Tuesday, September 17, 2019

Elizabeth Warren Needs To Change Her Medicare For All Stance Right Now

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.


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.


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.


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.

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