By Jack Runyan
One of the prevailing themes of the election in 2016 for Democrats was voting for Hillary Clinton was about protecting the Obama legacy. But the reality we face under President Trump is that Republicans are coming for it all. To approach Trumpcare as merely the repeal of the Affordable Care Act (ACA) is to miss the bigger picture, as the bill is actually an insidious attack on all of the achievements that the Democratic Party has made on health care for the past several decades.
The language of the Democratic platform indicates that the party will “will never falter in our generations-long fight to guarantee health care as a fundamental right” and supports “should be able to access public coverage through a public option, and those over 55 should be able to opt in to Medicare.” So why aren’t Democrats in Congress saying something to the effect of “the ACA fixes we’ll accept include a public option and a Medicare buy-in” right now? The unpopularity of Trumpcare would only be enhanced if Democrats were regularly reminding Americans what they stand for, which includes a public health insurance option that generally polls well (admittedly, polling could change based on the terminology used). With the threat of the American Health Care Act’s passage looming, which stands to reign in the ACA’s comparably more generous subsidies and alter Medicaid as we know it, I would argue that it’s time for Democratic answer to the Republican assault on health care to be Medicare for All.
Some may question the utility of such a strategy at a time when Republicans control both the White House and Congress given that a bill congruent with Medicare for all has no chance of becoming law under a Trump presidency. But that is precisely why Democrats should be loud and clear on the issues now. Never has there been a more critical time for Democrats to show the American people what they stand for, which is key to resisting a Donald Trump presidency. In this piece, I make the case for Medicare for all based on an appreciation for what Republicans are attempting to do now, I make the case for Medicare for all as an engine for Democratic messaging and answer common objections to doing so, I bring up a unique challenge for Medicare for all advocates that I believe goes unappreciated, and I make the case for Medicare for all simply based on what it means policy-wise.
Let’s call Trumpcare for what it is: a slippery slope to Medicare for none.
To think of Trumpcare as merely the repeal of the ACA is unwarrantedly reductive when you examine the policies in this bill as well as the consequences. It is actually a three-pronged assault on the ACA, Medicaid, and Medicare, albeit through different mechanisms.
The major takeaway from the recent CBO report is that 24 million more people will be uninsured by 2026 should Trumpcare come to pass.
The ACA subsidies and tax credits are restructured such that the older and poorer have to pay ridiculously higher premiums; via the CBO report, under the ACA, a 64 year old earning $26,500 has to pay a $15,300 premium and receives a premium tax credit of $13,600, so the net premium he or she pays is $1,700. Whereas a 64 year old earning $26,500 who pays $19,500 for his or her premium only gets a $4,900 tax credit, thus he or she must pay $14,600 net premium. This is a devastating change, although Republicans are apparently floating a variant of Trumpcare that will ameliorate this change somewhat.
But again, Trumpcare isn’t just an attempt to reign in the ACA’s subsidies and the tax increases that go along with it. It is nonetheless an assault on Medicaid and Medicare as we know it using different mechanisms.
Medicaid is a healthcare program jointly funded by the state and federal government where the federal government reimburses some of the health care expenses provided by the state. This federal reimbursement, typically called the “match rate”, varies from state-to-state (50 to 75%) and depends on state per capita incomes (i.e. states with lower per capita incomes receive a higher federal match rate). Under the ACA, Medicaid was to become eligible for people up to 138% of the federal poverty level (FPL), although thanks to the Supreme Court, the expansion effectively became optional for the states. In states that opt for the expansion, the ACA offers a 90% federal match rate for people newly eligible. What Trumpcare would do is reduce the federal match rate for these newly eligible people to the traditional Medicaid federal match rates. The CBO anticipated two major consequences of this provision: it would reduce the willingness of state governments that have not adopted the Medicaid expansion to do so and maybe even entice some states to reverse the expansion.
