Time for a Health Care Post

So . . . John Edwards has a health care plan. You can find some serious analysis from Jonathan Cohn and Ezra Klein. Mark Schmitt's reaction, however, was just to say that candidates shouldn't release detailed plans at all:

[T]here will be particular problems with any health care proposal. They all have vulnerabilities, they all create situations in which people might have to accept change or might get less than they currently have. And the people who are most likely to vote based on health care are also people likely to be fearful of losing what they have. It will always be for political opponents to push that fear button.

I've argued in the past that it's good to campaign on a specific plan because if you do lay one out and do leave yourself exposed to the vulnerabilities Mark highlights and win anyway, then you're in a strong position as president to get your plan passed. Conversely, if you stand for election on vague promises and then try to get something passed, you'll have a big problem. As Kevin Drum says, "you'll get the feel-good vote during the election but then lose later on when you try to fulfill your campaign promise and run smack into....the fear button." The more I think about it, though, the more I think both perspectives on this are correct.

Which is part of why I came to the conclusion I reach in this column. I don't think it's smart for candidates to either run on specific universal healht care plans or to run on a promise to devise a specific universal health care plan once in office. Rather, what I'd like to see is a candidate who says that Medicare For All is the right idea, who concedes that Medicare For All probably won't be passing congress in 2009, and therefore promises to bring Medicare for As Many As Possible:

First, change the 2003 Medicare reform bill to give the government meaningful price leverage over the pharmaceutical companies and eliminate the role for private insurance companies. Beyond that, see what you can get -- Robert Kuttner laid out a few options yesterday. Propose that Medicaid cover everyone under 25. If you can't get that, take everyone under 21. If you can't get that, take everyone under 18. If you can get that, propose adding full-time students under 25. Then all full-time students. Then everyone under 25. Lower the threshold for Medicare to 50. Or to 55. Or to 60. Lower it to 64 if that's all you can get. Then come back next year and propose lowering it to 50. Or to 55. Or to 63. Keep coming back. Let people under the threshold "buy in" to Medicare on some terms.

To my way of thinking, this kind of approach (call it "flexible intransigence") is the best way of getting things done in the context of an American political system that makes large-scale change intrinsically difficult. And I think that when you look at successful partisan positioning on domestic policy, this is the sort of thing you see. When Democrats run and win on minimum wage hikes, they don't run and win on minimum wage plans they're running and winning on the general idea that the Democratic Party is committed to making the minimum wage higher. Similarly, the GOP will make taxes lower. Democrats, similarly, should be committed to "Medicare for more!" People like Medicare.

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Comments

The problem is where to get the revenue to pay for each of these incremental expansions. People may like medicare, but they don’t like higher taxes.

Posted by: RC on February 6, 2007 05:29 PM

People have been advocating "incremental plans" for nearly a generation now on the grounds that whole scale medical reform is "politically too risky."

The result: nothing, zilch, zippo, take-a-hike.

If it were possible to reform medicine incrementally, we would be much more than half-way there already. Incremental reform means no reform. It does not mean anything else.

Which means that if a candidate is really serious about healthcare reform, he cannot propose incremental steps or "politically realistic compromises," but rather he must present a detailed overhaul of the system.

Anything else is not credible - the lack of credibility being the reason why reform has failed these many years.

Posted by: Duncan Kinder on February 6, 2007 05:37 PM

as long as liberals chant the mantra "but healthcare won't happen before XXXX" it won't. the "fact" that a universal single-payer plan will necessarily cost more than the bizarre system we enjoy now is not established either...other countries have better outcomes than we do for substantially less money, and they don't have more than 40 million people with no insurance at all.

Posted by: supersaurus on February 6, 2007 05:37 PM

Baby steps are good if they get taken- we need less waiting around and more action. Why do the senators that are running have to be so concerned with the way they look- shouldn't they just focus on doing.
According to the Borgen Project it only costs $19 billion annually to end world hunger, and another $30-40 billion annually to accomplish all of The Millennium Development Goals by 2015- and that includes the reduction of disease and other health related issues.
So I say get those goals accomplished- quit waiting around. Afterall, the accomplishment of these goals will reduce health problems for everyone- so fewer expensive trips to the doctor.

Posted by: KatieL on February 6, 2007 05:45 PM

"Rather, what I'd like to see is a candidate who says that Medicare For All is the right idea, who concedes that Medicare For All probably won't be passing congress in 2009, and therefore promises to bring Medicare for As Many As Possible"

You want Matt Santos to run?

Posted by: Jeremiah J. on February 6, 2007 05:49 PM

Medicaid and CHIP in theory already cover many more kids than are actually part of these programs. Politicos do not actually like these programs (or the kids) enough to suffiently cut the red tape to make it happen.

