Editor’s Note: This post was originally published on May 12 with portions of the essay missing. The corrected text is below.
By Ted Marmor
Presidential campaigns in the United States are not typically fought over competing manifestos, with policy details set out in reasonably clear language. Rather they are disputes among candidates about the state of the country and what values—or aspirational visions—they endorse. And, for at least a century, most American debates about health care reform have been dominated by ideological slogans, misleading claims about financing, and mystifying labels. Republicans have exemplified the mystification this year, repeatedly mislabeling Obamacare as socialized medicine and falsely claiming it a “takeover of American medicine.”
In fairness, the Democratic primaries have generated their own version of mystification. The two candidates do agree on the goals of universal health insurance. But clarity ends there. The Clinton campaign has emphasized incremental reform possibilities and criticized Senator Sanders’ proposal of Medicare for All as unrealistic. Sanders, by contrast, has offered a compelling conception of a fairer and less expensive version of what Americans want, but no incremental steps to get to it.
Each candidate has answered only one of two key questions. The Sanders campaign asks how American medical care arrangements can be more equitable, less costly overall, and less complex? What, pragmatically, the Clinton team asks, would be the next incremental steps to take in 2017 were a Democrat to win the presidency?
The most obvious point is that the likely politics of 2017 and beyond are incompatible with a major reform of any American public policy—whether it is federal aid to higher education, climate change policy, or Medicare for All. That should frame the discussion of Sanders’ proposal around the aspirational values it reveals. Such a debate framing would provide Clinton the opportunity to outline a competing long-term vision that builds on her initial plan for incremental improvement of the ACA.
The Sanders campaign has repeatedly emphasized what is appealing about expanding Medicare to all, taking for granted that celebrating the popular program would be enough, but lacking an incremental map of any kind.
A recent article in the American Prospect illustrates this point. The central contention is this: Sanders proposes to shift the costs of all private health care to Medicare, in one fell swoop, which would substantially expand the federal budget and require increased taxes—taxes that seem impossible in contemporary American politics. A number of economists with ties to the Clinton campaign have offered the fiscal grounds for such ridicule. For example, Kenneth Thorpe, an economist at Emory University, estimates Sanders’ proposal would cost the federal government $1.1 trillion a year. But this claim confuses Sanders vision of what the future could be like with a tax plan for 2017 he does not offer. To claim Sanders ignores the practical impossibility of his reform expansion is misleading. Such fiscal criticism can easily distort rather than illuminate what Sanders was proposing. It ignores—or downplays—the foregone private expenditures a Medicare for All program would replace. But it is also true that Sanders is not admitting to his supporters that his plan, given the current partisan deadlock, is infeasible.
The Clinton campaign, by contrast, aligns with Obamacare’s expansion of health insurance coverage and promises to strengthen and build on it. But it pays little attention to the millions of Americans who remain uninsured—or under-insured—or what steps candidate Clinton would take to address this problem. Nor have Clinton and her defenders addressed seriously the reliance on deductibles and co-insurance that no only makes access to care difficult for many, but also threatens the economic security of those with health insurance. In short, there is considerable cheerleading about the ‘signature’ health reform program of the Obama Presidency, but little clear engagement with what further reform is needed and what would be productive first steps (just as this is going to press, Clinton has offered one possible first step–a Medicare buy-in option).
The most obvious point is that the likely politics of 2017 and beyond are incompatible with a major reform of any American public policy—whether it is federal aid to higher education, climate change policy, or Medicare for All. That should frame the discussion of Sanders’ proposal around the aspirational values it reveals. Such a debate framing would provide Clinton the opportunity to outline a competing long-term vision that builds on her initial plan for incremental improvement of the ACA.
A sensible debate in 2016 must also address incremental possibilities. The debate could turn to state experimentation. It might lead to considerations discussion of moving the eligibility for Medicare down by a decade to 55. Or it could awaken interest in making Medicare less complex, which it has become, as have private health insurance policies.
Most fundamentally, it would recall the long struggle over Medicare itself, starting with a plan to initially cover Social Security retirees with what amounted to a Blue Cross plan for hospitalization only. Those reformers—Wilbur Cohen, Robert Ball, Oscar Ewing, and Nelson Cruikshank—first sketched this idea in 1951 and some of them were there to implement that program’s first step in 1965-66. That’s evidence of incrementalism with purpose and vision, not the opposite. The same is needed now.