Alongside this provision is a proposed per capita cap on the federal matching rate; currently, if state Medicaid expenses increase, the raw amount of federal reimbursement increases according to the designated matching rate without limit. A per capita cap basically means if a state spends more than a calculated limit for federal reimbursement, the federal government offers no more matching support. The consequences of this cap are potentially enormous as this means state governments bear much more of the cost burden for Medicaid expenses, and states can handle that reality in a variety of ways (e.g. cutting payments to health care providers is one consequence cited by the CBO), but this would further disincentive state governments from adopting or even maintaining the Medicaid expansion.
As if all of this were not horrible enough, Republicans are seeking to placate more conservative lawmakers by agreeing to Medicaid work requirements and funding Medicaid via block grants.
Trumpcare also comes with a repeal of an ACA payroll tax on high earners—0.9% for individuals making more than $200,000 or joint filers making more than $250,000—which proved to be essential in preserving the solvency of Medicare. In other words, Trumpcare seeks to hasten a solvency crisis for Medicare.
Whether there will be a CBO score for the final iteration of this bill remains up in the air, but the takeaway from all of this is that Republicans are thinking big, ergo it stands to reason that Democrats should answer in kind by thinking big as well — and loudly so. Republicans are offering a plan that is a slippery slope to Medicare for none; not only are the ACA subsidies restructured so that the older and poorer effectively can’t afford health insurance, Medicaid as we know it is strangulated and a crisis regarding Medicare’s solvency is expedited. To reiterate, it’s an attack on the Democratic Party’s legacy over the past several decades regarding progress on universal health care.
With the entire Democratic Party’s legacy on health care at stake, the most fitting thing to run on is Medicare for All
The ACA has achieved a plethora of policy objectives: protecting people from coverage denials for pre-existing conditions, protecting people from annual and lifetime limits on coverage, expanding Medicaid, making health insurance affordable in health care exchanges via subsidies, and eliminating many out-of-pocket costs for preventative health care services. All of these provisions have resulted in more people having health insurance coverage, a lower cost burden for poorer Americans, and a reduced rate of health insurance premiums annually. Democrats are under an onus to fight to defend this law using any means necessary at their disposal, but the case can be made that the best defense is a good offense. And perhaps that means Democrats stumping on this message: “The only ACA fix we will accept is a pathway that provides Medicare to every American and Republicans are the party that want to take away your health coverage.”
To be clear, “Medicare for All” in terms of policy typically describes a public single-payer system that completely divorces profit from the administration of health coverage, which is guaranteed for every American. But it’s also messaging that is easily understood by virtue of the fact that people know what Medicare is and the “for all” denotes that Medicare should be available to every American. Democrats should adopt “Medicare for all” as messaging by virtue of the fact it is a constant reminder to American voters what they are fighting for.
That said, there are a wide range of objections from Democrats that I’ve come across with respect to whether it’s wise to campaign on Medicare for all.
- “Republicans will just call Medicare for all a huge tax raise on every American and that eliminates choice!” There are two important things to bear in mind here. First of all, this presumes a scenario where Democrats propose any kind of health care bill and Republicans and the conservative mouthpieces don’t do that. They will be calling your health care bill a tax raise that eliminates choice regardless of what you propose, and if you listen to the likes of Rush Limbaugh, you would know they think everything is a slippery slope to a single-payer system. And anyone who was around conservatives when the ACA was signed into law knew that many reacted as if the ACA was the equivalent of socialized medicine. The second important thing to bear in mind here is that Democrats have an obligation to take control of the framing. Yes, Republicans will frame a single-payer bill as the loss of choice; there’s only one payer. But Democrats can counter this by driving the point home that Medicare for All empowers choice. There are no health insurance networks in a single-payer system. The choice that matter is the doctor you want.
