By John E. McDonough
Health Affairs Blog, February 21, 2020
Too much time has been spent in this presidential campaign season arguing about Medicare for All. It is not because it’s a bad idea. It is because, for the foreseeable future, Medicare for All has zero political chance to become law. To begin understanding why, consider the 70-year history of legislative efforts in the US to advance toward universal coverage. And then consider the realities in the current US political environment.
Exhibit 1 details six health coverage expansion efforts by five US presidents, indicating the year of decision, plus party control of the White House, Senate, and House of Representatives. I characterize each effort as comprehensive, meaning an attempt to achieve full universality in one bill, or incremental meaning advances for discrete and previously disenfranchised subpopulations. The final column shows the outcome of the effort.
Insights leap from this table. First, over 70 years, serious, full-on presidential and congressional campaigns to enact full or near-universal health coverage—with the exceptions of President Richard Nixon in 1974 and President Bill Clinton in 1997—were during periods of unified Democratic control of the White House, Senate, and House of Representatives (aka: the Trifecta). Furthermore, landmark coverage advances in 1965 and 2010 came from US Senates with 68 and 60 Democratic members, respectively, while losses in 1950, 1974, and 1994 occurred with 54-, 56-, and 57-seat Democratic majorities, respectively. Based on this small sample, it is not just having a Trifecta that matters; it’s having a super-majority Trifecta.
Second, since 1950, windows of opportunity to advance universal coverage occur rarely.
Third, among these six efforts (no hint at statistical significance although 70 years is a good run), three comprehensive bills lost and three incremental bills passed. Except for the limited—and subject-to-appropriation—CHIP program in 1997, a substantial Democratic Trifecta was a precondition for success.
Four of the past 40 years saw Democratic Trifectas in two fleeting periods, the first two years each of the Clinton and Obama administrations, both characterized by contentious and ambitious drives to advance universal coverage, comprehensive and incremental respectively. Both drives were factors in Democrats losing their majorities in the House and Senate in 1994 and in the House in 2010. One clear conclusion: Since 1980, Trifecta control comes and goes, and goes more easily than comes.
Now, let’s examine the same results for the New Deal era: 1933–80 (exhibit 3).
What a difference a political era makes! In contrast to the New Deal era, our modern neoliberal era, kicked off by President Ronald Reagan, is characterized by a decided preference for divided government. Since moments of Democratic Trifecta control have been so fleeting, that demands responsibility to be mindful and strategic when those opportunities arise.
What are the prospects for Democratic majority control of the US Senate in 2021—and for a supermajority with at least 60 Democratic votes needed to avoid death by filibuster? According to the non-partisan Cook Political Report and the University of Virginia’s Center for Politics’ “Crystal Ball,” If Democrats beat the odds and win a Senate majority, they will at best have a 1–2 votes majority. While impeachment and economic uncertainty could upend that balance, hopes for a Democratic supermajority are close to zero, and hopes for a slender Democratic majority are 50–50 at best.
Going for the gold ring of Medicare for All with a slender Democratic majority may guarantee repeating the 1950 and 1994 experiences, squandering another rare moment of Trifecta control. Meanwhile, groups such as the Urban Institute and the Commonwealth Fund have crafted sophisticated and smart reform proposals to achieve near-universality short of Medicare for All. Many of their proposals could be enacted by Congress using the budget reconciliation process that only requires 51 votes for Senate passage. Plausible pathways to universal coverage exist without the “burning down the house” risks of Medicare for All.
Just about anyone I know who supports the public purpose behind Medicare for All (I’m one of them) also supports action on other urgent, compelling matters affecting the nation’s health and well-being, including climate change, immigration reform, voting rights, campaign finance reform, tax reform, education policy, infrastructure, gun policy, and so much more.
If Democrats can further advance toward near-universal coverage without the life-or-death struggles of Medicare for All, they just might achieve meaningful and historic progress even as they preserve political capital to make progress on other compelling and urgent policy needs. They might even figure out how to hold Trifecta control in Washington for more than two years.
By Don McCanne, M.D.
When you have the right policy and the politics are wrong, you don’t change the policy to comply with the dysfunctional politics, you change the politics instead.
On policy, the single payer model of Medicare for All automatically includes everyone under an efficient model of financing care that recovers hundreds of billions of dollars in administrative waste (Annals of Internal Medicine 1/7/20), while removing financial barriers to care. Instead it would be funded with equitable progressive taxes that each of us could afford. Because of the administrative savings and other efficiencies we could actually spend less than we do now (PLoS Medicine 1/15/20). In rejecting the single payer model because of the alleged lack of political feasibility, the default model is an incremental approach that builds on our current programs, including ACA, and maybe adding a public option. Such an approach fails to recover the profound administrative waste, fails to establish stability in individual coverage, will still perpetuate uninsurance and underinsurance, and will perpetuate provider networks that limit choice and access to care.
And those private insurers that we would lose under single payer? Seven investor-owned publicly traded health insurers now control almost a trillion dollars of our health care spending. In the last year their revenue increased by 31% whereas their profits increased at double that rate: 66%! Their combined membership is 165 million – half of the U.S. population (Modern Healthcare 2/18/20). The primary obligation of publicly traded corporations is to maximize profits for the shareholders even if doing so is not in the best interests of patients. We should strive for a system dedicated to patients, not to passive investors.
And political feasibility? Over three-fourths of Republicans and Democrats rank “taking steps to lower the cost of health care” as “extremely” or “very” important – the top priority of Americans – according to the latest Politico/Harvard poll. The political barrier exists only because people still do not understand the vast superiority of an improved Medicare that covers everyone over the expensive, administratively wasteful, dysfunctional multi-payer system we have.
As more people understand that a single payer system will always be there for them and their loved ones, the support grows, and that support is what will create the political feasibility that too many claim is lacking. Telling people that they want to keep their insurance they get through work should not be used to dictate policy when over 60 million people leave their jobs each year (BLS).
Instead of bemoaning the divisive politics that impedes progress, the policy community, with the help of the media, should be informing the public about this great opportunity we have to provide affordable care for everyone by merely taking our revered Medicare program and fixing it so it works better and then expanding it to cover everyone. If a critical mass of the people clearly understand this concept, the political barrier would melt away.
PNHP advocates for health care justice for all in the form of the single-payer model of an improved Medicare that covers everyone. As an organization we do not support any political candidate nor any political party.
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