The Residential Library

The sometimes demented, frequently irreverent, and occasionally stupid musings of Ron Hargrove

Don’t Make Health Care a Purity Test

There are multiple ways to achieve universal coverage.

By Paul Krugman

We’re now in the silly season of the Democratic primary — a season that, I worry, may last all the way to the nomination. There are many honorable exceptions, but an awful lot of reporting seems to be third order — not about the candidates, let alone their policy proposals, but about pundits’ views about voters’ views of candidates’ electability. It’s a discussion in which essentially nobody has any idea what he or she is talking about.

Meanwhile, however, there are some real continuing policy debates. They’re not mainly about goals: Whoever the Democrats nominate will profess allegiance to a progressive agenda aimed at reducing inequality, strengthening the social safety net and taking action on climate change. But there are some big differences about how to achieve those goals.

And the starkest divide involves health care. Almost surely, the eventual platform will advocate “Medicare for TK.” But what word is eventually chosen to replace the placeholder “TK,” and more important, what that means in terms of actual policy, will be crucial both for the general election and for what comes after if Democrats win.

On one side, there’s “Medicare for All,” which has come to mean the Bernie Sanders position: replacing the entire existing U.S. health insurance system with a Medicare-type program in which the government pays most medical bills directly.

On the other side, there’s “Medicare for America,” originally a proposal from the Center for American Progress, now embodied in legislation. While none of the announced Democratic candidates has endorsed this proposal yet, it’s a good guess that most of them will come around to something similar.

The big difference from a Sanders-type plan is that people would be allowed to keep private coverage if they chose — but they or their employers would also have the option of buying into an enhanced version of Medicare, with substantial subsidies for lower- and middle-income families.

The most important thing you need to know about these rival plans is that both of them would do the job.

Many people realize, I think, that we’re the only advanced country that doesn’t guarantee essential health care to its legal residents. My guess is that fewer realize that nations achieve that goal in a variety of ways — and they all work.

Every two years the Commonwealth Fund provides an invaluable survey of major nations’ health care systems. America always comes in last; in the latest edition, the three leaders are Britain, Australia and the Netherlands.

What’s remarkable about those top three is that they have radically different systems. Britain has true socialized medicine — direct government provision of health care. Australia has single-payer — it’s basically Bernie down under. But the Dutch rely on private insurance companies — heavily regulated, with lots of subsidies, but looking more like a better-funded version of Obamacare than like Medicare for All. And the Netherlands actually tops the Commonwealth Fund rankings.

So which system should Democrats advocate? The answer, I’d argue, is the system we’re most likely actually to create — the one that will play best in the general election, and is then most likely to pass Congress if the Democrat wins.

And there’s one big fact on the ground that any realistic health strategy has to deal with: 156 million Americans — almost half the population — currently receive health insurance through their employers. And most of these people are fairly satisfied with their coverage.

A Medicare for All plan would in effect say to these people, “We’re going to take away your current plan, but trust us, the replacement will be better. And we’re going to impose a bunch of new taxes to pay for all this, but trust us, it will be less than you and your employer currently pay in premiums.”

The thing is, both of these claims might well be true! A simple, single-payer system would probably have lower overall costs than a hybrid system that preserves some forms of private coverage.

But even if optimistic claims about Medicare for All are true, will people believe them? And even if most people do, if a significant minority of voters doesn’t trust the promises of single-payer advocates, that could easily either doom Democrats in the general election or at least make it impossible to get their plan through Congress.

To me, then, Medicare for America — which lets people keep employment-based insurance — looks like a much better bet for actually getting universal coverage than Medicare for All. But I could be wrong! And it’s fine to spend the next few months arguing the issue.

What won’t be fine will be if activists make a no-private-insurance position a litmus test, declaring that anyone advocating a more incrementalist approach is no true progressive, or maybe a corrupt shill for the medical/industrial complex. As you might guess, my concerns aren’t drawn out of thin air; they’re things I’m already hearing.

So Democrats should try to make this a real debate, one about the best strategy for achieving a shared goal. Can they manage that? I guess we’ll find out.


Paul Krugman has been an Opinion columnist since 2000 and is also a Distinguished Professor at the City University of New York Graduate Center. He won the 2008 Nobel Memorial Prize in Economic Sciences for his work on international trade and economic geography.
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