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While there are some legitimate concerns that can be raised about Medicare-for-All on the merits–as opposed to on the politics–I am not convinced that it’s a problem that some people, like members of organized labor, have worked hard to negotiate good private health care plans. To me, this is a bit like arguing that we don’t need to eliminate Lyme disease because we can treat it with antibiotics. There is simply no value-added by having a profit or commercial basis to health insurance. If it is to exist at all, it should be strictly as a supplemental product.
But that’s an ideological opinion of mine and not a strategic analysis of what the Democrats should be pursuing on the health care front during the 2020 campaign. Watching the CNN debate on Tuesday night, I agreed with Warren and Sanders on the merits, but I thought the moderates had the better argument.
I have three concerns about pushing for Medicare-for-All right now. The first is that it’s obviously controversial and has big political vulnerabilities. Sanders freely admits that to pay for it will require taxes to go up on everybody who pays taxes, including the middle class. Warren is more reluctant to acknowledge this, although she doesn’t outright deny it. What they both argue, instead, is that overall costs will go down for the middle class because they will no longer have to pay premiums, co-pays, or out-of-pocket costs. This is most likely true in a general sense, although  on an individual basis it might depend on how much health care someone uses in a given year. So, one problem lies in convincing people that a tax hike will benefit them, especially when it is not guaranteed that it will.
Another problem is the same one we see anytime health care reforms are proposed. People freak out about losing plans or access to doctors they like or having to wait in a queue to get treatment. This vulnerability isn’t avoidable or a good argument for not pursuing reforms but it does make it risky to propose something as disruptive as the abolishment of all private insurance. For me, this means that you should never propose something like this unless you’re serious about putting all your muscle behind it. And that gets to my third concern.
There is a basic cost-benefit error here. The chances of pushing a Medicare-for-All plan through the next Congress are almost nil. The Democrats would either have to overcome a Senate filibuster or they’d have to eliminate the legislative filibuster altogether. Let’s examine both of those scenarios.
The Democrats would need 60 votes to end a filibuster and they couldn’t get that many votes even if they won every competitive or semi-competitive Senate race next year. So, we can rule this out.
To end the legislative filibuster, they’d need 50 votes and the vice-president breaking a tie. But the Democrats will be lucky to have more than 51 or 52 seats even in a total landslide election. The problem here is that they’re unlikely to have enough unanimity in their caucus to end the legislative filibuster unless they can get closer to 55-57 seats. That’s both because senators are institutionally opposed to the change and because moderates get two valuable things out of the filibuster. First, it prevents radical legislation from passing which would endanger their political careers. Second, it puts them in the strongest negotiating position because they are the ones who can cut deals with Republicans (or so they like to think).
So, it’s not likely that the legislative filibuster will be eliminated by the next Congress. If it is, it will probably be after the first and most important year when even the moderates have to acknowledge that the rule is crippling their new president.
So, on a cost-benefit basis, there are easily identifiable downsides to proposing something that makes people apprehensive and that can be easily attacked and mischaracterized. What I can’t find is the upside. Where is the benefit in proposing something you won’t be able to enact?
And it’s not just the filibuster that makes it hard to enact. It’s also the lack of unanimity about it in the Democratic caucuses. I’m not at all certain that Nancy Pelosi could pass Medicare-for-All through the House. In the Senate, there could be a dozen or more Democratic senators who would never sign off on it. If the idea is to move the Overton Window to make Medicare-for-All more popular, that’s the job of a message candidate, not a candidate who plans on being the nominee.
This lack of unanimity was definitely on display during the debate last night when candidates like Joe Biden, Pete Buttigieg and Amy Klobuchar all attacked Warren for proposing Medicare-for-All. That footage will be manna from heaven for Donald Trump or whoever runs in his stead next year. We can be angry about Democrats echoing Republican talking points, undermining support for Medicare-for-All, prattling about budget deficits, and giving ammunition to the GOP for the 2020 campaign. But we can also be angry that we have serious potential nominees who couldn’t predict these problems and avoid them.
What’s particularly annoying is that if Sanders or Warren were to become president, they’d probably struggle to pass the plans proposed by Biden and Buttigieg and be accused of Leninism for even trying. That’s the best they could hope to do, and they’d be exceeding my expectations if they succeeded. So, all this is is a big fat political weakness that has no discernible upside at all.
And I simply can’t understand why anyone would gift a person like Donald Trump something he can grab and beat them with. It’s dumb politics and for once the moderates have the better side of an argument.
