Let's talk health care - music to my ears (after spending my career in health policy).
My perspective is not to talk about Medicare for all, but to talk about Universal Health Care (not coverage - coverage brings up issues over what is covered). As most of you know, there are many different systems around the world that achieve Universal Health Care; Sanders' Medicare for All is just one way to achieve the goal. If, instead of getting bogged down in the details, we focus on the goal itself, I believe there would be much more buy-in.
We have to keep it simple - acknowledge the need, commit to getting there, and discuss concrete goals.
I believe the goal rings true in the hearts of even the most moderate of Dems - this does not need to be a divisive issue if handled correctly.
M4A/Open Medicare/whatever could provide the one true "tentpole" we've been needing for the whole big-tent approach. You can basically say, "As long as you're on board with this, you're a Democrat, and everything else is OK to buck party orthodoxy about". It's a way to welcome people back into the tent, offering both reconciliation and absolution.
And it could end up lessening the salience of odious Omnicause litmus tests by offering up one big litmus test that always has one glaringly obvious answer.
However, I do want to raise a couple notes of caution.
1. The elephant in the room is the way that Pelosi hijacked Obama's presidency by forcing healthcare reform on him. It was the wrong move because of the broader economic crisis at the time, and it really undermined our entire political movement for voters to see us obsessing about the wrong thing at the time. And depending on how things go in the 2028 cycle, we may end up needing to have the flexibility to postpone a M4A push until after we can de-Trumpify the country.
2. As you note, we can't do M4A unless we dramatically expand the supply of doctors. But what often gets lost on pundits -- almost all of whom have never tried to get into med school -- is that the financially toxic nature of residency is what gives the AMA so much leverage for its members to continue endorsing their policy of restricting the number of residency slots. You spend 4 years paying undergrad tuition, and THEN another 4 years paying even MORE outrageous med school tuition, and it can EASILY come out to at LEAST half a million dollars in debt. That debt comes immediately due during residency, which has publicly-set salary rates that are INSULTINGLY low (avg $68-71k), and you're forced to endure that for the next 3-8 years of your career. Which most likely means that you're going on IBR/forbearance for that duration, so the debt piles up even MORE.
So by the time you're done with residency, you're SICK of a decade-plus of forced poverty, and you are going to have ZERO patience for any salary that doesn't IMMEDIATELY (1) cover your full loan payments, and (2) provide the upper-class lifestyle you were promised at the start of all this. Which all means starting salaries in the lower-mid 6 figures, which is something that can ONLY be provided by a supply restriction inflating their wages.
In order to solve all this, you basically have to restructure the entire medical education system AND make-whole all the people currently suffering under it, which is a demographic that spans all the way up into the age-50 bracket (IE those still paying their loans off).
Just chiming in to say that I agree with this diagnosis of the structural problems with our medical profession. I think that when the US does get around to universal health care, it will have to solve the problem of doctors replacing car salesmen as the core of the MAGA right. I'm already astounded by the number of specialist physicians who vote GOP reflexively even now because of taxes. The AMA has a bad reputation for a reason. Some of it no doubt is due to the mountain of medical debt. A lot of it is due, let's be honest, by the fact that medicine is a field a lot of people go into to make money -- to be the country club people in their communities. So changing that culture / expectation / syndrome is going to be hard.
Addendum: The paranoia and greed are particularly powerful BECAUSE of the trauma inflicted by forced poverty.
It’s hard enough to try convincing a man to reject something his paycheck depends upon. It’s a whole other ballgame to tell him the government’s gonna control healthcare costs by forcing his paycheck down AFTER the government just forced him to spend a whole decade of his life in artificial poverty.
Well, they go into the field expecting to automatically become members of the upper class, which is also why a lot of people go into other fields as well.
But the startup costs and enforced suffering/poverty are what really drive and lock in the insane paranoia and greed later in life.
I’m friends with several doctors and not a single one of them I know is poor. They have big houses/compounds and high end German cars and go on lots of vacations all over the globe.
Great column, with one small edit: "It doesn’t account for the fact that most people are already insured, and most of them are basically fine with the health insurance that they have."
Ahem.
Literally NO ONE I know is basically fine with the health insurance they have. As noted in another comment, people are staying in jobs they hate because of not wanting to lose their coverage. Others (like me) pay, with help from Obamacare a still exorbitant amount. I think you'd agree that the correct to way say this is that people have become inured to the costs of the healthcare they have, as much as they hate it. They fear that whatever might come later will be worse, and Republicans are all too willing to fan those flames.
