of them PLUS abolish the redundant bureaucracies. But if incremental reform is what’s on the menu, I’d like to see some further commitment to cutting that sort of garbage out.
Chief Oshkosh
Baud has spoken!
Butch
Can I guarantee you that if you’re over 40 in an underserved area you are not a fan of the ACA and don’t think a few minor tweaks can fix anything? I’ll be first in line for any alternative to the ridiculously expensive, worthless bronze plan we have now.
Kay
@Betty Cracker:
My husband and I were laughing because one of the requirements was a blood test. Apparently we’re not getting enough blood tests. The county employees have this same insurance so they had us all go to this county conference room where we waited in huge lines for a blood draw. You get like 300 points toward your bullshit, invented “goal” for blood test (a lot!) and since that might avoid answering an additional 500 questions on the website I was like “dear God, just take the blood if it gets me points”
Hysterical. It’s like every “government health care” horror story and
it’s the private system.
Chief Oshkosh
Yes and yes.
There’s a political process wrt the role of aspirational plans versus operational execution on those plans in the context of primary vs general elections. I think a lot of people understand that. Do you think that people don’t understand that?
Chief Oshkosh
They literally want your precious bodily fluids.
Baud
@Chief Oshkosh:
I do think a lot of people don’t.
burnspbesq
You might start with repeal of the McCarran – Ferguson Act, a relic of the Truman administration that essentially blocks Federal regulation of insurance. Except in a handful of states (most notably California, where Dems have an effective monopoly on the elected job of Insurance Commissioner), state regulators are on a continuum that runs from “well-meaning but outgunned” to “blatant capture by the industry.”
Kay
@Betty Cracker:
Also? Everyone is lying on this website. They know they have to say “I exercise 3X a week for 20 minutes” to get 50 points so they’re grabbing the easy points.
My daughter is a PA and she says she usually doubles peoples self-reported “number of drinks per week” number. You tell her “two” she’s using “four”, you know, in her HEAD :)
Zzyzx
@Betty Cracker:
That’s my fear, that we’ll have 10% of the potential Democratic voting population that won’t come out to vote unless we propose policies that will turn off 25% of the group.
It’s a frustrating coalition with lots of groups big enough to sink the election if they don’t show but none big enough to win it on their own.
Zzyzx
@Chief Oshkosh:
Of course people don’t believe that. They’ll be calling Warren a sell out by April when M4A somehow doesn’t magically pass. It’s amazing how many people confuse the president with a king.
LanceThruster
@Betty Cracker:
Great observation.
Richard Guhl
The data point almost always omitted in the discussion about how we provide for health care is how skewed spending really is. The Kaiser Family Foundation did a study on how health care spending varies across the population and found that in 2016, 58% of all spending went to caring for the sickest 5%!, and only 3% went for the healthiest 50%!
When you also factor in that whatever the employer pays for health insurance is, for most employees from an emotional standpoint, unreal Monopoly money, it’s no wonder they aren’t enthused about M4A. And enacting M4A will likely create a lot of losers who see their taxes hiked, with little benefit of better health care.
The vast majority of our health care spending goes to two groups of people— those with chronic conditions and those for whom extraordinary care is provided in the last six months of life.
oatler.
Nunes is currently describing Ukraine’s “delicious and tasty food”.
Cheryl from Maryland
My husband and I are the typical well insured white suburbanites. We both believe universal health care is a human right, and the US system is wasting money left and right. We’ll support whatever happens. BUT, my husband has multi-health problems (heart issues, renal failure, sarcoidosis, osteoarthritis, depression {not surprising considering his health}). We battle gatekeepers every week and are successful at it as we were federal bureaucrats — spouse was a lawyer for the FDA. We are under no illusions that this situation will not continue under M4A or similar – applying for Social Security is hard. Democrats have to have answers for this.
Wapiti
@topclimber: I think that Wyden has thrown a lifeline here to the primary candidates. Health care is a third rail. If asked about M4A, a candidate can down say something like “Senator Wyden is the gatekeeper for health care, and he says that any change in the next 2-4 years will be incremental. I think we can all agree, however, that we need to replace Donald Trump.”
JR
I’m glad to see that I’m not alone in these thoughts.
I’m still adrift sans-Warren. She may believe in the policy but endorsing M4A was a grave misstep, and not just for her own campaign.
BCHS Class of 1980
@Wapiti: And outside of the crowd at The Jake, it’s really hard to ding Wyden as insufficiently liberal.
Omnes Omnibus
@Betty Cracker: But is M4A galvanizing for a significant number of people? Me, I don’t fucking care how we do it, I want everyone to be have decent healthcare and I would like us to pay a rational amount for it. That’s it.
glory b
@LanceThruster: Can I just say that I always find it hard to believe that there are a bunch of voters (enough to tank the election) who will stay home and watch Trump tank the entire system, including letting people with pre-existing conditions, poor people, etc,. if they don’t get exactly what they want exactly when they want it? What are they, 4 year olds?
patroclus
McCarran-Ferguson was enacted under FDR and was a compromise piece of legislation that, as you say, pre-empted all federal regulation of health care but also required states that did not provide occupational safety and health regulation to be regulated for unfair trade practices by the FTC. It should not be repealed in its entirety – it should be amended to eliminate the anti-pre-emption language and empower federal regulation. It was a response to the South East Underwriters case which over-ruled Paul v. Virginia which had established that insurance did not constitute interstate commerce. It was good legislation for its time but has long outlived its usefulness.