Try extending Medicare to a more needy, albeit a more expensive group: the disabled. An individual who qualifies for RSDI disability has a two year wait for Medicare. This is a national travesty and naked cost shifting to local governments.

I like Edwards but he suffers from having a real chance at the presidency.

Posted by: Nat on February 6, 2007 06:04 PM

Great ideas Matt. I've always thought universal Medicare was the way to go. I agree that Medicare for more is the best way to get there.

Posted by: Gary Sugar on February 6, 2007 06:39 PM

Matt is right that Dems should campaign on a platform of "Medicare for all". He is wrong to assume that if you have a plan, and you're elected President, you'll have a good chance to see your plan enacted.

In fact, that's probably the biggest single lesson of American political history, is how wrong that idea is. Think Roosevelt and the NRA. Think Woodrow Wilson and the League of Nations. Think Andrew Jackson and his hatred of the Bank of the US.

Then think about Abraham Lincoln. He had no plan, but everyone knew what he felt strongly about. Lincoln entered office determined to preserve the Union, and did what he had to to accomplish that.

Plans, bills, laws, and programs come from the Congress. This may not be perfect from the viewpoint of a guy who thinks he has a good plan, but in terms of governing the country it hasn't worked that badly.

The Dems should stay strictly big-picture and emphasize that if we're as smart as the Europeans we'll be able to save 5% of our GDP by providing medicare coverage to all. Social Security did not happen because Roosevelt had a plan- it happened because people all over the country knew it was necessary and told their congressmen to make it happen. Roosevelt himself said on one occasion "You've convinced me- now go out and make me do it".

As for incrementalism, that just lets everyone kick the can down the road and doesn't help the people who need help. Forget that BS.

Set the terms of the debate as universal coverage and national savings, and let the other guys try to explain why we're too stupid to do what other nations can do.

Posted by: serial catowner on February 6, 2007 07:23 PM

I'm less concerned about what happens to people who earn 12k a year (at least with respect to health care - one way or another this kind of universal health care scheme will end up subsidizing them) but people who earn 19k or 25k or even 40 or 50k if they have kids. There will be a lot of people who earn too much to qualify for government subsidies but not enough to afford the kind of comprehensive coverage they currently have from their employer (who will no more provide them with health insurance than they provide them with car insurance). Per always, the working class loses.

Posted by: Linus on February 6, 2007 09:20 PM

The Dems should stay strictly big-picture and emphasize that if we're as smart as the Europeans we'll be able to save 5% of our GDP by providing medicare coverage to all.

Serial: We can certainly have Medicare coverage for all if the votes can be found, but how on earth do you figure we'll save $650 billion (5% of GDP) by doing so? Don't you suspect the rise in utilization rates from all those newly insured (or newly better insured) people will mean, more, not less healthcare being consumed? Ain't that going to cost more money? What about physicians' salaries? I can't foresee any law coming into effect in the next decade that successfully lowers how much money doctors make. Single payer is certainly feasible in America, but it's also certainly going to be expensive.

I think this is one reason the piecemeal effect makes sense. If you want to expand Medicare, I say propose an expansion that would be very difficult to oppose, politically, like, say, expanding it to all minors not covered or underinsured by their parents' plans. Or to people who get laid off. Or to small businesses who can't get affordable policies for their workers. Something along these lines might be difficult to stop if it were introduced into a Democratic congress and sent to the desk of a Democratic president. Costs will quickly mount, but it will be impossible to reduce coverage. What politician is going to get behind the idea of removing Medicare coverage from high school kids or from the unemployed? This process will in turn invite more people clamoring to get in. If we included small businesses, why not the self-employed? Or people with preexisting conditions? Or college students? Or businesses who spend more than X% of their revenues on insurance premiums? Pretty soon we do have Medicare for all.

But "The Medicare for All Act" of 2011 accompanied by a $900 billion price tag? I just don't see how it could possibly materialize absent some sort of national calamity along the lines of the Great Depression.

Posted by: Jasper on February 6, 2007 09:45 PM

Medicare is universal for everyone age 65 and above. Age matters. Costs go up as people age.

By reducing the medicare age to 60 or 55 we take a larger portion of medical care consumers off the insurance company lists and put them on the Medicare list instead.

This will save employers tons of money. The money not paid in premium can be paid in taxes to provide the expanded medicare benefits. And since medicare is far more efficient that private health insurance more medical care can be provided for the same dollar.

Keep reducing the qualifying age until everyone is covered.

Medicare for all is the smart solution. It is simple. It is understandable. It benefits both business and consumers. It saves money. It is affordable. And it is politically feasible.