I fear this is a selection effect among people who have progressive-minded and politically engaged friends. I will say I dislike my health insurance plan because I don't think BCBS adds any value to the world; my insurance status shouldn't turn on my or my wife's employment status; if something bad happens I suspect they'll try to deny coverage. But abstracting all of that out of the equation: It's fine. I feel insured! And that's how data suggests most people feel. https://www.nbcnews.com/politics/politics-news/poll-are-satisfied-health-insurance-quarter-report-denials-delays-rcna248908
I appreciate you're bringing this information to the comments, but having looked at the article I would suggest that the word "satisfied" is doing a lot of work here. I wonder what the response would be if people were asked if they were HAPPY with their coverage and how much they were paying for it. Also, with rural hospitals closing (or this is anecdotal? I'm willing to listen) this is not a simple "Progressives hate their healthcare" discussion. Again, I will be happy to stand corrected, but it would seem that people all over the political spectrum live in fear of losing their coverage, and what seems to me to be the bigger obstacle is convincing them that the government can do a better job of giving them healthcare than the private companies can. Millions have (and will) be spent in telling them otherwise, and those deep pockets sadly buy politicians on both sides of the aisle. I am old enough to remember when Reagan told us that those nice ol' corporations will be a lot better at doing what's right than the big bad government. I don't see much changing since then.
Excellent idea. I do have question, as Medicare isn't free and to get better healthcare with Medicare one currently also needs to purchase some form of supplemental coverage. That said, Universal Health Care, a plan where the country as a whole pays in, so everyone has free healthcare and access would in the end save money. I worked as a medical coder in a hospital for several years. People need preventive care and a place to go, a clinic for basic health needs. In the charts I read, I saw people coming in for very expensive Emergency Room Treatment, which is excellent treatment, but they could have gone to a clinic or to a primary care physician if that care was covered. Not addressing hardcore healthcare needs in this comment. Keeping it simple.
Dump both Medicaid and Medicare monikers and go with Open Healthcare or Open Health for short. It sounds "new" and people get excited about new stuff, most anyway.
Nothing is ever going to change in D fissure over M4A until every last person in the party who can remember the 1990’s is pushing up daisies.
Both Republicans *and centrist libs* can recite every Limbaugh-era critique of everyone having health care, and centrist libs (and politicians) don’t really oppose universal healthcare for practical reasons. That’s the political equivalent of believing in efficient market theory.
They oppose it because the status quo is both the way things have always been (and therefore represent either eternal reality or God’s will, however they happen to think of it), and the idea of The Poors seeing a doctor just strikes them as against the natural order of things. In centrist minds if someone wanted health care they should have studied harder in graduate school or invested early enough in the right tech company. And if they didn’t, that’s on them.
They don’t want the poors to die if untreated medical conditions per se, but neither do they care enough to do anything about it.
At this point would the left really be satisfied with a “sellout” version of M4A that wasn’t the full-bore, free at point of service, unlimited usage version?
I could see this being just one more vicious fissure point within the party.
My wife's been a medical professional (OD) for 18 years. She is paid well but our debt is high. We live paycheck to paycheck. Among the many things we can't afford is medical coverage for me. I don't have any idea if or when that'll change.
On one hand it would be really neat to know that I could go to a doctor, get the tests and care I need, and not die early of some preventable or treatable problem. On the other hand, some kind of restructuring of her profession that involved forced pay cuts would also force us out of our home and probably require us to relocate. Tricky! Too bad that student debt relief plan didn't work out. Sure do hope I don't get sick.
So, according to everything I’ve read over time, the biggest argument against Medicare for All is that people who get health insurance through their jobs are reluctant to lose it. So why mandate M4A and force them off their preferred providers? Wouldn’t it be smarter to provide a robust, optional PUBLIC option as the solution for everybody else, and then let the benefits of the public option erode people’s commitment to employer-provided coverage? We’d get to Medicare for All eventually, if the public option is properly designed.
Republicans are facing the worst conditions I've seen since 2008, but my huge fear is Democrats will gain power, spend that victory to pass Medicare for all and incur a face a massive backlash instead of reforming any guard rails to protect civic democracy.
I honestly don’t believe you need to worry about Democrats passing M4A. You need to worry about them holding one hearing on Trump’s abuses and then wanting to turn the page and do nothing.
Regarding one of your comments on climate policy, a carbon tax is thoroughly out of fashion amongst climate policy types. It is seen as a political loser. A carrots approach (like the IRA) had is seen as much more effective.
