By Paul Krugman
The New York Times, October 21, 2019
On Sunday, Elizabeth Warren said that she would soon release a plan explaining how she intends to pay for “Medicare for all.” Like many policy wonks, I’ll be waiting with bated breath; this could be a make or break moment for her campaign, and possibly for the 2020 election.
There are three things you need to know about Medicare for all, which in the current debate has come to mean a pure single-payer health insurance system, in which the government provides all coverage, with no role for private insurers.
First, single-payer has a lot to recommend it as a way to achieve universal health care. It’s not the only route — every major advanced country besides the United States achieves universal coverage, but many of them get there via regulations and subsidies rather than by relying solely on public insurance. Still, single-payer is clean and simple, and many health economists would support it if we were starting from scratch.
But we aren’t starting from scratch, which is the second thing you need to know. More than half of Americans are covered by private health insurance, mainly through employers.
Not many people love their insurance companies, but that doesn’t mean that they’re eager to trade the coverage they know for a new system they don’t. Most people probably would end up better off under single-payer, but convincing them of that would be a hard sell; polls show much less support for Medicare for all than for a “public option” plan in which people could retain private insurance if they chose to.
Which brings me to the third point: In reality, single-payer won’t happen any time soon. Even if Democrats win in a landslide in 2020, taking control of the Senate as well as the White House, it’s very unlikely that they will have the votes to eliminate private insurance.
Warren, who has made policy seriousness a key part of her political persona — “Warren has a plan for that” — surely knows all of this. And early this year she seemed to recognize the problems with a purist single-payer approach, saying that she was open to different paths toward universal coverage.
Since then, however, she seems to have gone all in for the elimination of private insurance.
The right question is whether the overall costs facing U.S. families would go up or down. Warren has been claiming that for most families, they would go down, but she hasn’t offered specifics.
Also, let’s get real: If Warren gets the Democratic nomination, the outcome of the general election isn’t going to hinge on dueling think tank estimates.
The election might, however, hinge on the support of people who have good private coverage and would be nervous about making a leap into the unknown, no matter how many facts and figures Warren deploys.
Whatever Warren comes up with, this is a crucial moment. There are many excellent things in her overall policy agenda; but she won’t get a chance to do those things unless she can extricate herself from what looks like a health policy trap.
NYT Reader Comment:
By Don McCanne, M.D.
As policy, the single payer model of Medicare for All is vastly superior. It is efficient (recovering hundreds of billions of dollars in administrative waste), effective (includes everyone throughout life), comprehensive (covering all essential health care services), and equitable (financed with progressive taxes based on ability to pay and thus affordable for everyone). Our private plans, even with ACA marketplaces or with a competing public option, cannot come close to that.
Yet those who understand this often slide into the argument that we can’t do it because the politics are too difficult, and, by implication, we need to compromise on policy, accepting reform that achieves none of these goals.
When the proposed policy is right and the politics are wrong, you don’t change the policy, you change the politics. That begins with people having a clear understanding of the single payer Medicare for All model. If they understand it, most will demand it.
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