Elizabeth Warren appears to have finally come up with a
health care plan that makes sense. How
she got there was ugly. After an excessively
ambitious Medicare-for-all proposal damaged her candidacy, she has pivoted to a
more modest, and much more politically feasible, set of ideas. Jordan Weissman wisely points
out that it would have been better if she had done it with fewer political
contortions.
Michael Brendan Dougherty, one of the last
(God bless him) anti-Trump
conservatives, thinks
that it’s a political mistake, because the left will feel betrayed and abandon
her. He might be right. A big part of the Democratic base insists on
universal Medicare: a complete overhaul of the health care payment system, abolishing
all private insurance. It is a foolish
demand. Whatever the merits, it is politically
impossible. If you hope to excise the
ugly boil that is Donald Trump, you need to understand why.
The basic problem of American health care reform is that as it
has developed, insurance has been selectively extended to slivers of the
population – people with decent jobs, the elderly, the poor, veterans - that
were either unusually politically powerful, unusually sympathetic, or
both. When the majority, and the most
politically vocal parts of the majority, have full protection, then it is hard
to expand further. This generated what
Paul Starr calls
a “policy trap”: so many people were given a stake in the new status quo that
further change, in the direction of universal health care, became extremely
difficult.
In 1994, Bill Clinton fell squarely into the trap. Most Americans are satisfied with the health
insurance that they have. Yet his
central idea was to have all insurance funneled through new health insurance
purchasing cooperatives, which would negotiate with insurance companies and
then present a menu of options to their customers. A national health board would administer a
global budget. Employers could no longer
purchase coverage directly; they would have to purchase through the
cooperatives instead. Small employers
that did not provide insurance for their employees would be required to do
so. Many doctors and hospitals would
have to affiliate with health plans.
Perhaps most importantly, employees would probably have to choose
different health plans than they already had, and thus change doctors and
hospitals.
This was the deepest political flaw in Clinton’s proposal, and
Obama learned from it. Obama built on
the existing system rather than trying to replace it entirely. (I tell this story in the first chapter of my
book, The
Tough Luck Constitution and the Assault on Health Care Reform.) The result is inelegant, but it passed, it is
working, and millions of Americans are better off as a result. Lives have been saved. The fear of change nonetheless made the bill
a very near thing, and there continues to be enormous grievance about the tiny
amount of change that did happen. In
selling his plan, Obama repeatedly said
that if you like plan you have, you can keep it. When that turned out to be true a mere 98% of
the time, he was given enormous grief for it. Politifact declared
it the lie of the year. It is a massive
political mistake to mess with the existing system more than you absolutely
must.
That’s why so many of the smartest Democratic political
analysts have argued
that the demand for Medicare for All, if it is embraced by the Democratic
candidate, is a good way to help Trump get a second term.
Trump, who offered nothing but a vague promise to replace
Obamacare with “something great,” was able to persuade
many voters that he would give them better coverage at lower cost with
lower deductibles. That’s what they
actually care about. Warren should focus
on that and not get lost in the wonky details.
Perhaps now she can.