Political Animal


June 27, 2012 1:26 PM “Medicare For All” No Political Silver Bullet

By Ed Kilgore

With all the recent talk about how Republicans might respond to an invalidation (in whole or substantial part) of the Affordable Care Act, it’s worth asking now and then how Democrats will respond, other than (for the most part) anger. And among many progressives, the answer is actually pretty clear: with a renewed push for a single-payer national health insurance system, which is what many preferred in the first place.

This is not the time or place for a discussion of single-payer on the merits, though I have to say I’ve personally begun warming to it more with each recent encounter with the health care system.

But I do want to address something that I think an awful lot of progressives believe reflexively: that single-payer, if marketed as “Medicare For All,” would be politically unassailable thanks to the popularity of Medicare itself. This seems to be the premise of a drive already underway in anticipation of an adverse Supreme Court ruling on ACA, as reported by TPM’s Brian Beutler:

[D]isappointed activists aren’t sweating Thursday’s Supreme Court ruling. If the health care law fails, they believe it will open up a whole new set of political and substantive opportunities for liberals.
“The right fought [the Affordable Care Act] just as bitterly as they would have fought if it was single payer,” said Chuck Idelson, spokesman for National Nurses United — a union and trade association of registered nurses that has consistently supported Medicare for all.
“Medicare continues to be an extremely popular reform — it’s one of the most popular reforms in U.S. history,” said Idelson.

Absolutely true. But the idea of making Medicare universal—even if it initially gains a positive response in public opinion—is going to run into some serious heavy weather once specifics are discussed and criticism begins.

As I’ve argued for a good while as others wondered why Republicans have been able to pit Medicare beneficiaries against those benefitting from ACA, many and perhaps most seniors receiving Medicare do not perceive the program as a social good that government gives them, but as an earned benefit—earned through lifelong payroll taxes, premium payments (once retirement age is reached), and more abstractly, through a lifetime of work that is performed before eligibility is reached. Extending “Medicare” to “all” would change that assumption rather dramatically, particularly with respect to younger beneficiaries (including children) who haven’t “earned” much of anything, from the point of view of seniors. The GOP talking points write themselves: Liberals want to give YOUR Medicare to THOSE PEOPLE! If “Medicare For All” is vastly easier to understand than ObamaCare, then so, too, are the racial and generational arguments against making it available to darker and younger people as opposed to just “cutting” Medicare (or setting up “death panels”) to give something new to THOSE PEOPLE. I’m afraid anyone who thinks a universal Medicare would be as popular as the current Medicare is missing this important if unfortunate point.

The bottom line is that the case for universal health coverage has to be made, on both moral and economic grounds, again and again until a durable majority insists on it. Hijacking the popularity of Medicare to turn it into something very different won’t get around that painful but essential task.

Ed Kilgore is a contributing writer to the Washington Monthly. He is managing editor for The Democratic Strategist and a senior fellow at the Progressive Policy Institute. Find him on Twitter: @ed_kilgore.


  • mb on June 27, 2012 1:46 PM:

    "The bottom line is that the case for universal health coverage has to be made, on both moral and economic grounds, again and again until a durable majority insists on it."

    Unfortunately, however, it appears the American Healthcare System is about to be crashed into a bridge by the Court. If the mandate goes down, with the rest of ACA in place, the status quo vis a vis the insurance industry cannot survive. I find much mordant amusement in watching conservatives destroy their own institutions by turning against policies they devised.

    Really makes you want to turn the whole circus over to them. Yeah, that's the ticket.

  • Lifelong Dem on June 27, 2012 1:46 PM:

    "But I do want to address something that I think an awful lot of progressives believe reflexively: that single-payer, if marketed as 'Medicare For All,' would be politically unassailable thanks to the popularity of Medicare itself."

    Does anyone actually believe that, Ed, or do you just think they do? I think most progressives who lived through the 90s are aware that any form of government-provided health care coverage will be fought like a war by the right.

