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Progressive idealism and Medicare For All

Summary:
I have suggested (here and here) that idealism is leading progressives astray.  Idealism leads progressives to ignore the political opposition that their proposals will encounter, and the need to win over reluctant allies through policy design, messaging, and – yes – compromise. A clear example of the pitfalls of progressive idealism is provided by the current debate over Medicare for All. The case for single payer health insurance in the United States is quite strong but treating Medicare for All as a short-term policy goal is a serious political error.  The problem is not just that immediate implementation of single-payer health insurance will meet insurmountable political resistance, which of course it will.  MFA turns social insurance – which should be

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I have suggested (here and here) that idealism is leading progressives astray.  Idealism leads progressives to ignore the political opposition that their proposals will encounter, and the need to win over reluctant allies through policy design, messaging, and – yes – compromise.

A clear example of the pitfalls of progressive idealism is provided by the current debate over Medicare for All.

The case for single payer health insurance in the United States is quite strong but treating Medicare for All as a short-term policy goal is a serious political error.  The problem is not just that immediate implementation of single-payer health insurance will meet insurmountable political resistance, which of course it will.  MFA turns social insurance – which should be one of the Democrats’ greatest electoral advantages – into a serious liability.  If the election is close, which at this point seems quite possible, this unforced error may result in a second term for Trump.  Since re-electing Trump would be a calamity, and MFA has virtually no chance of being passed even if the Democrats hit the trifecta and win the presidency and both houses of Congress, this is a huge mistake.

Rather than running on a platform calling for immediate implementation of MFA, Democrats should promise to protect and modestly expand Social Security, Medicare, and Medicaid, in ways that will visibly help struggling Americans.  They should increase Social Security payments for seniors with limited income and assets and for the very old.  They should push to expand health insurance coverage, to improve drug coverage, and for a public option at least in rural areas.  They should promise paid family leave and expanded tax credits for families with children.  What they should not do is insist on dismantling the existing system of employer-based coverage in a big-bang transition to a single-payer system.

Social insurance should be a huge electoral advantage for Democrats . . . 

Social Security, Medicare, and Medicaid are highly popular, and people tend to trust Democrats more than Republicans on social insurance issues.  This is hardly surprising, since Republicans have a long history of trying to cut or dismantle these programs.

Trump ran on a promise to protect and improve these programs.  His liberal position on social insurance may have been disingenuous, but it was politically significant because most voters, including many Republicans, are liberal on economic issues.  Once he got into office, however, Trump became a standard-issue conservative on taxes and on Social Security, Medicare, and especially Medicaid and the Affordable Care Act.  He recently floated the possibility of cuts to Medicare and other entitlement programs.  The best hope that Democrats have for prying away Republican voters is to focus on voters who are liberal on economic issues, especially social insurance.

Trump’s duplicity on social insurance is not just a policy issue.  Trump played his voters for suckers, and voters hate being lied to by politicians.

Social insurance should be the political gift that keeps giving for Democrats.  Most House and Senate Republicans are vulnerable on Social Security, Medicare, and Medicaid.  Many of them have supported cuts to these programs, and their reckless corporate tax cuts will put continuing pressure on the financing for social insurance.  Democrats can and should hold all Republicans accountable for their continuing efforts to subvert these programs.

But MFA will turn social insurance into a political liability . . . 

For all these reasons, social insurance should be a huge advantage for Democrats.  But MFA will turn social insurance into an electoral liability, with no compensating advantages.

Special interest opposition to MFA will be intense.  All of the cost savings that MFA can achieve come from eliminating jobs and reducing the income and profits of people and companies in the health care sector.  Insurance companies will lead the fight against MFA, but they will be joined by other groups – people who do medical billing, people who work for insurance companies, some hospitals and health care workers, etc.  Their opposition will matter.  It was Democratic Senator Joe Lieberman of Connecticut – home of the insurance industry – who killed the public option in Obamacare.  Special interest opposition can only be defeated using “salami tactics” – chopping off one piece of the private health insurance system at a time, over a period of years.  We need to get the camel’s nose into the tent first, the body will follow.

Critically, electing a president who stakes out an aggressive position on MFA will make reform harder to achieve, not easier, because it will make it easier for insurance companies to scare voters into opposing reform.  Americans have been primed to distrust government by 50 years of “goverment failure” messages.  Distrust of government will be a powerful obstacle to immediate implementation of MFA.  People will understandably worry that government will screw up a quick implementation of MFA (not without reason, in my view, but here I am just concerned with the electoral politics).  By emphasizing that their goal is to protect existing programs, and to build on them in modest but important ways, doubts about government competence and fairness are much less salient.  There is no question that the government can run Social Security, Medicare, and Medicaid.  Focusing attention on the threat to these programs from Republicans makes loss aversion work in favor of the Democrats rather than against them.

Some form of single-payer health insurance makes sense for the United States.  It’s fine for Democrats to say this.  But they need to acknowledge that putting such a plan in place will take time and needs to be done carefully to build voter support, overcome resistance by vested interests, limit job losses, and avoid major implementation disasters.  If we play our cards right, we can build on the Affordable Care Act and position ourselves to have some kind of single payer system in place in 20 years.  If we overplay our hand, we may end up with four more years of Trump.

My guess is that most of the candidates for the Democratic nomination are aware of all this.  They could explain to Democratic voters why implementing Medicare for All will be a long, drawn-out struggle.  They could teach voters to distinguish between universal coverage, which should be achievable in the short-run, from single-payer, which is not achievable in the short-run and may lead to electoral disaster.  They could encourage Democrats to be hard-nosed, patient, and strategic.  Instead, they are pandering to idealistic primary voters.  The path to a realistic progressive politics will be long . . .

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