Incremental Change: Ur Doing it Wrong

We’ve seen this crop up here, as well, but in this thread at CT several people are advocating an alternative scenario to the ACA: going for a small expansion of Medicare rather than comprehensive reform. The idea that expanding Medicare would be an incremental path towards Medicare-for-all, however, fundamentally misunderstands the dynamics of health care reform.

First of all, the version presented in LGM comments — arguing that a Medicare buy-in for 55-year-olds would be better than the ACA — is evidently horrible. Among other things, it would prefer a a modest expansion of one of our single-payers over a much more expansive extension of single-payer directed at some of the most vulnerable of American citizens. This is the kind of tradeoff that makes clear that most leftier-than-thou types aren’t really leftier-than-thou, unless thou is convinced that core progressive principles are defined by the contention that any deviation from optimal policy is the result of the unfettered will of Barack Obama.

The version presented at CT, at least, would replace the ACA with a small Medicare buy-in plus the Medicaid expansion. Here, another political problem presents itself — I just don’t think it’s plausible to think that the Medicaid expansion could have been secured except as part of a comprehensive reform package.  There’s a reason why it’s been easier for Democrats to protect Social Security than to protect the unemployed or food stamp recipients. (The Medicare buy-in has the additional problem that Joe Lieberman opposed it after he favored it; perhaps the dynamic would have changed had the Medicare buy-in been the only issue on the table, but since Lieberman was clearly determined to stick it to liberals one way or another, this is a pretty dubious assumption.) But let’s assume that Lieberman would have dropped his opposition to a Medicare buy-in and it could have passed instead of the ACA. Would this be a superior alternative because it would make Medicare-for-all more likely in the long run?

No, because — to borrow a point from Paul Starr — every time you take a relatively affluent and politically active constituency out of the employer/exchange market, you make comprehensive reform more, not less, difficult. Opposition to the ACA is strongest among those who have Medicare or are about to become eligible. This isn’t surprising: they no longer have anything to gain and potentially have things to lose. A small expansion of Medicare just increases the number of people with no stake in comprehensive health care reform, making overcoming the many vested interests to who oppose comprehensive reform even more difficult. Incidentally, another problem with the Diaz-Alvarez argument I failed to mention at the time is that it seems to assume that insurance companies are the only relevant vested interests. But this isn’t true: practitioners, who would stand to lose big if the United States adopted any kind of European model, are an even more formidable obstacle.

Indeed, if you want to do heighten-the-contradictions right, the real villain of American health care reform isn’t Barack Obama but Lyndon Baines Johnson. By taking the path of least resistance and targeting the most unprofitable customers of health insurance companies and giving a relatively politically powerful constituency no reason to support comprehensive reform, he made European-style health care reform even more difficult. Now, like most heighten-the-contradictions arguments to claim that LBJ should have forsaken Medicare out of hope that it might make Medicare-for-all more likely some day would be monstrous. Delaying Medicare would have certainly meant a lot of unnecessary suffering, and the unprecedented destruction of the American health insurance industry would have remained enormously unlikely. And depending on when Medicare happened it could have been a crappy voucher system instead of the Medicare we know today. Johnson was clearly right to take the bird in the hand rather than the magic pony in the imaginary bush, and since Johnson was a Democratic president nearly a half-century ago rather than a contemporary one I assume almost nobody would disagree. But as the fact that we’re no closer to Medicare-for-all now than we were 50 years ago makes clear, Medicare-for-some isn’t an inexorable path towards single-payer, and on net makes it even less likely.

So going for a modest Medicare buy-in instead of the ACA would have been a really bad idea. It would mean that the offer to the many of the uninsured between 18 and 55 would be “nothing” for the foreseeable future. Removing the comprehensive framework would, at the minimum, have created a substantial risk of no Medicaid expansion or an inferior one, and possibly more vulnerable to outright nullification by the Supreme Court as well. It would make the constituency for better comprehensive reform smaller and less powerful (while, on the other hand, nothing about the ACA takes future Medicare buy-ins off the table.) It’s certainly a better argument than daydream believing about how Prime Minister Obama could have gotten single payer but he DIDN’T EVEN TRY, because it’s at least tethered to some recognizable political reality, but it’s not a good one.