What the Medicare for All Fight Is Really About

https://www.nytimes.com/2019/10/17/opinion/medicare-for-all.html

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Like a Boston family relitigating its annual Thanksgiving argument over whether to sell Grandma’s house on the Cape and how to split the profits, the Democratic presidential candidates spent Tuesday night picking the same fight about health care.

At issue, as always, was Medicare for All — Senator Bernie Sanders’s health care plan, which Senator Elizabeth Warren also supports, that promises universal coverage without co-pays, premiums, deductibles or haggling over claims, under a single government-run insurance system.

The debate: Is single-payer health care, to use Ms. Warren’s words, “the gold standard” or, as Senator Amy Klobuchar puts it, “a pipe dream”?

The moderates, led by Joe Biden and Pete Buttigieg, believe that Medicare for All is needlessly heavy-handed and prohibitively expensive.

Mr. Sanders and Ms. Warren say that replacing private insurance is the only way to guarantee every American affordable health care as a human right.

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Mr. Biden, deploying one of his favorite rhetorical weapons against Medicare for All, said Tuesday night that the plan would cost $30 trillion, or roughly 278 Jeff Bezoses, over the next 10 years. But Mr. Sanders has pointed out that that figure is much less than what the current system is projected to cost.

The truth is that no one knows for certain whether the country’s health care costs — which in total and per person far exceed those of any other industrialized country — would go up or down under Medicare for All. Ezekiel J. Emanuel and Victor R. Fuchs explain in The Times:

Medicare for All would move money from one column (private health insurance spending) to another (federal health spending); it does not automatically increase total costs. … We have our doubts about Medicare for All. But unaffordability is not a reason to oppose it.

“In some estimates, the country would not pay more for health care,” a Times analysis of five studies found. Rather, there would be “a drastic shift in who is doing the paying.” For that reason, it is more accurate to think of Mr. Sanders’s plan not as an outlay of (imaginary) money but as a redistribution of it away from insurers, drug companies, health care providers and higher-income people.

Ms. Warren has drawn criticism for her continued unwillingness during debates to say whether Medicare for All would cause taxes to go up for middle-class families. Mr. Sanders admits they would, but Ms. Warren has refused the premise of the question, emphasizing the money most taxpayers would save overall after premiums (which come out of many people’s paychecks like taxes), deductibles, co-pays and coverage gaps are eliminated.

Middle-class people would “save a lot of money on health care,” the Kaiser Family Foundation’s Larry Levitt told NPR in July. Yet how exactly their net costs would change depends on the particulars of Medicare for All’s funding plans, which neither Mr. Sanders nor Ms. Warren has fully outlined. The Times wrote in a fact check:

Mr. Sanders has suggested various possible tax increases that could pay for this expansion, including a payroll tax that would affect workers across the economic spectrum. He has not provided enough details about the mix and magnitude of taxes for economists to measure what sorts of families would be better or worse off under Medicare for all.

Americans should be allowed to keep their private health insurance, Mr. Buttigieg has argued.

“The problem, Senator Sanders, with that damn bill that you wrote, and that Senator Warren backs is that it doesn’t trust the American people,” Mr. Buttigieg said during September’s debate. “I trust you to choose what makes the most sense for you, not my way or the highway.” He elaborated on his own health care plan, which he calls “Medicare for all who want it,” in an earlier debate:

You take something like Medicare, a flavor of that, you make it available on the exchanges, people can buy in. And then if people like us are right, that that will be not only a more inclusive plan, but a more efficient plan than any of the corporate answers out there, then it will be a very natural glide path to the single-payer environment.

Critics of public option proposals point out that the path may not actually be so glide-y. That’s because the price of health care services — not insurance or pharmaceutical profits — is the primary driver of America’s ballooning health care spending. Only a single-payer system can restrain those costs, Benjamin Studebaker and Nathan J. Robinson argue in the left-wing magazine Current Affairs, because it gives the government a monopoly on access to patients. “If instead there are a large number of insurance companies, providers can play those insurance companies off each other,” they write.

The New Republic’s Libby Watson adds:

There is a reason American health spending is so much higher than other countries … the United States is the only country that includes — indeed, prizes — such a huge and profitable role for private actors in the health care industry. In order to ensure that everyone has good health care, a lot of these bad actors are going to have to make less money.

How much less? Providers would face an estimated average 11 percent to 13 percent pay cut under Medicare for All. And by design, it would decimate the insurance industry, potentially wiping out two million jobs, writes Elisabeth Rosenthal in a Times Op-Ed. (Medicare for All sets aside funds to help displaced workers with training, benefits and income support.)

