David Leonhardt: The Medicare-for-All trap

Most issues will strongly favor the Democrats in 2020. Taking away people’s health insurance is an exception. View in [Browser]( | Add nytdirect@nytimes.com to your address book. [The New York Times]( [The New York Times]( Wednesday, January 30, 2019 [NYTimes.com/David-Leonhardt »]( [Op-Ed Columnist] Op-Ed Columnist A couple of weeks ago, one of the country’s most respected health care pollsters — Kaiser Family Foundation — conducted a survey on “Medicare for All.” And [the top-line results]( looked great for advocates of the idea, like Bernie Sanders and Kamala Harris. Some 56 percent of respondents said they favored “a national plan called Medicare for All in which all Americans would get their insurance through a single government plan.” A large majority of Democrats backed the idea. Almost a quarter of Republicans did, too. The poll’s details, however, were a lot of less positive about Medicare for All. In fact, they showed why single-payer health care may turn out to be one of the few problematic issues for Democrats heading into 2020 — if the party isn’t careful. Harris has [highlighted the tensions]( this week, saying on Monday night that she supported the most aggressive version of Medicare for All before [moderating her position]( via aides, late yesterday. When Kaiser pollsters were putting together their survey, they understood that not all Americans thought of “Medicare for All” as meaning the same thing. So the poll asked people whether they believed that they would be allowed to keep their private insurance plan under such a system. Almost 60 percent of respondent said yes. “In reality,” [as HuffPost’s Jonathan Cohn wrote]( in an analysis of the poll, “the whole point of Medicare for All would be to wipe away current insurance arrangements and replace them with a new public plan.” Not only that, but when the pollsters described a version of Medicare for All in which private insurance was wiped away, support plummeted. The idea flipped from being popular to unpopular: 37 percent of respondents favored it, and 58 percent opposed it. This same hostility to change helped sink Bill and Hillary Clinton’s health care plan in the 1990s. It also became the mainline of Republican attack against Barack Obama’s health care law — and one reason that law remained unpopular (until President Trump started attacking it). Many Americans are happy with their current insurance, polls show. Even among those who aren’t, many worry about being forced into a new plan. “Loss aversion is a hell of a drug,” notes [Brendan Nyhan]( a University of Michigan political scientist. I understand the arguments in favor of mandatory Medicare for All. It could reduce bureaucratic waste and insurance-company profit skimming. It could help the United States lower its world-leading medical costs. And I’m thrilled to see presidential candidates willing to offer [bold economic ideas](. But I think this particular plan is an unforced error. It comes with huge political vulnerabilities — and a less problematic, but still bold, alternative exists: [A vastly expanded version of Medicare]( that allows people to buy in voluntarily. That plan could also be called Medicare for All. And if it proved to be as popular as Democrats expect, advocating for the mandatory version would become much easier. Until then, as Nyhan says, the mandatory approach “splits Ds and unites Rs. That’s the opposite of smart politics.” The next Democratic president will need to prioritize among several big issues. I’d much prefer a winnable health care fight that also leaves room for action on climate, taxes, civil rights and other issues to an all-consuming uphill battle. Elsewhere … - Watch Harris explain her position during [the town hall on Monday]( [night](. CNN’s Jake Tapper said to her: “I believe it will totally eliminate private insurance. So for people out there who like their insurance, they don’t get to keep it?” Harris’s answer: “Well, listen, the idea is that everyone gets access to medical care. And you don’t have to go through the process of going through an insurance company, having them give you approval, going through the paperwork, all of the delay that may require. ... Let’s eliminate all of that. Let’s move on.” On Tuesday, her aides said she was [also]( [open to other approaches](. - [Philip Klein]( of The Washington Examiner tweeted: “Gallup poll finds that 70% of those with private insurance rate their coverage as ‘excellent’ or ‘good’; 85% say the same about the actual health care that they receive.” - “Democrats ... will have to navigate a tricky gap between what voters think of when they hear ‘Medicare for All,’ and what politicians mean when they say it,” [Molly Hensley-Clancy]( of BuzzFeed News wrote, in a reported piece from Nebraska last year. “Pressed on the details of Medicare for All, many voters in Omaha expressed skepticism — or outright distaste — about the single-payer plan that Sanders has championed.” - In Jacobin, [Tim Higginbotham]( recently offered a more favorable view of mandatory Medicare, arguing that the transition wouldn’t be as disruptive as some Americans fear. “It will certainly face complications, but the Medicare bureaucracy will be able to sort these out as they come,” he wrote. - [Sarah Kliff and Dylan Scott]( of Vox have analyzed the various versions of Medicare for All, as well as other Democratic health- care plans. - Elizabeth Warren, Kirsten Gillibrand and Julian Castro — three other presidential candidates — also support the Sanders version of Medicare for All that Harris backs. But they have generally not been as clear about ending private insurance as Harris was on Monday. When Gillibrand was asked about that part of the plan on a recent episode of “[Pod Save America]( she sidestepped the question. - My view is that the best answer is a version of: I’m for Medicare for All. If you want Medicare, you can have it, regardless of your age. If you’d rather keep your private plan, you can do that, too. This approach will give us universal coverage, lower costs and consumer choice. Oh, and I’m in favor of tax increases on the wealthy and corporations to help pay for it. They’re [not paying their fair share]( right now. The Axe Files Newsletter readers know that I’m a fan of David Axelrod’s podcast, “The Axe Files,” in which he asks guests to tell their life stories and eventually wends around to current events. I sat down with Axelrod in Chicago last week to tape an episode and had a great time talking about politics, economics and my wayward adolescent years. 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