Health Policy

Understanding #Medicare4All & the Democratic Primaries

By MATTHEW HOLT

Since Saturday’s Nevada primaries, confusion seems to be reigning about how Bernie Sanders seems to be winning. Time (and not a lot more of it) will tell who actually ends up as the Democratic nominee. But the progressive side (Bernie + Warren) is doing much better than the moderate side (Biden/Butt-edge-edge/Klobuchar) expected, while we wait to see how the  Republican side of the Democratic primary (Bloomberg) does in an actual vote. The key here is the main policy differential between the two sides, Medicare For All.

Don’t get too hung up in the details of the individual plans, especially as revealing said details may have hurt Elizabeth Warren. But do remember that there is one big difference between Sanders/Warren and the moderates. It comes down to whether everyone is in the same state-run single payer system (a modified and expanded version of Medicare) or whether the private employer system is left as it is, with expanded access to something that looks like Medicare (the public option) for everyone else. Note that no Democrat wants to stand pat on Obamacare “as is”. Everyone is way to the left of what Obama ran on in 2008 (or at least what he settled for in early 2009).

Why has this changed? Well there’s been a decade of horror stories. I’m not talking about the BS anti-Obamacare stories from people forced to give up their junk insurance, I’m talking about people with insurance being bankrupted or put through horrendous experiences, like this mother who was put through the ringer by various insurers when her 1 year old son was killed and husband injured in a road accident. Or this health tech CEO, who was an MD & JD and had to put $62,000 on his American Express card to get surgery

About 3 years ago as the dust was clearing from the Obamacare implementation, the impact of this started showing up in the polls. In 2017 for the Health 2.0 conference, Indu Subaiya & Hiliary Critchley ran a poll on health policy with Zogby. To me by far the most remarkable feature was that even though Obamacare was by then more popular than not among the public, the support for single payer had gone up dramatically since 2009–in the depths of the recession.

Zogby poll for Health 2.0, Fall 2017

In 2019 44% said they were utterly opposed to single payer (and 50% opposed overall). But by 2017 while the number strongly in favor had just edged up, 48% were in favor overall, with another 30% neutral or not sure. Now only 19% were strongly opposed.

Meanwhile, just a year later (October 2018) a lot of fuss was made about a poll from The Hill that had 70% of Americans supporting Medicare For All. This was the poll that had 52% of Republicans saying they were in favor of it. (Full data here). (Don’t forget that only about 30% of Americans identify as Democrats, while about 35% identify as Republicans and 40% say they’re independent). So if we are to believe that somewhere between 45% and 70% of Americans say they are in favor of single payer, almost all Democrats are. And in fact that is true. The Hill found 92% were and the Kaiser Family Foundation (KFF) shows 75%.

The issue of course is what “Medicare For All” means in reality. The KFF poll is very up to date and I can’t decide if it shows that the electorate is very confused or if the poll itself is a mess. (I highly recommend clicking though it). It basically says that Democrats want Medicare For All and want a public option while wanting to keep their own insurance (presumably many of them now have employer-based private insurance).

But luckily there was another recent poll done by Bob Blendon at Harvard (who I worked within the 1990s), and (as I told the KFF folks and Topher Spiro on Twitter) this poll was not a mess. In fact it was crystal clear in herding its respondents into one of three camps and thus very instructive for the Democratic primaries. (Details here) The poll gave people a straight choice between single payer, or extending the ACA, or the Republican “alternative”.

Basically when you tell Americans that Medicare For All means “Medicare for You too” (i.e. All Americans would get insurance from Medicare), but offer them a choice of an ACA expansion, roughly a third choose either alternative.

Somewhat more remarkably this split is not just along party lines. Democrats in the poll were also evenly split between Plan A (Medicare for All) and Plan B (expanding Obamacare) although few of them wanted the Republican alternative and, if you include independents who lean Republican, a third of them want single payer or extended Obamacare!