  • DAY on June 27, 2012 1:46 PM:

    As Rachel Maddow details in her book "Drift", our nuclear arsenal is in a SHOCKING state
    of disrepair!
    Thus, we cannot afford universal health care any time in the foreseeable future. (If you want insurance, then go get a job at a defense contractor. . .)

  • Daddy Love on June 27, 2012 1:50 PM:

    "The bottom line is that the case for universal health coverage has to be made, on both moral and economic grounds, again and again until a durable majority insists on it. "

    I would say yes and no. What we need is some sort of universal health care to be passed that maybe doesn't take ten years to phase in, so that EVERYONE'S in, people see the tangible benefits, and yes, they become dependent upon it reasonably soon. THAT'S what gives you a durable majority.

  • James E. Powell on June 27, 2012 1:51 PM:

    Extending “Medicare” to “all” would change that assumption rather dramatically, particularly with respect to [non-white] beneficiaries (including children) who haven’t “earned” much of anything, from the point of view of [whites].


    Because that is exactly how it would be argued.

  • c u n d gulag on June 27, 2012 1:55 PM:

    If Jesus himself came down and gave a plan covering EVERYONE to Democrats, the Conservative would go all "birther" on Jesus, and claim he was actually Satan, and to prove that he wasn't.

    And no amount of proof would ever suffice.

    And if Jesus himself came down and gave a plan covering EVERYONE to Republicans, they would take a look at it, and go all "birther" on Jesus, and claim he was actually someone else, because the plan helps EVERYONE - so there's no sinners and no saints, and no one's got better coverage than someone else.
    And how not rewarding rich and powerful people with better coverage is Socialist, and not very Christian at all.

    In other words, cruelty and a sense of superiority are part and parcel of the Conservative mindset.

    And, any system that didn't allow for some cruelty and that sense of superiority for them, wouldn't stand a chance.

    Conservatives will fight tooth and nail, because they are cruel @$$holes, who think themselves superior to everyone else - and want to see people in abject pain and misery because it reinforces their own sense of superiority.

    So, good luck!

  • Plume on June 27, 2012 2:15 PM:

    Easy way around that problem. Just charge a premium. And all premiums could be reduced across the board, because an influx of young, health people would help balance the risk pool.

    Currently, Medicare covers the most expensive demo in the entire health care risk pool. Bring in a lot of young, healthy people, and you offset that risk and drive down overall costs.

    In fact, you could drive them down so much, it could even break even or make a profit. Right off the bat, its overhead is much lower than any private company's. It doesn't have to pay our massive compensation to executive, shareholders, lobbyists, tax attorneys, ad agencies, marketing firms and the like. It's far cheaper to run.

    Everyone would pay a premium, and that premium would be lowered because of the radical change in demographics and health risks.

    If CBO scored this, it would actually shock the country. No more Medicare loss. It would probably be a profit for taxpayers -- or we could reduce premiums to a break even stage.

  • Peter C on June 27, 2012 2:27 PM:

    "But I do want to address something that I think an awful lot of progressives believe reflexively: that single-payer, if marketed as “Medicare For All,” would be politically unassailable thanks to the popularity of Medicare itself."

    I agree with @lifelong; I've never heard any progressive who says that getting Americans (and Republicans in particular) to accept single-payer health care would be EASY, just that it is clearly the best outcome for the country. We know it will be a fight (and that Republicans will fight dirty).

    It's a fight that Progressives WANT TO HAVE, though. And, it has been frustrating to have to 'toe the line' and defend a compromise-laden ACA which is full of concessions which did not, in fact, garner it any opposition support.

    It was especially frustrating that even DISCUSSION of single payer was effectively blocked by filibuster in the Senate. An endless debate procedure was used to prevent any debate of it (not that ANY debate actually occurs anymore - it's all a shouting match of adamant people with fixed and unshakable opinions).

  • MURPHRO2 on June 27, 2012 2:29 PM:

    Instead of trying to persuade this current batch of seniors we are dealing with, why not make the health care debate about it will help business thrive? If you can tell business owners that having universal health care means they no longer have to pay for their employees benefits, no longer have to carry any workman's comp insurance (a huge burden for many small businesses) and that cost of lawsuits would drop dramatically (all health related issues would already be covered) thus greatly reducing the cost of liability insurance, would not the business community jump at the chance? Universal health care should be sold as a boon to small business.
    And for large corporations with pension plans, universal coverage would remove this whole burden from their bottom line. Frankly, I don't understand why the business community is not all over this.

