By James A. Morone, Ph.D.
The New England Journal of Medicine, October 25, 2017
In April 1946, President Harry Truman introduced a single-payer health plan and met the same reaction that would greet Senator Bernie Sanders (I-VT) and his colleagues when they proposed “Medicare for All” in September 2017. “It is believed by competent Congressional observers to have little chance of approval,” reported the New York Times back in 1949. Newsweek was blunter: “No chance at all.” Neither Truman nor Sanders even bothered to include financing for their plans. Truman had no more success with a scaled-back proposal to cover only people over 65 years of age, but 13 years later President Lyndon Johnson signed the Truman revision into law as Medicare, declaring that the United States was finally harvesting “the seeds of compassion and duty” that his predecessor had sown. A proposal with no chance in one era had become law in another. Medicare proved so popular that it came to be a third rail of American politics — dangerous to touch. What lessons does Truman’s success hold for today’s “no chance” Medicare for All?
The usual metrics for evaluating policy proposals — vote counts, Congressional Budget Office scores, and tax calculations — are misleading because Medicare for All is an idea for the long run. For a more accurate assessment of its prospects, keep an eye on four key questions.
Is there a right to health care? The Affordable Care Act and the efforts to repeal and replace it raised fundamental ethical questions about whether Americans have a right to health care and, if so, whether government should secure it. The Medicare-for-all proposal responds with a strong claim for a right to roughly equal health care coverage for everyone. The American patchwork — superb health insurance for some; no health insurance for 30 million others; and shaky high-deductible, high-premium plans on the individual market and in many workplaces — is not just poor policy. It is wrong. It violates the norms of communal decency. Late-night talk-show host Jimmy Kimmel distilled this view when he tearfully responded to the House repeal-and-replace plan: “No parent should ever have to decide if they can afford to save their child’s life. It just shouldn’t happen. Not here.”
Medicare for All is, first and foremost, an exercise in moral persuasion. It will become a serious policy proposal if it creates a major surge in public opinion. That’s how “no chance” reforms win in the United States, whether it’s the passage of Medicare or the right of same-sex couples to marry. On this measure, Sanders is making progress. Last time he proposed his plan, he stood alone; this time, 16 Democrats crowded beside him — including some leading contenders for the next presidential nomination. The difference sprang from the 12,029,699 votes Sanders racked up in the Democratic presidential primaries. To handicap the future prospects of the plan, watch what happens as candidates take it to the voters.
Won’t the cost savings eventually convince skeptics? International comparisons reveal that other wealthy countries cover most of their populations with much lower spending. Although every country is unique, no other nation supports the sprawling administrative, insurance, and billing bureaucracies that reach into every U.S. clinic and practice; moreover, single-payer systems offer budgetary levers that our own fragmented nonsystem does not have. The results are striking. For example, Canadian health costs were indistinguishable from those in the United States until Canada finished introducing its national health insurance program in 1971; then, health care’s share of the Canadian economy flattened out dramatically. By 2014, according to the World Health Organization, Canada spent 10.4% of its gross domestic product on health care, as compared with the 17.1% we spent in the United States. Closer to home, our own single-payer plan, Medicare, appears to constrain rising costs more tightly than private insurers do.
The data tempt advocates to push Medicare for All as an efficiency fix for U.S. health care. However, mere efficiency arguments are unlikely to propel a change this big through the multiple checks and balances of U.S. politics. In politics, good data are not enough. They are a necessary but not sufficient condition for winning major legislation. Proponents will first have to create a movement.
Still, the efficiency claim always lingers in the middle distance: like Charles Dickens’s ghost of Christmas yet-to-come, single-payer plans challenge us to change our ways. If more conventional approaches fail to control costs and offer Americans more reliable access to health care, Medicare for All will continue to beckon as the fairer, less expensive, cross-nationally tested alternative.
But what about the taxes? Skeptics emphasize the new taxes that Medicare for All would require. In a white paper accompanying his proposal, Sanders fills in some vertiginous details: raise marginal income tax rates to 40% on incomes from $250,000 to $500,000; raise rates to 52% for incomes above $10 million; and tax capital gains and dividends like income from work. Do those kinds of increases doom Medicare for All? Perhaps just the reverse, for this is one of the few policies that directly confronts American inequality.
No other country has experienced a rise in inequality as steep or as high as the one we’ve seen in the United States. In 1970, standard inequality measures pegged the United States at roughly the same level as France and Japan; almost 50 years later, U.S. inequality levels are closer to those of Mexico and Brazil than to those in Northern Europe. Today, the top 1% of households control 38.6% of the country’s wealth, far more than the bottom 90% (which controls just 22.8%). The median white family (in the exact midpoint of the income distribution) is 10 times as wealthy as the median black family. Intergenerational economic mobility has stagnated. Political scientists generally believe that rising inequality and slowing mobility have a destabilizing effect — and they may be driving the angry populism that is now stirring on both the left and right ends of the political spectrum.
Medicare for All offers politicians a way to squarely address the issue. It would lift a substantial financial burden from low- and middle-income families — their health insurance premiums — and shift the weight to wealthier Americans by raising their taxes. In reversing inequality, taxes are not a bug but a populist feature. Disruptive populism ended past American gilded ages, and it shows signs of challenging the current one. If so, Medicare for All is on a short list of available policies designed to push back on inequality.
Isn’t Medicare for All politically implausible in antigovernment America? It is easy to forget how dramatically U.S. politics changes from era to era. New issues rise onto the agenda, different national values grow more (or less) important, underlying political assumptions evolve, and an entirely new coalition grows influential. What seems impossible in one generation is taken for granted in another. The kind of turbulence we are experiencing in contemporary party politics often signals precisely this sort of sea change. One necessary condition for a breakthrough change is already in place: a righteous band of reformers, deeply committed to a cause, pushing against all odds.
Medicare for All fits awkwardly into the Washington conversation because it is more than a health policy prescription. It aims to foster changes on three different levels of analysis. It is a policy proposal designed to improve health care delivery, an ambitious claim about equality and social justice, and an effort to usher in a more progressive era in American politics. Each is a long shot, but Medicare for All and its advocates stand in a venerable reform tradition that has rewritten U.S. politics many times in the past. It would be a mistake to dismiss them now.
James A. Morone, Ph.D. is the John Hazen White Professor of Public Policy and Professor of Political Science and Urban Studies, Brown University
By Don McCanne, M.D.
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