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Yesterday’s “Quote-of-the-Day” e-mail from San Juan Capistrano’s tireless single-payer warrior Dr Don McCanne (of Physicians for a National Health Plan) quotes in its entirety a Monday NYT column from Nobel-prize winning liberal economist Paul Krugman, and then responds to him:
The New York Times
October 21, 2019
Can Warren Escape the Medicare Trap?
By Paul Krugman
On Sunday, Elizabeth Warren said that she would soon release a plan explaining how she intends to pay for “Medicare for all.” Like many policy wonks, I’ll be waiting with bated breath; this could be a make or break moment for her campaign, and possibly for the 2020 election.
There are three things you need to know about Medicare for all, which in the current debate has come to mean a pure single-payer health insurance system, in which the government provides all coverage, with no role for private insurers.
First, single-payer has a lot to recommend it as a way to achieve universal health care. It’s not the only route — every major advanced country besides the United States achieves universal coverage, but many of them get there via regulations and subsidies rather than by relying solely on public insurance. Still, single-payer is clean and simple, and many health economists would support it if we were starting from scratch.
But we aren’t starting from scratch, which is the second thing you need to know. More than half of Americans are covered by private health insurance, mainly through employers.
Not many people love their insurance companies, but that doesn’t mean that they’re eager to trade the coverage they know for a new system they don’t. Most people probably would end up better off under single-payer, but convincing them of that would be a hard sell; polls show much less support for Medicare for all than for a “public option” plan in which people could retain private insurance if they chose to.
Which brings me to the third point: In reality, single-payer won’t happen any time soon. Even if Democrats win in a landslide in 2020, taking control of the Senate as well as the White House, it’s very unlikely that they will have the votes to eliminate private insurance.
Warren, who has made policy seriousness a key part of her political persona — “Warren has a plan for that” — surely knows all of this. And early this year she seemed to recognize the problems with a purist single-payer approach, saying that she was open to different paths toward universal coverage.
Since then, however, she seems to have gone all in for the elimination of private insurance.
The right question is whether the overall costs facing U.S. families would go up or down. Warren has been claiming that for most families, they would go down, but she hasn’t offered specifics.
Also, let’s get real: If Warren gets the Democratic nomination, the outcome of the general election isn’t going to hinge on dueling think tank estimates.
The election might, however, hinge on the support of people who have good private coverage and would be nervous about making a leap into the unknown, no matter how many facts and figures Warren deploys.
Whatever Warren comes up with, this is a crucial moment. There are many excellent things in her overall policy agenda; but she won’t get a chance to do those things unless she can extricate herself from what looks like a health policy trap.
Don McCanne reponds
San Juan Capistrano, CA
As policy, the single payer model of Medicare for All is vastly superior. It is efficient (recovering hundreds of billions of dollars in administrative waste), effective (includes everyone throughout life), comprehensive (covering all essential health care services), and equitable (financed with progressive taxes based on ability to pay and thus affordable for everyone). Our private plans, even with ACA marketplaces or with a competing public option, cannot come close to that.
Yet those who understand this often slide into the argument that we can’t do it because the politics are too difficult, and, by implication, we need to compromise on policy, accepting reform that achieves none of these goals.
When the proposed policy is right and the politics are wrong, you don’t change the policy, you change the politics. That begins with people having a clear understanding of the single payer Medicare for All model. If they understand it, most will demand it.
VERN PONDERS:
We’ve been trying for years to convince Americans of the vast savings, of life and treasure, that’ll come from single-payer (Medicare for all). Dr. McCanne has been trying for decades, EVERY DAY. Are we really going to convince Americans within the next year, before/during the Presidential Election, to take that great leap of faith? And how?
What is this “public option” plan Krugman references? Will it actually save money and lives? And could it be an incremental way to get to the grand goal of single-payer? I know that hard-core single-payer folks say it won’t, but why should THAT be impossible?
And how do we make our way to a dazzling future in which the majority of Americans are not bamboozled fucktards?
Discuss.
“What is this “public option” plan Krugman references?”
Very nearly enacted in 2009 with the ACA, the public option proposed a ‘US Postal System’ to run in tandem with UPS/FedEx. It passed Pelosi’s House, failed in the Senate due to the filibuster (Lieberman broke ranks, but likely other senators were grateful he took the heat on that).
“Will it actually save money and lives?”
Almost certainly – but the savings in lives will be measured in the hundreds of billions/decade (where the savings from a true M4A would be measured in the trillions). And yes, it would almost certainly save lives too (just not as many lives as M4A).
“And could it be an incremental way to get to the grand goal of single-payer?”
MAYBE. It has worked that way in some countries, BUT no country has deep pocketed adversaries as determined to prevent it from happening as we have. No country has quite so many vectors to prevent it from coming into existence as we do. Few things are truly impossible.
But perhaps Krugman – and most economists – have been asking “the right question” too long – it’s not “whether the overall costs facing U.S. families would go up or down” – but whether the power balance should favor those who get to dictate those costs, rather than those who have to pay them. This may not be a problem that economists can solve: questions about a fair and efficient distribution of resources do not apply when the life of a loved one is on the line – an occurrence that is, unfortunately, destined to arise for all of us some day.