  • Steve on June 27, 2012 2:31 PM:

    Another way to get there is to gradually lower the age for Medicare eligibility. Right now you have lots of people in their late 50s or early 60s who are desperately clinging to their jobs so they can keep insurance until they go on Medicare. If those people don't actually want to work any longer, I'd love to free those jobs up to be taken by recent college graduates. Also, the people in the 55-65 bracket who lose their jobs are just royally screwed in every sense. So maybe just lower the eligibility age to 55 and then go from there.

  • Plume on June 27, 2012 2:39 PM:

    Aside from the reduced costs for business, conservatives should be on board for this, because they're always talking about entrepreneurs and how important they are in America, and how Obama is supposedly solely responsible for their troubles.

    Okay. So, a lot of people stay at their jobs because of their health care. They fear losing it. Perhaps if they didn't have to worry about that, they could start new companies, spur innovation, etc. etc. etc.

    In short, Medicare for All would reduce costs for patients, taxpayers, businesses, spur innovation and lower the deficit dramatically.

    What's not to love?

  • gdb on June 27, 2012 2:44 PM:

    Agreed with many above. Medicare Part E (for Everyone) is not an easy sell--nothing in health care is an easy sell. But it helps make the sale for half a dozen reasons others note above. And a plurality to majority support the concept. BHO never tried-- he compromised WAY too soon and too often.

  • mb on June 27, 2012 2:44 PM:

    Careful, Plume, you're making sense.

  • FlipYrWhig on June 27, 2012 2:57 PM:

    Plume is right on the merits. Ed is right on the politics. It doesn't matter how good an idea it is or how much people would benefit. It would be distorted into a form of "welfare," a giveaway to undeserving losers who haven't worked hard enough to deserve it, just like the actual ACA was, on less of a basis. Conservatives in both parties are opposed to giving people more benefits. To win this argument you need to convince _them_ that they're more likely to win by backing it than by opposing it as a sign of bleeding-heart liberalism run amok -- and politicians who think that way, and voters who vote that way, are a big chunk of _Democrats_ in the Sun Belt and the Rust Belt.

  • Plume on June 27, 2012 3:02 PM:

    Not sure about the politics. How could they turn it into a "giveaway" when people would be buying it? They would pay a premium for coverage, just as they would a private policy.

    It would just be far lower, and current Medicare recipients would see a big fat REDUCTION in their premiums, thanks to extending it to everyone.

    It can't lose.

    The CBO could score it and show that it would reduce the deficit by hundreds of billions a year. Trillions over the course of the next decade. How on earth could that not win?

  • David E. Ortman on June 27, 2012 3:02 PM:

    The biggest single obstacle to "single-payer" are those who conjured up the misleading term "single-payer" in the first place.

    What does the term "single-payer" convey? It conveys a magical Santa Claus somewhere who is a single individual who will somehow pay everyone's medical bills. This shorthand term completely skips over the fact that there is no "single-payer," but requires all taxpayers to pay for a national health care system. There is no free lunch, just as there is no free medical care from a single-payer.

    The sooner health care advocates get around to some honesty in what is proposed, "We advocate a government run taxpayer funded health care system, including a simplified claims and payment system that will reduce health care administrative costs." the better.

    In summary, stop using the term "single-payer."

  • SecularAnimist on June 27, 2012 3:09 PM:

    Ed Kilgore wrote: "This is not the time or place for a discussion of single-payer on the merits"

    There is never a time or place for discussion of single-payer on the merits in today's Democratic Party. That single-payer stuff is for the "professional left".

    That's why Nancy Pelosi and Obama both declared single-payer "off the table" before the debate over the ACA even started, and why advocates of single-payer were systematically excluded from the "health reform summits" that the Obama White House convened.