- “The 2010 midterms were disastrous for Democrats after the Affordable Care Act was signed into law. Imagine what Democrats would be in for if we passed single-payer.” Let’s be very clear about what happened in 2010: Democrats passed the most important health care bill in decades. Then they proceeded to not act like it on top of trying to demonstrate their independence from the President who signed into law. Meanwhile Republicans had no problem branding the ACA as big government and tying everyone who voted for it with President Obama. Confronted with this aggressive negative branding effort, Democrats had a choice: aggressively counter-brand in favor of the law and the President who signed it into law, or cede ground to the Republican brand. Democrats opted for the latter, and that is why they paid a price at the midterm ballot. There is always a price for running away from a law you’re trying to push; it says you don’t even trust what you’re selling. As it turns out, Republicans are learning that now in their push for Trumpcare; there’s no real enthusiastic push for this law, and voters are already picking up on that. Only 24% of voters support Trumpcare as a result. Maybe there is some baseline price the Democratic Party would pay by passing health care reform, but perhaps there were gains for passing health care reform had Democrats in unison stood by the law and pledged to strengthen it further. Something to bear in mind should a Medicare for all single-payer bill ever become legislatively viable.
- “Uh, what makes you think a Medicare for All single-payer system is going to pass under this Congress and this President?” Is a Medicare for all single-payer system likely to pass under President Trump and a GOP-controlled Congress? Absolutely not. But you’re talking to me about policy, and I’m talking to you about messaging. The case I am making is for running on Medicare for all messaging for the long run. While you’re telling me “We don’t have a Congress and White House controlled by progressive Democrats”, what I am saying is “What if I told you that running loudly on Medicare for All messaging in unison for years is a crucial component to securing a progressive Democratic Congress and a progressive Democratic White House?” Look to the Republicans of all places for how this works. Over the past several years, Congressional Republicans pushed a variety of ACA repeal bills, none of which had any chance of passing because of President Obama’s veto power. But it was messaging via legislation; they never stopped reminding their base that “Obamacare is bad!” Of course, it’s 2017, and now that they have a responsibility to deliver on repeal and replace, and they can’t just gin up their base, the fact that Trumpcare is the best they could do says a lot.
- “We need to focus on protecting the ACA. A push for Medicare for All can wait.” It is entirely possible to do two things at the same time. “The only fix to the ACA that we will accept is Medicare available to everyone.”
- “Look to ColoradoCare for a how a push for single-payer will go.” It is true that ColoradoCare was a disaster at the Colorado ballot in 2016. Nearly 80% of Colorado voters voted against it. It is also true high-profile opponents to the law far outnumbered high-profile proponents of the law, but more importantly, opponents included a mixture of Republicans, business organizations, AND Democrats. Both governor Hickenlooper and former governor Bill Ritter were opposed to ColoradoCare, and in the state government, Republican and Democratic legislators joined in opposition to it. When voters saw that both parties were actively knocking this law in an atmosphere where all these business organizations were essentially calling it huge tax raise on working families, they were inclined to distrust this measure at the ballot. Of course, one could make the argument that ColoradoCare was not an ideal implementation of single-payer at the state level as well, and people voted accordingly. That led to problems even among supporters of single-payer. Progressive organizations such as NARAL came out in opposition to ColoradoCare because they questioned whether elective abortions would be covered under ColoradoCare within the framework of Colorado law. Specifics like this were never really worked out in the Amendment’s language. There’s no question a push for single-payer will require relentless organizing, a coherent message, well-crafted policy as the core, and Democrats 100% on board. ColoradoCare was not an example of this, and it shouldn’t be confused as a paradigm for how a push for single-payer should go.
Medicare for all will not just be the target of corporate greed. It’s a threat to white supremacy.
A challenge for the left that is sometimes unappreciated is how racism comes into play when you advance redistributionist policies in racial heterogeneous. In the 1940s, President Truman spearheaded a push for a national health insurance plan run by the federal government. There were two chief opponents of the law. The American Medical Association engaged in tactics that were effectively a progenitor for McCarthyism by calling Truman’s bill a push for “socialized medicine” and called White House staffers “followers of the Moscow party line.” But there was another faction against this measure. From Paul Krugman’s Conscience of a Liberal:
There was also crucial opposition to national health insurance from Southern Democrats, despite the fact that the impoverished South, where many people couldn’t afford adequate medical care, would have gained a financial windfall. But Southern politicians believed that a national health insurance system would force the region to racially integrate its hospitals. (They were probably right. Medicare, a program for seniors equivalent in many ways to the system Truman wanted for everyone, was introduced in 1966—and one result was the desegregation of hospitals across the United States.) Keeping black people out of white hospitals was more important to Southern politicians than providing poor whites with the means to get medical treatment.