Posted by: ken on February 6, 2007 11:18 PM

[Matt] is wrong to assume that if you have a plan, and you're elected President, you'll have a good chance to see your plan enacted.

Umm...what?

The NRA was enacted, but was struck down by the Supreme Court. Furthermore, Roosevelt most certainly did not talk about anything like the NRA in his campaign. Nor did Woodrow Wilson advocate anything like the League of Nations in either of his presidential campaigns in 1912 or 1916.

As to Jackson, he was entirely successful in getting rid of the Bank of the US, following his successful 1832 re-election campaign, which largely focused around the Bank.

So, um, what on earth are you talking about, catowner?

Posted by: John on February 7, 2007 01:18 AM

I am agnostic on approach, and not smart enough to figure out what strategy will work. However, I also want to point out that expanding health care to all minors has a lot of appeal for secondary reasons. First, it is relatively inexpensive -- as the young are much cheaper and derivative benefits from early prevention will have longer term payoff. Second, this will have a cultural effect on every young American and future voter having grown up with this system. Third, it would seem to me that a plan that allowed people to continue on this plan at would be impossible to oppose politically.

As far as cost goes out, I hear very few people explaining to the most influential voters that in general changes to take home pay would, or should be revenue neutral, if not better. The increase in government taxes would be offest by removing what employers take out for healthcare.

Posted by: theCoach on February 7, 2007 09:26 AM

So like message discipline and teasing the press are important when you're a nominee and the news is about you every day.

But when you're a primary candidate trying to get attention and show why you are different from the alternatives? Full blown plans are much more likely to do that than "I will bring medicare to more people".

Posted by: Tony V on February 7, 2007 09:58 AM

So like message discipline and teasing the press are important when you're a nominee and the news is about you every day.

Posted by: Tony V on February 7, 2007 10:52 AM

Historical notes- Of course the NRA was enacted- because it was voluntary. Few credit it with any success in curbing the Depression. Andrew Jackson- viewed by most historians as Captain Ahab with the Bank of the US as his White Whale. League of Nations- rejected by the Congress and the public at the next election. Wilson in fact campaigned on his promise to keep us out of the war (this was after the sinking of the Lusitania). See also: George Washington and his first appearance in Congress.

Why Medicare For All saves money instead of costing money-
1) The people who cost us money are already being treated as indigents. We're already spending that money. Adding in the population with nascent problems that can be treated preventively will reduce costs over the long run.
2) Coverage for people who are basically healthy costs almost nothing. 1-2% will be chronic whiners and doctor-shoppers. The rest will see a doctor as often as they are told- and now that we know an annual physical is of very little value, it won't be that often.
3) Striking reduction in paperwork costs, both for insuring agency and doctor's offices.
4) Ability by insuring agency to bargain aggressively for best prices on care and drugs.

As for incrementalism, well, it's just about the exact opposite of all the cost-saving factors listed above. First, you deny coverage to anybody who might be healthy enough or wealthy enough to not use very much. Then, typically, 50 different states set up 50 different programs with rules written by the legislative process of each state, adding more cost and less service at every step of the road. Then the programs are underfunded so only the most pathetically ill, who would make unpleasant newspaper headlines, get treatment. End result- programs that are very expensive per client, but most of the clients die anyway, leading almost everyone to wonder if this isn't just a big waste of time and money.

Incrementalism has had its 30-year "day in the sun" and it's time to go to universal coverage.

Posted by: serial catowner on February 7, 2007 11:16 AM

Re: The result: nothing, zilch, zippo, take-a-hike.

Not quite nothing: CHIPs programs and the HIPAA law. Of course that's a long way from where we really need to be. And both were really just middle-class anxiety calmers, intended to defuse the middle-class support for real reform by making sure people could change jobs without losing coverage and if they ended up unemployed for a stretch at least their kids would still have healthcare.

Posted by: JonF on February 7, 2007 01:34 PM

trying to maximize their take. These medications are not meant for someone so young. WBR LeoP

Posted by: Pharmacy Choice on March 30, 2007 08:36 AM

Assuming that there was a liberal media bias, we didn't believe the media, even though they were correct. The obvious solution, now that the media is vindicated and we were proven wrong, is to correct the liberal media bias which, as I just stated, only existed in our imaginations...

Posted by: sohbet on August 15, 2007 05:20 PM

Great ideas Matt. I've always thought universal Medicare was the way to go. I agree that Medicare for more is the best way to get there.

Posted by: sohbet on August 19, 2007 03:29 PM

I agree that merely increasing the number of democratic member states is unlikely help with the enforcement problem plaguing the United Nations. The number democratic member-states is already high, yet enforcement is feeble at best: Adding more democratic states (or more rules!) is unlikely to improve this situation.

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