Medicare for All would theoretically allow you to keep your doctor, since the country would have only one insurance network. But the reduced payment rates could cause a doctor and nurse shortage, argues Marc Siegel in the conservative National Review. Medical school often costs hundreds of thousands of dollars, and he adds:

There is already a growing doctor shortage in the U.S., and it is only going to get worse … No matter what your plan, you simply can’t pay doctors and hospitals less to do more while rationing essential services. That would be a poison pill for the health care crisis, not a solution.

Along those lines, the Congressional Budget Office reported that patients could face increased wait times. But it also said that such problems are not inevitable under a single-payer system: “In the longer run, the government could implement policies to increase the supply of providers.”

Mr. Biden has said that Medicare for All would be a raw deal for union members who have bargained for their employee-sponsored health care plan. “You’ve broken your neck to get it,” he said last month at an event hosted by the Philadelphia A.F.L.-C.I.O. “You’ve given up wages to keep it. And no plan should be able to take it away.”

But some unions say that unlinking health insurance from employment would free up space for bargaining over other issues. “Wouldn’t it be great if we had a single, universal access point for health care and we could instead spend our time bargaining for lower class sizes and wraparound services and increases to people’s pay?” Randi Weingarten, president of the American Federation of Teachers, told Politico.

“I’m simply concerned about kicking half of America off their health insurance,” Ms. Klobuchar has said, echoing a common anxiety about transitioning the 153 million people on employer-sponsored plans to Medicare for All.

“People lose their employer-sponsored insurance constantly,” counters Matt Bruenig of the People’s Policy Project, a left-leaning think tank, whenever they change jobs or employers switch plans. Mr. Sanders has proposed a four-year transition that would roll out his plan first for minors and seniors and then bring down the eligibility age each year until everyone in the country is enrolled.

But concerns about the speed and scope of such a transition abound, even for those who support eliminating private insurance in theory. “The details are literally life and death for my community,” says Matthew Cortland, a disabled health care lawyer, who worries many disabled people wouldn’t survive the rollout. He tweeted in April:

There is nothing that would bring me more satisfaction, that would fill my soul with more joy, than destroying Cigna. They tortured me — I mean that literally. But … the only thing I want more than to watch them burn is for us to be okay.

On health care, the past four debates have proved largely beside the point. Medicare for All’s opponents have yet to explain why they believe the profit motive should play any role at all in medicine, while Ms. Warren and Mr. Sanders have yet to explain why they believe it has to be eliminated entirely before superior nonprofit insurance can exist. (Or if the profit motive must be eliminated, why a single-payer system is preferable to one like Germany’s in which private nonprofit insurers compete against the government’s plan.)

The candidates will doubtless have a fifth chance to shed light (or darkness) on these essential distinctions at the next debate, which will take place on Nov. 20.

Do you have a point of view we missed? Email us at debatable@nytimes.com. Please note your name, age and location in your response, which may be included in the next newsletter.

“I am alive today not because of insurance companies but despite them”: Rachel Madley says a single-payer system is the only way. [The New York Times]

“Biden’s attacks on Medicare for All undermine the entire Democratic agenda,” argues Eric Levitz. [New York]

David Brooks says single-payer is an “impossible dream.” [The New York Times]

Peter Suderman writes that a deep-blue state’s failure to enact a single-payer system proves a national version is unlikely to succeed. [The New York Times]

Ben Burgis argues Mr. Suderman is wrong. [Jacobin]

How could we fund Medicare for All? Slash the military, says Lindsay Koshgarian. [The New York Times]

Which country has the best health care system in the world? Here’s a tournament. [The New York Times]

Here’s what readers had to say about the last debate: Putting out Trump’s Syria fire.

Thomas from Vermont commented: “Both sides using the same American arms? Sounds like a dream come true for the military industrial complex. N.R.A. foreign policy. What could go wrong?”

Ed from Maine commented: “This was always the danger with Trump. His lack of knowledge or even curiosity, his impulsive ‘stable genius’ actions, his complete ignorance of the consequences of abandoning allies on a whim, have all combined to produce this unmitigated disaster of foreign policy. This is irreparable. No one will fully trust America again.”

And Tom from Miami commented: “We are the greatest country in the world, everyone knows that, but we cannot solve everyone’s problems, fight everybody’s wars and pay for everybody’s mistakes … We are leaving you because our time is up, we have spent as much money as we could trying to protect you but there seems to be no end to it.”