This Won't Be The Final Medicare-For-All Argument-- But It Should Be

I've been all wound up this week in getting to know a whole bunch of new candidates, trying to suss out, in the immortal words of Chris Hayes "what they'll fight for" and "who they'll fight for." The other day I was on the phone with a young attorney, Marqus Cole, in Gwinnet County northwest of Atlanta. Healthcare is a big deal for him and we got down to discussing Medicare-For-All. A Bernie supporter and big fan of Pramila's new-and-impoved Medicare-For-All bill, he insisted on differentiating what Pramila and Bernie are talking about from the bumper-sticker mentality that leads people think that what Medicare-For-All means includes the obvious flaws in the current Medicare, namely unjustifiably high drug price-- tacked onto Medicare by the GOP, without one Democratic vote in the House (Part D)-- and the dearth of dental, vision and hearing care, again, courtesy of conservatives who, for years, have refused to allow these essential updates-- updates that Bernie and Pramila make in their new Medicare-For-All proposals.

And that takes us right to the new Jacobin, where Matt Bruenig has a timely piece, Medicare for All Critics Are Telling Lies. "Lies" is a harsh word and I've been attributing Pelosi's misleading on this to... confusion, ignorance (maybe willful, maybe not) and pride in her greatest legislative accomplishment, Obamacare. Bruenig, of course, was referring to Pelosi when he wrote "critics."

One of the most common myths about the US health system is that if you like your insurance, you can keep it. But millions of people are thrown off their employer-based coverage every year-- so the only solution is Medicare for All.

Nancy Pelosi said this about Medicare-For-All the other day: "When most people say they’re for Medicare-for-all, I think they mean health care for all. Let’s see what that means. A lot of people love having their employer-based insurance and the Affordable Care Act gave them better benefits,” said Pelosi, who shepherded the ACA through Congress in 2009 and 2010 in her first speakership."

The bolded part is probably the most dishonest argument in the entire Medicare for All debate. It implies that, under our current health insurance system, people who like their employer-based insurance can hold onto it. This then is contrasted with a Medicare for All transition where people will lose their employer-based insurance as part of being shifted over to an excellent government plan. But the truth is that people who love their employer-based insurance do not get to hold onto it in our current system. Instead, they lose that insurance constantly, all the time, over and over again. It is a complete nightmare.

I have illustrated this point previously by showing just how often people switch jobs. The latest JOLTS data shows that, in 2018, 66.1 million workers separated from their job at some point. And longitudinal data from BLS shows that the average worker has 11.9 different jobs by the time they are fifty. This labor turnover data leaves little doubt that people with employer-sponsored insurance are losing that insurance constantly, as are their spouses and kids.

But we don’t need to indirectly surmise this fact from labor turnover data. A study from the University of Michigan tracked insurance churn directly by surveying Michiganders in 2014 about their health insurance situation and then following up with survey participants twelve months later. The amount of insurance churn they picked up was even higher than I would have imagined.

Among those who had employer-sponsored insurance in 2014, only 72 percent were continuously enrolled in that insurance for the next twelve months. This means that 28 percent of people on an employer plan were not on that same plan one year later. You like your employer health plan? You better cross your fingers because one in four people on employer plans will come off their plan in the next twelve months.

The situation is even worse for other kinds of insurance. One thing opponents of Medicare for All frequently say is that poor people in the US are already covered by free insurance in the form of Medicaid and that Medicare for All therefore offers them relatively little net benefit while potentially raising their taxes some. But what this argument misses, among other things, is that people on Medicaid churn off it frequently, with many churning into un-insurance.

According to the Michigan researchers, a whopping 30 percent of Michiganders on Medicaid in 2014 faced a spell of un-insurance in the twelve months after they were initially interviewed. Medicaid is a godsend for many, but it’s wildly unstable coverage, and that’s even in a state where the GOP is not doing everything it can to kick people off the Medicaid rolls.

As with many things in current U.S. politics, the divide of opinion on whether Medicare for All is a good idea is heavily generational. Young people are for it. Old people are more skeptical. This age gap is probably mostly driven by ideological differences between the generations: the current crop of young people is much more left-wing than the current crop of old people. But there may also be an objective material basis for this divide. In this Michigan survey, 47 percent of adults aged eighteen to twenty-four churned off their insurance plan during the twelve-month survey span. Only 18 percent of adults fifty-six or older did.

It is easy therefore to see why young people are not as spooked by the idea of losing their current insurance as part of the transition to a Medicare for All system: half of them already lose their insurance every single year. Although older people have it somewhat better, it is worth emphasizing that their churn is still unacceptably high with nearly one in five of them churning off their insurance every year.

Critics of Medicare for All are right to point out that losing your insurance sucks. But the only way to stop that from happening to people is to create a seamless system where people do not constantly churn on and off of insurance. Medicare for All offers that. Our current system offers the exact opposite. If you like losing your insurance all the time, then our current health care system is the right one for you. If you like having permanent coverage no matter your life situation, then you should want Medicare for All.