On topic, I agree with Senator Wyden; not Senator Warren. She endorsed Wilmer’s plan to appeal to his voters; she needs to become more realistic to attract my vote.
Michael Cain
The biggest “hidden” advantage of single payer is that essentially all providers have to accept it. There’s just not enough rich people to allow very many doctors to operate non-insurance boutique practices. When my wife and I had to go through changes of plan in 2018 — once to the ACA and once to Medicare — the first thing that we found when planning was that we were going to have to decide which doctors we would have to replace.
We ended up going with Kaiser for the switch to ACA because we could then switch to their Medicare Advantage plan and keep all of the same new docs.
gene108
@Baud:
Pretty much how Republicans and their backers killed Clinton Care.
gene108
@satby:
I have several good friends who are union families and pretty loyal Democratic voters, but they love their union insurance, which is far better than any employee thing I ever had, and would not like to lose it. Make a public option attractive enough to be competitive, and they probably would voluntarily switch at some point, but not before. And I sympathize with them, they have lots of health issues from working hard, physically demanding jobs.
I think Sanders represents the wing of liberals, who want to end private heatlh insurance companies outright.
A better selling point is a base level of coverage everyone gets. If you have employer coverage, like current Medicare, the employer coverage will be primary.
If you lose your job, the Medicare you automatically have becomes active, so you aren’t struggling with COBRA bills.
Just seems like a better way to sell it, in my opinion.
Kelly
I’ll age into Medicare in 2021, my wife in 2025. Our current healthcare system is like the ancient mainframe spaghetti code I spent most of my career maintaining. I see a lot of what the bright young MBAs I used to work for called low hanging fruit. Get rid of the 400% subsidy cliff. Add an out of pocket cost ceiling to Medicare. Mandate a universal pharm formulary and universal set treatment codes. Full federal Medicaid to get around the ridiculous SC ruling that let the red states rob there poor citizens of healthcare. Replacing a a bunch gradually evolved spaghetti with clean modern stuff to a big team and blew way past estimates more often than not whilst I could code specific little patches in a week or two.
Annie
Great. Let’s do exactly what the reich-wing does — support lots of policies that galvanize our base* but are too far to go for general election voters.
I put an asterisk next to “Base” because an awful lot of Democrats are moderate Democrats, not the Balloon Juice commentariat. And what’s with the sneering at people who don’t want to lose the insurance they have that works for them? Some of us do have that.
We often point out the ways in which TR*** voters vote against their own self-interest; why should Democrats join that club?
Another Scott
@Another Scott: Yeah, it was Drum. Here’s how corporate America took over America
Anyone still with a good union and good union benefits has a target on their back.
Cheers,
Scott.
Taumaturgo
The nice Senator from Oregon who could be the gatekeeper for any legislation that could do away with the horrific current system of profits before care would rather side with those that send
bribesmoney to remain in power. Follow the money.opensecrets.org/members-of-congress/summary?cid=N00007724
smintheus
Brilliant strategy: leave in place the very system that Republicans have been and will continue trying to eliminate or undermine, which they will succeed in doing as soon as they regain the majority in Congress or find the right judges to overturn the law. Heaven forbid that a presidential candidate might want to stop playing defense on unfavorable ground.
low-tech cyclist
And those Ukraine girls really knock him out.
ProfDamatu
@Kay: That’s just infuriating…and grimly amusing.
Those BS “goals…” My insurer did something similar a few years back; they’d send you a free Fitbit if you’d let it upload activity to their website, and you got credit towards a gift card if you logged something like 9 “active” days out of 21, and so on. There was a diet one too, totally reliant on self-reported data so complete nonsense.
It did make me a bit nervous, though, about a possible future version with teeth. Those BS targets especially make me nervous, because at a certain point, further “improvement” isn’t realistic.
I wonder if the really onerous BS your insurer imposed wasn’t partly actually to deal with people who are already pretty healthy…like, if someone already has normal BP and cholesterol readings, you can’t give them a premium reduction for reducing it further, but you also can’t just subject them to the surcharge – basically penalizing them for already having healthy numbers. Solution: make them fill out a bunch of e-paperwork to get the “discount” (and of course, as you say, it also probably works as a backdoor premium hike due to the difficulties of complying).
ProfDamatu
@Kelly: Yes, and following Charles Gaba, I’d add a couple more low-hanging fruits:
–Eliminate the subsidy cliff, and beef up the APTC formula. 9.65% of income for premiums alone really isn’t all that affordable for people making below the median income – and that applies to people making say 300% FPL as well; their required percentage of income is also rather high, especially given the skyrocketing cost-sharing.
— Expand cost-sharing reduction subsidies. We’re very rapidly reaching the point where very, very few buyers on the Marketplace or state exchanges will be able to afford to use their insurance, unless they’re poor enough to qualify for CSR subsidy help. With the dramatic increase in deductibles and OOP limits, many if not most people who don’t get CSR subsidies have to think twice about getting medical care, because they’ll be on the hook for the first few-several thousand dollars. And don’t even get me started on how bad this is for people with chronic conditions, who are guaranteed to max out their cost-sharing every year!