This is an emergency communication. It
is becoming increasingly possible that Elizabeth Warren will be the
Democratic presidential nominee. She could make it. But if she does
make it, she will need to win the election, and among the tasks for
achieving that goal is reducing her vulnerabilities. I believe one
of her greatest liabilities will be her support of Medicare For All.
MFA is neither good policy nor good
politics. Medicare as a public option for anyone to buy into –
Medicare Available For All (MAFA) -- including employers who buy
health insurance for their employees, and with automatic enrollment
for those who have no other insurance, makes a lot more sense. I
call this an “emergency communication” because if she changes her
position, as she really needs to, she needs to do it as soon as
possible.
Politics
There are several major reasons that
MFA is bad politics. MFA will seem dangerous to many voters, who
will become fearful – all of a sudden I won't have the insurance
and access to care I'm used to? It will seem like a take-away to the
majority who already have insurance, which is absolutely not what
wins elections. And it can be legitimately be viewed as government
coercion. Can you envision the Republican campaign that accentuates
that fear? “She's a socialist” sounds a lot more realistic if
they can credibly say, “She will take away your insurance and
replace it with a government promise, and you have no choice, you
will be in one big pool with no one caring about you individually.”
Most people in America have been conditioned to disbelieve the
claim, “I'm the government and I'm here to help you.” Just wait
for the Republican ads of a couple asking friends where to get their
health care, and they answer: “Just go on down to the DMV.”
Going for MFA would be a classic case of turning a Democratic winning
issue – health care – into a losing one. Elizabeth,
politically, you just can't do it.
To try to make the point more vividly:
If you are a common citizen with current insurance from your
employer, say, you have access to health care in recognizable
circumstances. Others might have insurance and access problems, but
they are a minority, and you are not among them. You might wish the
best for them, but your most pressing concern is yourself. If you
are told that you will have to give up this insurance and this
access, but that it will be replaced by a governmental program, and
that you will then be in a pool with the entire rest of the nation,
and that there will be many obvious problems (such as paying
hospitals and ensuring that all physicians will sign onto the new
program) that will have to “be worked out,” is this really
something that will fill you with confidence? No, it will feel
dangerous, and it's your health care, so it's important. It's buying
a pig in a poke, which is something that no sensible person will do.
Policy
But besides politics, what about the
policy argument that MFA will actually be a better system than the
one we have now? The answer is that it would be hard to find a
system that wouldn't be better than the one we have now. But is MFA
the only one that would be better? That's not at all clear.
Guaranteeing access to health care for all Americans is not the same
thing as MFA, of course, there are many ways to skin that cat. Some
say, well, the Medicare system works now pretty well for Americans
over 65, why not just expand it to everyone? That's not a bad
argument, but it's simplistic.
The current Medicare system works, but
it is far from perfect. Fraud and abuse are severe and persistent,
it's not clear that payments are fairly allocated, the government is
often in bed with the large monopolistic providers in its provisions,
there is little flexibility with so large a system in which it is
almost impossible to individualize and individual variations and
waivers are not well received, the system would have to be
reconfigured to accommodate all the new age groups (especially
pediatrics), Medicare traditionally overpays proceduralists and
underpays the cognitive specialties, prevention is chronically
under-recognized, pricing of drugs is not well handled, Congressional
meddling with Medicare is traditional, many of the administrative
savings are overstated, and so on.
Moreover, Medicare involves a
bureaucracy. It's not like Social Security, a large bureaucracy with
a simple task – enroll, verify, send out checks. Medicare's tasks
are profoundly more complex. The more complex the task, the less
appropriate is a large bureaucracy. Were Medicare to stand alone, it
is unclear where pressure for change and innovation would come from,
and it is unclear that the program would be able to withstand the
usual pressure for bureaucracies to ossify. If MFA were to be
adopted, there would be a need for a lot of work to design the new
inclusive Medicare program so that bureaucratic ossification would
not happen. I personally would favor decentralization of
administration and the establishment of a policy of at least two
competing Medicare programs in every area – both would be funded
identically from the central government, but they would compete for
patients and medical practitioners and institutions locally. We have
this exact program with managed care Medicaid in California, and it
has proved viable. But this would take time and experimentation,
which would not be available on a rushed schedule that would have to
be adopted were electoral promises to be fulfilled.