Source: Commonwealth Fund/New York Times/Harvard T.H. Chan School of Public Health,
Americans’ Values and Beliefs about National Health Insurance Reform. July, 2019.

The inference is relatively clear. Almost all Democrats want Medicare (or something like it) “available” for All and about half of them (and about 1/3 of independents) are prepared to “mandate” Medicare For All.

How will that translate into the primaries? It’s relatively obvious that the most passionate and most progressive Democratic voters are a little more likely to vote in the primaries. I’ve cut some data from another poll from The Hill (Jan 15, 2020) that suggests that 58% of Democrats say they are certain to vote in the primary but 67% of liberals will, while only 50% of those who “lean liberal” will.

Question: How likely are you to vote in the Democratic primary election or caucus in your state to choose the Democratic nominee for the 2020 Presidential Election?

Which gets us back to the voting. Everything thus far is weird. Caucuses are stupid and unrepresentative, although they have elements of a good idea (2nd choice votes in multiple candidate fields). New Hampshire doesn’t look like America and neither does South Carolina. But with Sanders/Warren coming in at between 35% & 55% so far, and most more liberal and more activist Democratic primary voters favoring single payer, I suspect that we will see a majority of votes/delegates for Sanders/Warren by mid March assuming that health care stays the dominant and dividing issue.

That likely means that even if all but one of the “BBBKS” moderates drop out, there wont be enough moderate delegates to stop the progressives at the convention. (Worth noting here that Warren has been saying “Medicare For All after we fix Obamacare” which gives her a little slack).

If that’s right and Sanders is the nominee, then the Democrats face an interesting problem. If like 2018, they can run on how evil Trump and the Republicans are on health care, but not say too much about their own plan, then they’ll likely win. If Trump succeeds in making it all about single payer socialism making people fear the devil they don’t know, it’s likely to be a losing issue.

Matthew Holt is the publisher of THCB and likes to remind people now and again that he has a Political Science degree and worked for a pollster once!

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Barry Carol
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Barry Carol

One more thing. Sanders also wants to cover long term custodial care which Medicare currently covers only on a very limited basis following at least a three day inpatient (as opposed to observation status) stay in a hospital. The AARP estimates that family members now provide long term care for loved ones that it values at over $400 billion per year. If Medicare for All covers comprehensive long term care, people are going to come out of the woodwork by the hundreds of thousands to claim benefits. How will that be paid for?

Peter
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Peter

How will anything get paid for if we keep subsidizing the wealthy with tax breaks?

Barry Carol
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Barry Carol

Taxes can and should go up on the wealthy, but what’s reasonable and how much money will that raise compared to what’s needed? I would support getting rid of the carried interest rule that benefits hedge fund and private equity moguls, the 1031 exchange rule that benefits real estate investors, raising the top marginal income tax rate back to 39.6%, taxing dividends as ordinary income as they were prior to 2001 and raising the capital gains tax rate back to 28% where it was back in 1986. That would include the 3.8% tax on investment income for couples who make… Read more »

Peter
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Peter

It’s about who can afford more taxes – certainly those at least above somewhere of $250,000. How would more taxes hurt the wealthy, keep that Escalade an extra year, maybe buy a 30 foot boat instead of that 36 foot, downsize to 4000 square foot home.

Barry Carol
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Barry Carol

Higher taxes are not about how it will affect one’s lifestyle. The cost of housing varies enormously around the country so $250.000 may provide a comfortable living where you live but it’s not a lot in NYC, SF and numerous other places. Besides, a lot of people like my wife and me live well below our means — small house (1700 sf), 15 year old car, etc. Does that mean I should pay more in taxes than someone with the same resources who spends most of it on a more lavish lifestyle? The top 1% of the income distribution already… Read more »

Peter
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Peter

Assuming if you live in high rent areas then your income will reflect that. Certainly attracting high wage employees means that companies don’t pay standard wages which do not reflect the local cost of living. We’re not looking to tax the money left over due to frugal living, just the money you earn. In Ontario Canada the minimum wage went to $15/hour. An acquaintance who owns a chain of local shoe stores (inherited from daddy) complained about the cost to his business – however his lifestyle did not change. So it IS not about lifestyle for the extreme wealthy, but… Read more »