I remember the “robust public option” that almost got into Obamacare. A lot of us including (pre-dick-pic-fame fighting progressive) Anthony Weiner believed that could be a pathway to real single-payer, because it would show its affordability. And I remember that weenie Lieberman nixing it “because if Weiner’s for it then I’m against it!”
(BTW I have the bragging rights of being a Democrat in Connecticut in 1988 when that snake Lieberman first came out of his hole and ran against the decent Republican Lowell Weicker, and I voted for Lowell. Never trusted Holy Joe and I was right. Sent money to Ned Lamont years later. but anyway…)
After that I kept thinking “well maybe California can at least make a “robust public option” so WE’ll be on our way to single-payer, but lotsa my progressive friends were all NO, NO, NO TO INCREMENTALISM. Sometimes I wonder if they’re being Leninists who think things just have to get worse and worse before we can achieve perfection.
“Sometimes I wonder if they’re being Leninists who think things just have to get worse and worse before we can achieve perfection.”
There may be a few Susan Sarandon style “if not Bernie, then Trump” voters out there, but anyone following that logic is coming from a world of privilege (they may not make much money, but they are not seriously worried about climate or ICE – they’ll shed some vapid twitter tears and blame others for what they made happen).
Leninists? I don’t think so. Lenin was quick to put his life on the line (quicker to put millions of other lives on the line). More like they listened on Lennon once and imagined an easy, simple change against an adversary so stupid that it could easily be overcome with nothing but moral suasion.
Beating power takes mastery of the tools used by the powerful. Warren has a clear command of the debt side of that equation: it’s the biggest part of capital that the capitalists tend to get wrong, and the street level Leninists shrug aside (though theyd be crushed in an instant unless debts to the troops cause them to desert…).
*The trouble with making rules for others…is: Not many like that too much. The truth is that the Medicare concept, needs to be ramped in slowly. It needs to continue to offer Private Insurance for the next 10 to 15 years as an option. Every procedure, every visit to the doctor’s office should be a Five Dollar Co-Pay. Every Prescription Drug taken should have a Five Dollar Co-Pay. There should be four tiers of Medicare for all. Bronze – the bare bones for catastrophic illnesses. The Silver for Catastrophic illnesses and Emergency room and Annual Physicals. and the Gold and Platinum! You get the picture. Anyway, we cannot go Cold Turkey and not expect huge job losses from the Insurance and Medical Industries when we go to the new system. Gradually, is going to be the only way. As Kamala said, many Union Members have made serious Wage Concessions in order to get their Healthcare programs and Retirement Programs. This will take 15 years to unwind across the country. What we can do however is Defund Big Pharma completely. Since we are getting our drugs from India and China……why do we need middlemen?
“The trouble with making rules for others…is: Not many like that too much.”
Alas, somebody else wrote the rule that said who gets cancer, who doesnt. Somebody else wrote the rule that said how much it costs to try to save a life. Folks may not like these rules: Medicare 4 all is about rewriting them.
In terms of defunding big pharma: good luck with that. We can threaten and cajole, but if you change the price of one drug (or the patent expires), you still dont change the price of medicine very much – because the folks writing the rules know how to squeeze every last penny they can from the rest of us.
Re “incrementalism” – folks who’ve never seen a revolution routinely romanticize/fantasize about what they look like. Or they assume what happened elsewhere will never happen here (sure the Brits can do something silly like Brexit, but that has nothing to do with us…).
Incrementalism is the tactic you try when legislation is impossible. You do what you can with what you have, and never stop trying to make things better. If you can’t make them a lot better, you still can make them a bit better.
You make “incrementalism” sound good. It often isn’t, in the sense that the failure of an effort that was too small to solve a problem (that it might well have solved if it were larger) may then discredit the larger effort that would have worked.
This is pretty much what happened with the 2009 “stimulus packages” that were too small — *needlessly* too small — to stop the Great Recession. Republicans and conservative Dems kept them from growing to the levels needed or them to work — based on deficit hobgoblin worries that seem quaint (or, more accurately, disingenuous) after the ginormous Trump Tax Cuts for the wealthy —and this discredited the use of economic stimulus to get out of a big recession generally. (In fact, we’ve only recently gotten out of the Great Recession thanks to the long slow action of the too-small Obama stimulus, which was slow enough that the rich could still successfully argue for this ginormous Trump tax cuts on “trickledown” grounds.)
Greg – acknowledging that sometimes, there’s no better option is not the same as suggesting that the tactic is ever ideal. One has to do what one can with what we have, while trying to amass power to do more.
What I think that you overlook is that there is a middle path between an actual “revolution” and piddling and unsure “incrementalism” — which we might call “aggressive action.” That’s what the Krugman level tax cuts would have been. That’s what Obama’s “Grand Bargain” on Social Security would have been — albeit in the wrong direction. And I don’t know whether the imposition of Social Security, the rest of the New Deal, Medicare, and the rest of the Great Society Would have been considered “Aggressive Action” or “Revolution,” but I think it’s fair to say that NONE of them would have been produced through incrementalism.
I never suggested that ‘revolution’ and ‘incrementalism’ are the only options – they’re options one considers when better ones aren’t available.
But I would say that folks who invoke ‘revolution’ without having seen one up-close and personal…might reconsider.