MAFA is a much better option. Look at
it this way: we are on one side of a creek, and we want to get to the
other side, where the grass looks greener. How do we get there? Do
we take a big run up to the edge and leap over the creek in a single
swoop, hoping for the best? I don't think so. Instead, it would be
better for us to have stepping stones that look secure, carefully,
one after the other, with a chance to change direction or move back
if the path became insecure. That's just sensible.
If Medicare turns out to be a superior
choice, let this be a choice of the buyers. As an employer, I
evaluated competing plans and chose the one that seemed best for me
and for my employees. If employers all have the choice that includes
buying into Medicare, let them make the assessment, let them weigh
the wishes and the interest of their employees as well as their own,
and let nature take its course. Believe it or not, people will take
directions issued by their employer more readily than they will from
government. Let the earlier adopters jump right in, with the
knowledge that they can pull out if the experience is unpleasant, and
let the more cautious decide on the basis of the experience of
others. Who knows, maybe some programs devised by groups other than
the Federal government will prove superior. That's a prospect that
respects choice and respects feelings and fears. To me, this
scenario makes a lot of sense.
Timing
If one is persuaded by this political
and policy argument, the question then becomes, when is the best time
to change your position? The answer is, right away. If you change
right now, Elizabeth, you will be criticized by the Bernie left. You
are a great explainer, and you can argue that it's a disagreement
about means, not ends. You might lose some of them in the general
election, but that will be more than made up for by those you gain
from the middle.
If you are attacked as a wobbler on
policy, you can do what Keynes did when he was confronted on a change
of opinion. You can say that you have been talking to many and
listening to many, and you have been persuaded that MFAWWI is the
smarter way to go; you changed your opinion. This could well be
portrayed as a strength. If you are asked if you did this to peel
off Biden voters, you could say: “I listened to many people,
including Joe. I concluded he was right on this, and I'm happy to be
corrected. I'm not trying to peel off his voters, I'm trying to
propose the best policies I possibly can, and that means being open
to the arguments of others. I'm not buying all of his argument, but
he had some things that were right, and I've adopted them, just the
way I adopted Jay Inslee's environmental proposals. If you are going
to be President, you can't think that your brain and your ideas are
the only ones that count.” Tell me that's not a winning
explanation.
If you wait too long to make the
switch, however, you will be more vulnerable to charges of
opportunism, the way Hillary was with the TPP. Do it now. If the
Republicans attack you as a socialist, your best defense will be a
history of conflict with Bernie over MFA. If they attack you as a
flip-flopper, you can easily point out that you probably lost Bernie
votes as you consulted your conscience and your intelligence.
Very soon, it will be too late to
change your stance without looking opportunistic and unreliable.
Changing now, you can make the reasoned argument that the ideal is to
guarantee access to medical care to everyone at a reasonable price,
and that making Medicare a choice for everyone is an important step
that will reach that goal. Beyond that, to achieve the reduction in
cost objective, there are many roads one can take, and it is exactly
within the Warren point of view to avoid large concentrations of
authority and resources, and to introduce competition to drive
quality up and cost down.
Do it now. Carpe diem.
It's an emergency.
Budd Shenkin
PS - 10-22-2019: Here is a link to a quick description of Medicare For America, which is a phase in to Medicare for most people in a way that should be quite acceptable. I understand that Beto O'Rourke has adopted this as his plan. If I were Elizabeth, I'd say, this makes a lot of sense to me: https://twitter.com/charles_gaba/status/1185940209856385026.
PS - 10-22-2019: Here is a link to a quick description of Medicare For America, which is a phase in to Medicare for most people in a way that should be quite acceptable. I understand that Beto O'Rourke has adopted this as his plan. If I were Elizabeth, I'd say, this makes a lot of sense to me: https://twitter.com/charles_gaba/status/1185940209856385026.
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