Indeed, but GND works around this with mandates that would raise prices; and in the current fiscal environment, a purely spending-based clean energy program would be inflationary. Almost invariably we’re talking about “people pay more for stuff.” Personally speaking, I’d go with the carbon tax but my point was that GND has real (as in, non-denial based) political vulnerability and doesn’t substitute well as the organizing policy of the movement.
Seriously the only difference between a 1990’s vintage doodoo-lib and a Republican of that era is whether their Mrs brought in and liked a gay interior decorator.
That so many Dems prefer to fight others within their own party rather than the disaster that is the GOP is both infuriating and pathetic. But I guess if self preservation is what it takes to move the Dem establishment and “centrists” to support MFA, great!
That said, I don’t think that would slow down the rise of the left flank and/or their supporters but it would be good policy and something the party could rally behind. That would be inherently good.
Let's talk health care - music to my ears (after spending my career in health policy).
My perspective is not to talk about Medicare for all, but to talk about Universal Health Care (not coverage - coverage brings up issues over what is covered). As most of you know, there are many different systems around the world that achieve Universal Health Care; Sanders' Medicare for All is just one way to achieve the goal. If, instead of getting bogged down in the details, we focus on the goal itself, I believe there would be much more buy-in.
We have to keep it simple - acknowledge the need, commit to getting there, and discuss concrete goals.
I believe the goal rings true in the hearts of even the most moderate of Dems - this does not need to be a divisive issue if handled correctly.
I like this overall idea.
M4A/Open Medicare/whatever could provide the one true "tentpole" we've been needing for the whole big-tent approach. You can basically say, "As long as you're on board with this, you're a Democrat, and everything else is OK to buck party orthodoxy about". It's a way to welcome people back into the tent, offering both reconciliation and absolution.
And it could end up lessening the salience of odious Omnicause litmus tests by offering up one big litmus test that always has one glaringly obvious answer.
However, I do want to raise a couple notes of caution.
1. The elephant in the room is the way that Pelosi hijacked Obama's presidency by forcing healthcare reform on him. It was the wrong move because of the broader economic crisis at the time, and it really undermined our entire political movement for voters to see us obsessing about the wrong thing at the time. And depending on how things go in the 2028 cycle, we may end up needing to have the flexibility to postpone a M4A push until after we can de-Trumpify the country.
2. As you note, we can't do M4A unless we dramatically expand the supply of doctors. But what often gets lost on pundits -- almost all of whom have never tried to get into med school -- is that the financially toxic nature of residency is what gives the AMA so much leverage for its members to continue endorsing their policy of restricting the number of residency slots. You spend 4 years paying undergrad tuition, and THEN another 4 years paying even MORE outrageous med school tuition, and it can EASILY come out to at LEAST half a million dollars in debt. That debt comes immediately due during residency, which has publicly-set salary rates that are INSULTINGLY low (avg $68-71k), and you're forced to endure that for the next 3-8 years of your career. Which most likely means that you're going on IBR/forbearance for that duration, so the debt piles up even MORE.
So by the time you're done with residency, you're SICK of a decade-plus of forced poverty, and you are going to have ZERO patience for any salary that doesn't IMMEDIATELY (1) cover your full loan payments, and (2) provide the upper-class lifestyle you were promised at the start of all this. Which all means starting salaries in the lower-mid 6 figures, which is something that can ONLY be provided by a supply restriction inflating their wages.
In order to solve all this, you basically have to restructure the entire medical education system AND make-whole all the people currently suffering under it, which is a demographic that spans all the way up into the age-50 bracket (IE those still paying their loans off).
Just chiming in to say that I agree with this diagnosis of the structural problems with our medical profession. I think that when the US does get around to universal health care, it will have to solve the problem of doctors replacing car salesmen as the core of the MAGA right. I'm already astounded by the number of specialist physicians who vote GOP reflexively even now because of taxes. The AMA has a bad reputation for a reason. Some of it no doubt is due to the mountain of medical debt. A lot of it is due, let's be honest, by the fact that medicine is a field a lot of people go into to make money -- to be the country club people in their communities. So changing that culture / expectation / syndrome is going to be hard.
Addendum: The paranoia and greed are particularly powerful BECAUSE of the trauma inflicted by forced poverty.
It’s hard enough to try convincing a man to reject something his paycheck depends upon. It’s a whole other ballgame to tell him the government’s gonna control healthcare costs by forcing his paycheck down AFTER the government just forced him to spend a whole decade of his life in artificial poverty.