    The leadership of the Democratic Party is not afraid of the political obstacles to single-payer -- they ARE a political obstacle to single-payer.

  • Plume on June 27, 2012 3:12 PM:

    IOW, current users would see their premiums lowered dramatically. What's not to love about that?

    It would dramatically reduce the deficit, because Medicare for All has a great chance of actually breaking even, perhaps even making a profit. Instantly, Medicare goes from a net drain on the budget to breaking even or a net plus.

    Businesses would save a fortune. People could afford to start businesses, because they wouldn't have to keep their present jobs because of health care.

    Americans would save a fortune if they're on Medicare or off.

  • bdop4 on June 27, 2012 3:20 PM:

    The underlying premise of single-payer is that the billions in premiums now paid to for-profit corporations would be diverted into a universal Medicare program. The advantage is that 15-20% of those premiums aren't allocated to shareholder dividends, executive salaries and promotional costs.

    Seniors need to understand that all the younger people paying into the system will be covering the drugs and medical procedures that they, as a group, need much more than younger, healthier participants.

    If you can't sell that, then you should find another job.

  • exlibra on June 27, 2012 3:26 PM:

    @Plume. But, if everyone had to pay a premium, that would be a "mandate", no? And mandate is what's likely to be tossed out first of all, by our unfriendly RATS (Roberts, Alito, Thomas, Scalia).

    And that's before we even begin to discuss whether everyone pays the same amount (in which case some people might *still* not be able to afford it), what the amount should be, and whether everyone -- even those who can afford a Cadillac-sized premium -- would be entitled to the same care (no 5 heart operations for Cheney, or else 5 for everyone).

    Nothing's ever simple, when it gets to something as huge as the healthcare system which involves hundreds of millions of people. That's why ACA looks like something a dog had dragged in, when you try to give it a closer look.

  • Plume on June 27, 2012 3:35 PM:

    No mandate. You don't have to buy into the program. It's your choice.

    But, the program could be made so incredibly attractive, Americans would be complete fools not to buy into it.

    But it would be voluntary. Not mandated.

  • Celui on June 27, 2012 3:41 PM:

    This is a very timely post, and I appreciate all the comments shared above. As for one who has just stepped into Medicare from private insurance, I can attest to the ease and universality of the coverage I now have, as opposed to the very exclusionary insurance coverages that I formerly paid for. Let's consider Medicare as a mandate, required payment in advance for the inevitable needs that come with age. No matter the current age of the wage-earner, s/he pays into a system with portability, with universality of records, with the (perhaps) eventual power to negotiate real pharmaceutical savings. And, let's forego the reality of the 'we' vs 'them others' mentality for a moment: is it not in the very best interests of this nation as a whole to provide for the medical needs of its citizens in ways that are both universal and cost-effective? Medicare is a foundation program, on top of which I overlay a private insurer additional coverage at cost-for-coverage that I can control. And the medical profession should be paid for health maintenance, not fee-for-service providers. And, one other thing: since when is it cost-effective to continue a hospital system that is redundant, repetitive, and more or less a series of choices for those who want a country-club atmosphere? Talk about adding to costs! There's no reason why this nation's decision-makers cannot agree on the basic concept of foundational coverage through payroll/Medicare taxes as we now have. And, yes, if it were a 'sliding scale', I'd be paying more for my share of Medicare, and I'd not balk, because I'd know that my elderly neighbors and relatives along with the less fortunate in my neighborhood would have responsible medical services without the high costs of the emergency room. Ed's got the right tack, and to recognize the political quagmire that it will encounter is not to detract from the very clear need for this type of medical services direction. Listen to Jim Wallis at Sojourners or any number of 'faith leaders' who are calling for universal coverage such as Medicare for all. They're on the right track. Quit protecting the high-cost insurance companies who have, so far, dictated the directions of medical services for too long.

  • Consumatopia on June 27, 2012 4:05 PM:

    It's worth noting that while this is a what a lot of Medicare beneficiaries think, it's false: Medicare is *not* an earned benefit--it *is* welfare. Today's beneficiaries are going to cost a lot more to the system than they paid into it. The proposals for addressing this seem to be either A) increase Medicare taxes or B) decrease benefits, but only for people under 55.