Barry Carol
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Barry Carol

For most employees, wages in high cost locations don’t come close to reflecting the cost of living. My son’s former employee relocated from suburban Chicago to Boston following a merger. He chose not to relocate but if he did, his salary would have been essentially the same but the cost of a similar house to the one he owns would cost twice as much as is current house is worth. A retail clerk at Walmart could probably afford a modest apartment in rural AK but good luck trying to find one in Northern NJ, Westchester county, NY or Long Island.… Read more »

Peter
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Peter

“For most employees, wages in high cost locations don’t come close to reflecting the cost of living.” Yes, certainly for those at the $7/hr wage rate. But at least higher paid workers usually also get heath care subsidy from their employer. Cost of housing is a problem all over the U.S. (and in big city Canada). Those with mortgages at least get to deduct from taxes – even those with high incomes. Housing equity is a big problem that maybe taxes could help alleviate. “By the way, a $15 minimum wage in Canada translates to $11.25 in the U.S. at… Read more »

Barry Carol
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Barry Carol

$15 per hour is probably still not enough to support a family of four in most places. I think liberals also underestimate the amount of automation that will be introduced in industries like restaurants if $15 per hour becomes the law of the land. Also, demand in that industry is highly elastic so as menu prices inevitably rise, many people either will stop going out to eat or at least eat our less often forcing many restaurants to close. What good is $15 per hour for those who work in restaurants that close or have to significantly cut back on… Read more »

Peter
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Peter

” What good is $15 per hour for those who work in restaurants that close or have to significantly cut back on employees or hours worked per week?”

What good is a job at $7/hr and no health coverage? Automation in restaurants will happen no matter what, and as the income gap widens less people will be able to eat out anyway.

But, less eating out at fast food places can only improve health.

Barry Carol
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Barry Carol

First, millions of low wage jobs are held by young people living at home with minimal expenses or while attending college. It’s their first rung on the workplace ladder and they learn valuable skills like being on time, working with others and taking constructive criticism. Second, automation happens when there is an economic incentive to make the investment. There will be a lot more incentive to invest in automation at $15 or $20 per hour than at $7.25. At any rate, let the states set the minimum at a rate that makes sense for them. There is a lot of… Read more »

Barry Carol
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Barry Carol

I would like to address three aspects of Medicare for All that voters need to better understand. They are (1) the favorable view of existing Medicare, (2) risks and unintended consequences of Medicare for All and (3) how to pay for it. Existing Medicare polls well. I think the main reason is that beneficiaries pay only a small percentage of its cost in premiums. Medicare Part A is financed by a payroll tax on wage earners, the Part B premium only covers 25% of Part B costs and Part D reinsurance for costs incurred by beneficiaries who enter the catastrophic… Read more »

Peter
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Peter

I’ve been to Stockholm, plenty of well dressed citizens and expensive cars, nice housing no visible homelessness. All have state run healthcare. Outside of Stockholm, in the sea approach, there are islands and shoreline where many Swedes have summer homes and cottages. No, not everyone is “rich” but they live a pretty good lifestyle – from observation.

At least with a VAT you’re getting something for it – unless of course politicians choose to give it away for corporate welfare, where there are never questions of, “How are we going to pay for it?”

Barry Carol
Member
Barry Carol

Of course you don’t see the people who died prematurely from heart disease, cancer, etc. because doctors viewed their “biological age” as too old to even be offered surgery, chemo, etc. whereas in the U.S. it’s routine to offer it. Even if it’s marginally useful at best or even futile, if the patient or the family wants it, they get it. That accounts for a significant piece of America’s higher healthcare costs. So does the fact that doctors, nurses, and just about everyone else who works in the healthcare system makes 50%-100% more than their overseas counterparts.