One of the harsh realities of advancing redistributionist policies in the United States is succinctly summarized by Alesina, Glaeser, and Sacerdote:
Racial discord plays a critical role in determining beliefs about the poor. Since racial minorities are highly overrepresented among the poorest Americans, any income-based redistribution measures will redistribute disproportionately to these minorities. Opponents of redistribution in the United States have regularly used race-based rhetoric to resist left-wing policies. Across countries, racial fragmentation is a powerful predictor of redistribution. Within the United States, race is the single most important predictor of support for welfare. America’s troubled race relations are clearly a major reason for the absence of an American welfare state.
To be sure, should we arrive at the point where Medicare for all becomes a viable policy in the form of a single-payer system, we will face an opposition that be unprecedented in scale. The entire health insurance industry would know what’s at stake and will use any appendage at its disposal to try and stop it; they will get Republicans (and probably some Democrats) and an array of special interests to deploy everything to stop it. But in attempting to push his national health insurance plan, President Truman was threatening both oligarchy and white supremacy. The reality is that white people have voted against their economic self-interest to preserve white supremacy. That’s why Donald Trump is President after all. Those on the left who advance the cause of Medicare for all must appreciate they will be up against not just corporate greed, but a fear among some people of uplifting “the others”, which Republicans will capitalize on. A reality of Medicare for all is that poor minorities would be the most uplifted by such a policy (provided it is administered fairly among racial lines, which admittedly is not guaranteed), and Republicans would frame this as a handout to minorities.
This is a challenge to be appreciated. It is not an excuse to refrain from running on Medicare for all.
Medicare for all is sane policy, the right message, and the right thing to do.
While Paul Krugman’s Conscience of a Liberal was written in the pre-ACA years, there is still one maxim he outlined that remains true even now:
Private insurance companies, however, don’t make money by paying for health care. They make money by collecting premiums while not paying for health care, to the extent that they can get away with it.
The reason big health insurers were declaring their intent to pull out of the ACA marketplaces? They’re losing on profits. Those on the right who would see this as an indictment of the ACA are missing the big picture: it’s an indictment of the administration of health coverage while simultaneously generating a profit. If every U.S. citizen is covered under Medicare, all the costs for health insurance that would’ve been funneled into profits go away.
In summary, let me note that I do not believe a fight for Medicare for all will be easy. On the contrary, it may be one of the arduous fights in American politics. But it’s a fight that elected Democrats across the country should start now, even if Trump controls the White House and Republicans control Congress. That’s all the more reason to start the fight for it now quite frankly. Many Americans are scared of losing their coverage or scared of going bankrupt, and they see that Trumpcare is nothing more than a tax cut for the rich that comes at the expense of the vulnerable. Campaigning for Medicare for All in lock step sends the message no American should be deprived of what should be treated as a public good, and Democrats being relentless on this front while never ceding to Republican framing is congruent with the spirit of resistance to Donald Trump and the Republicans who enable him. And bear in mind, the Republican base pretty much believes everything you propose is a slippery slope to socialized medicine. Based on that reality, the merits of the policy, and the potential opportunity for Democratic messaging, I do not see a compelling reason to hold back.
So to all elected Democrats: just run on Medicare for all!
UPDATE (1:24 AM, 3/21/17): Revisions to Trumpcare are out and focus heavily on turning Medicaid into a nightmare: work requirements for non-disabled, non-pregnant, non-elderly adults on Medicaid, allowing funding of Medicaid via block grants, and preventing any further states from taking advantage of the Medicaid expansion. To reiterate a major thesis of this piece, Republicans are coming for it all. If we’re essentially at the twilight of the Democratic Party’s entire legacy on health care, why not resist with “Medicare for all!” as our battle cry?