    For all people resent the mandate, it's surely a far, far greater injustice for people who can't afford insurance themselves to be forced to pay for someone else's insurance--especially when there's no guarantee that they themselves will ever receive those benefits. (Contemplate that for a moment--there are people paying into Medicare now who won't be able to afford life-saving care for themselves and therefore won't live to be old enough to use Medicare.)

    I say liberals should advance a simple principle--everyone paying into Medicare should get Medicare *now*. Either everyone gets Medicare, or nobody gets Medicare. Either outcome would be an improvement.

  • Barbara on June 27, 2012 4:25 PM:

    Well, I would say that Medicare buy-in would be one way to deal with these objections (these "other" people will have to pay more to get it, never mind the subsidies in place for those that can't afford it).

    The other point to be made to seniors is that if they want to continue visiting their community hospital, it's more likely to be there if not so many other people can't afford care there.

    The messaging can be done -- you can even "clone" Medicare and call it something else for those who are under 65, sort of like railroad workers are part of the RRB even though it is identical to Medicare.

    I actually think that a more promising model would be Tricare which actually manages most of the time to combine the best features of Medicare and private insurance, because it gets the information capabilities of private payers, who do not engage in underwriting, while applying most of the coverage, reimbursement, and beneficiary protection policies of Medicare.

    The real opposition will come from hospitals, but without the possibility of a mandate, even they might give up the ghost because right now, it probably means more to them to have fewer uninsureds than higher reimbursement per capita.

  • SecularAnimist on June 27, 2012 4:54 PM:

    You know, folks, Canada has figured out how to do universal single-payer health insurance, and how to do it quite well. And they even call it "Medicare".


    So what's the big freaking problem for the "exceptional" USA?

  • thebewilderness on June 27, 2012 5:43 PM:

    Considering that "those people" are our children and grandchildren I really don't think most of us would object.

  • JGH on June 27, 2012 6:57 PM:

    The last thebewilderness comment highlights something I have never really understood. I am not sure why my own parents want to screw me out of health care. And, in my case, that is actually true, since I come from a Republican family. But even in families where there is not a generational political divide, it seems the older generation seems perfectly happy screwing over their kids and grandkids.

  • Doug on June 27, 2012 8:26 PM:

    JGH, most often I think you'll find that the "generational divide" has been, shall we say, widened by opponents of some form of single payer national HCI. I have little doubt many, if not a large majority, of those seniors determined to maintain "their" Medicare status, do so believing that the only other option would be to have Medicare taken away from them. "If we try to ensure THEM, we'll have to make cuts SOMEWHERE..."
    Not that I'm accusing Republicans of lying or anything...

  • FlipYrWhig on June 28, 2012 12:55 AM:

    The older generation may not begrudge their children and grandchildren having access to Medicare. But they begrudge emphatically Negroes, illegals, and other assorted undesirables having access to it -- either because they didn't pay their dues to get it, or because they'll crowd the doctors' offices and force them to wait longer when they're sick. You have to look at it as a system based on the principle of taking stuff from your pocket and putting it in someone else's -- not as one where you get more stuff, or to keep the stuff you already had. To be a conservative is to be selfish and to think that you deserve everything you have, and to be convinced that there are millions of people out there itching to grab it away from you.

  • esaud on June 28, 2012 9:33 AM:

    My pipe dream:

    MoveOn buys airtime on TV every day for a month with two or three simple graphs. One would show how we pay twice as much as any other country for medical insurance and copays. The caption would read: Would you rather you and/or your employer fork over $6,000 to $7,000 for medical coverage, or write a check for $3,000 to Medicare?

    Another would be a simple graph of how the top 1% has been grabbing a bigger and bigger piece of the pie. A third would show vacation time in the US v every other developed country.

    Actually, in Massachusetts, Elizabeth Warren has been running very effective ads "the middle class is being hammered", while Scott brown is running his silly "Mr. Mom" ads.