The GOP-- as well as the sold-out conservative Democrats-- have been on an all-out jihad against Medicare-For-All in the last week. Yesterday, McTurtle spoke at the American Hospital Association conference, insisting that "this radical scheme would be serious bad news for America's hospital industry. You should not be the guinea pigs in some far-left social experiment." By the end of his well-received speech-- the hospital industry is concerned that their rates will be cut-- he was shrieking "Oppose Medicare for none" over their applause.

Also yesterday, The Hill ran an OpEd by notorious far right, anti-Choice fanatic Grazie Pozo Christie, who they identified as an "MD" without giving their readers any context about her politics. A Medicare hater, Christie introduced herself to the readers as "a physician living and working in a community with too many under and uninsured patients" and claiming to "sympathize with the impulse underlying the Democratic Party’s utopian Medicare for all Act." She added that "Like many doctors, I also dream of a sweeping legislative fix to provide high-quality, carte blanche medicine for all Americans, especially those facing serious medical challenges. But this bill seeks utopia by giving government centralized power and control over every aspect of medicine via a single-payer model, and comes with an astronomical price tag. The cost in dollars is in the trillions, but there is also another, hidden cost: the elimination of the conscience rights of nurses and doctors."

In other words, she's lying about the costs of healthcare-- which will come down drastically-- in order to carry on about her extreme anti-abortion bullshit. Her main point is simple: "Under Medicare for all,  gynecologists or nurses who refused to perform an abortion-- to end a human life-- would have their employment agreements revoked. In other words, they would no longer be able to work for the only medical employer in the whole country: the government. Medicare for all also strikes at medical conscience in the case of controversial treatments for gender dysphoria. Most liberals have decided that the only possible therapy for children who feel uncomfortable with their biological sex is puberty blocking, followed by life-long injections of opposite sex hormones and, eventually, mutilating surgeries." She concludes with a quote from Camus that reactionaries adore and use it to deny any progress is ever worth fighting for: "Utopia is that which is in contradiction with reality."

Back to Pozo's big lie about costs for a moment-- it's remotely possible she isn't lying and is just too stupid to understand, but I doubt that-- with an OpEd USA Today ran Monday by Gerald Friedman, an economics professor at University of Massachusetts Amherst who specializes in the economics of health care. Before he gets into the economics of it, he tased a little philosophy, which works well after Pozo's Camus citation. "There is an instinct among political pundits," Friedman wrote, "to confuse caution for practicality-- an assumption that those who advocate for incremental change are being reasonable, while those pushing for bold reforms aren’t. This is seen most starkly in the debate around health care reform, despite the fact that the 'practical' pushers of limited reform fail to address the real problems in our health care system.

We all recognize that the status quo isn’t working. We spend more per person than any other country on health care, but we aren’t getting any bang for our buck. We have lower life expectancy, higher infant mortality rates and more preventable deaths, and too many personal bankruptcies are due at least in part to medical bills.

Where we disagree is the solution. The favorite new “reasonable” plan is “Medicare for America,” a bill from Reps. Jan Schakowsky and Rosa DeLauro that has won the support of big names like Texas presidential hopeful Beto O’Rourke and the Center for American Progress, the left-of-center think tank where the plan originated as “Medicare Extra for All.” It has been extolled in opinion pieces for some of America’s largest newspapers as a “realistic” plan to fix what’s broken in our health care system.

On the other side, if punditry is to be believed, there are the Medicare for All “hard-liners” who believe in expanding a significantly improved Medicare system to every American, with coverage that includes dental, vision and long-term care. This is portrayed as radical or even unreasonable.

Time to get real. As an economist who has spent decades studying our health care system, I can tell you that Medicare for All advocates are the only ones who are being reasonable, because theirs is the only plan that will control health care costs while finally achieving universal coverage.

The problem with incremental plans, whether they are public options, buy-ins to Medicare or Medicaid, or pumping more money into subsidies in the Affordable Care Act's individual marketplace, is that they preserve the private health insurance system weighing down our health care.

This may be why pundits and centrist politicians view those plans as “reasonable,” but it means that they are leaving the main reason for our system’s dysfunction in place: the multipayer, for-profit financing model.

Commercial insurance companies are nothing more than middle men. They add no value to our system, but they do drive up costs with their bloated claims departments, marketing and advertising budgets and executive salaries. We pay for all of these things before a single dollar is spent on the delivery of care.

They also create extra costs for providers who need large administrative staffs to deal with billing systems, accounting for as much as $100,000 per physician.

Any plans short of Medicare for All leaves these costs in place. In other words, they leave hundreds of billions of dollars a year in savings on the table.

The waste goes beyond administrative savings. While pharmaceutical companies and hospital groups are consolidating and forming regional monopolies, our fragmented, multipayer system leaves no one insurance plan with a large enough share of the market to negotiate effectively. That allows these companies to essentially set their own inflated prices and bilk the public for hundreds of billions of dollars.

Is it any wonder that they oppose Medicare for All?

If we’re talking about which health care reform plans are serious about attacking cost, providing universal coverage and making sure everyone has access to health care, Medicare for All is the only reasonable answer. No other plan does this effectively, which is why I suspect that the Center for American Progress has not come out with spending estimates. Basic economic tenets tell us that their plan will not reduce health care spending as effectively.

Is Medicare for All bold? Absolutely. Is it reasonable? You bet. It is time to accept that Medicare for All is the practical alternative.