The Case for a Medicare Buy

The Case for a Medicare Buy-In Option Mandates vs options: The good, the bad, and the feasible Signing Medicare into law Abdul El-Sayed won the Democratic nomination for Michigan Senate on a platform advocating Medicare for All, aka single-payer health insurance. As I argued Tuesday, this makes a lot of sense in policy terms. Many healthcare experts would choose single-payer if designing a healthcare system from scratch. That’s not a hypothetical: my friend the late Uwe Reinhardt, who taught me much of what I know about healthcare economics, played an important advisory role in creating Taiwan’s highly regarded healthcare system — where he really could start from scratch — and argued successfully for single-payer. Furthermore, as I pointed out Tuesday, the United States is already most of the way to single-payer in terms of dollars spent: the government de facto pays for about two-thirds of health insurance and extensively regulates the rest. Except as providers of supplemental care, there is really no net positive added by private insurers. In fact, for basic health insurance coverge, private insurers are a net negative because they impose excessive administrative costs and often engage in fraudulent overbilling. Yet to adapt an old joke, if you wanted to get to a single-payer system, you wouldn’t start from here. The political obstacles to replacing private health insurance with a Medicare-like system are formidable, although arguably less formidable now than they were when Obamacare was created. As I’ll argue shortly, there’s a strong case for a soft transition in which people can choose to be covered by Medicare via a public option. But before I get there, let’s talk about why, in the realm of healthcare, there’s tension between good policy and political realism. Why won’t making the legitimate case that Medicare for All is the best system be enough to win the political argument? The pervasive corruption of our political environment by corporate and right-leaning money is part of the answer. Health insurers may be parasites, but parasites make campaign contributions. Other players will also spend big to fight single-payer. Drug companies, in particular, don’t want to see the U.S., like healthcare systems almost everywhere else in the world, bargain down their prices and reduce their monopoly power. And MAGA is against anything that would improve the health and well-being of average Americans. But it’s not just about money-driven corruption. Ordinary voters are inherently conservative, not in the left-right sense, but because they are understandably wary of change. El-Sayed does a very good job of making the case that most of the 183 million Americans now covered by private insurance would get better coverage under Medicare for All, and would pay less in additional taxes than they now pay in insurance premiums. But expecting most Americans to trust that promise is overoptimistic. It’s true that the healthcare industry is among the most disliked sectors in America: But look at which sector gets even worse ratings: the federal government. That’s deeply unfair to the many dedicated men and women who try to make government work for the people. Yet unjustified as it is, it’s a fact of life. Although Americans are extremely negative about what they think the federal government does, however, they are much more positive about what the federal government actually does. And no major government program is as popular as Medicare, which has an 82 percent favorable rating. So it may be possible to defuse attacks on a single-payer healthcare system by portraying the plan as more Medicare, not bigger government. However, Americans suffer a disconnect between the general and the specific on the topic of private healthcare insurance. Americans have strongly negative views, verging on hatred, about the insurance industry. Luigi Mangione, who is expected to plead guilty to the murder of UnitedHealthcare’s CEO, has become a folk hero in some quarters. Yet 77 percent of Americans with private health insurance report being satisfied with their coverage. So any mandate that moves Americans away from private coverage to a government system they haven’t yet experienced is likely to face stiff resistance. What, then, should Democrats of good will — that is, people who want their fellow citizens to have affordable access to quality healthcare like citizens of every other advanced country — support? Should they call for an all-out effort to implement the best policy – Medicare for All -- that is likely to face significant pushback and political roadblocks, albeit unjustified? Or should they settle for a strategy that is likely to involve a more drawn-out process to achieve universal coverage, but is also more likely to turn into reality? Let me do something I rarely do and call on both sides of this debate to tone down the rhetoric. If you spend any time in these discussions, you know that there is a faction on the left that turns Medicare for All into a purity test, denouncing anyone who calls for a more cautious approach as a neoliberal sellout. That’s unfair. The truth is that there’s a lot to be said for the Mick Jagger principle: You can’t always get what you want, but if you try sometimes you just might find you get what you need. Obamacare was and is a Rube Goldberg device, a messy, highly imperfect way to expand health coverage. But it has been a saving grace for millions of Americans. On the other hand, there are centrists who slide from political caution over the feasibility of Medicare for All into denunciations of those who advocate universal single-payer as socialists. Folks, this is equally unhelpful. This is a debate about tactics, not values, and it’s possible to back either side in good faith. For what it’s worth, I don’t believe that Medicare for All is as unrealistic politically as it was even a decade ago. Americans really do deeply distrust the health insurance industry, and a massive advertising and lobbying campaign by that industry, like the one that helped kill the Clinton health reform in 1993, might well backfire. And the right-wing propaganda apparatus has surely been damaged by its fealty to Trump, which would hamper any attempt to demonize healthcare reform the way the right demonized Obamacare in its early years. That said, a rapid transition to Medicare for All looks unlikely. Bear in mind that such a transition would require higher taxes, so that it would be necessary to persuade people that these taxes would be more than offset by lower premiums. And this would be a hard sell. But there is an alternative: A public option, better described as Medicare Buy-In. Allow individuals, and possibly more important, employers, to sign up for Medicare benefits, paying actuarially fair premiums to Medicare reflecting the health status of their workers. There’s no obvious reason a public option would be any harder to implement than payments to the Medicare Advantage plans offered by private insurers, which are also supposed to be actuarially fair. And if a Medicare Buy-In option were available, many people and many employers would surely take it. It would be a safe choice, with lower administrative and marketing costs than private insurance. A healthcare system in which many Americans under 65 buy into Medicare would not immediately deliver all the advantages of full Medicare for All. Some people and employers, despite the disadvantages, might retain private insurance. And some people, who currently either choose to be uninsured or fall through the cracks, might remain uninsured. It would lack the clarity of a system in which every citizen knows that they are entitled to care. But it would be far better than what we currently have. Moreover, a system in which private health insurance is a rump industry, covering a dwindling fraction of the population, would be a better starting point for a full transition to universal coverage. So that’s my idea of how we should proceed. But I’m not going to denounce people who want to be more ambitious, to push more quickly for full Medicare for All. For now, the crucial thing is to elect people who really are committed to providing Americans with the healthcare they deserve. MUSICAL CODA Obviously: As a retired small town family doctor, I advocate a federal national health program. Indeed, Medicare for All is the idea. But getting there by way of the buy in may be the most practical and possible--and probably the quickest. Getting to the end by the most expeditious means may be the principle. That Mick Jagger principle is doing a lot of work here. Medicare for All may be the cleaner moral architecture, but a Medicare Buy-In may be the door people are actually willing to walk through. The key distinction here is tactics, not values. If the goal is universal care, the path has to survive the insurance lobby, public distrust of “government,” and ordinary fear of losing what people already have. More Medicare, less private extraction, and a transition people can recognize before they are asked to trust it. Get me? Ok then. www.xplisset.com