Well, they go into the field expecting to automatically become members of the upper class, which is also why a lot of people go into other fields as well.
But the startup costs and enforced suffering/poverty are what really drive and lock in the insane paranoia and greed later in life.
I’m friends with several doctors and not a single one of them I know is poor. They have big houses/compounds and high end German cars and go on lots of vacations all over the globe.
Were you friends with them while they were residents? Or did you bother reading my comment at all?
None of them were forged into Republicanism by the experience I would add. I wouldn’t associate with Republicans.
No I wasn’t. Yes I did.
My wife and her residency cohort are going through this right now. We live in a HCOL area and her loan payments are higher than our mortgage!
Great column, with one small edit: "It doesn’t account for the fact that most people are already insured, and most of them are basically fine with the health insurance that they have."
Ahem.
Literally NO ONE I know is basically fine with the health insurance they have. As noted in another comment, people are staying in jobs they hate because of not wanting to lose their coverage. Others (like me) pay, with help from Obamacare a still exorbitant amount. I think you'd agree that the correct to way say this is that people have become inured to the costs of the healthcare they have, as much as they hate it. They fear that whatever might come later will be worse, and Republicans are all too willing to fan those flames.
I fear this is a selection effect among people who have progressive-minded and politically engaged friends. I will say I dislike my health insurance plan because I don't think BCBS adds any value to the world; my insurance status shouldn't turn on my or my wife's employment status; if something bad happens I suspect they'll try to deny coverage. But abstracting all of that out of the equation: It's fine. I feel insured! And that's how data suggests most people feel. https://www.nbcnews.com/politics/politics-news/poll-are-satisfied-health-insurance-quarter-report-denials-delays-rcna248908
I appreciate you're bringing this information to the comments, but having looked at the article I would suggest that the word "satisfied" is doing a lot of work here. I wonder what the response would be if people were asked if they were HAPPY with their coverage and how much they were paying for it. Also, with rural hospitals closing (or this is anecdotal? I'm willing to listen) this is not a simple "Progressives hate their healthcare" discussion. Again, I will be happy to stand corrected, but it would seem that people all over the political spectrum live in fear of losing their coverage, and what seems to me to be the bigger obstacle is convincing them that the government can do a better job of giving them healthcare than the private companies can. Millions have (and will) be spent in telling them otherwise, and those deep pockets sadly buy politicians on both sides of the aisle. I am old enough to remember when Reagan told us that those nice ol' corporations will be a lot better at doing what's right than the big bad government. I don't see much changing since then.
Excellent idea. I do have question, as Medicare isn't free and to get better healthcare with Medicare one currently also needs to purchase some form of supplemental coverage. That said, Universal Health Care, a plan where the country as a whole pays in, so everyone has free healthcare and access would in the end save money. I worked as a medical coder in a hospital for several years. People need preventive care and a place to go, a clinic for basic health needs. In the charts I read, I saw people coming in for very expensive Emergency Room Treatment, which is excellent treatment, but they could have gone to a clinic or to a primary care physician if that care was covered. Not addressing hardcore healthcare needs in this comment. Keeping it simple.
Dump both Medicaid and Medicare monikers and go with Open Healthcare or Open Health for short. It sounds "new" and people get excited about new stuff, most anyway.
My beliefs:
Nothing is ever going to change in D fissure over M4A until every last person in the party who can remember the 1990’s is pushing up daisies.
Both Republicans *and centrist libs* can recite every Limbaugh-era critique of everyone having health care, and centrist libs (and politicians) don’t really oppose universal healthcare for practical reasons. That’s the political equivalent of believing in efficient market theory.
They oppose it because the status quo is both the way things have always been (and therefore represent either eternal reality or God’s will, however they happen to think of it), and the idea of The Poors seeing a doctor just strikes them as against the natural order of things. In centrist minds if someone wanted health care they should have studied harder in graduate school or invested early enough in the right tech company. And if they didn’t, that’s on them.
They don’t want the poors to die if untreated medical conditions per se, but neither do they care enough to do anything about it.
At this point would the left really be satisfied with a “sellout” version of M4A that wasn’t the full-bore, free at point of service, unlimited usage version?
I could see this being just one more vicious fissure point within the party.
My wife's been a medical professional (OD) for 18 years. She is paid well but our debt is high. We live paycheck to paycheck. Among the many things we can't afford is medical coverage for me. I don't have any idea if or when that'll change.
On one hand it would be really neat to know that I could go to a doctor, get the tests and care I need, and not die early of some preventable or treatable problem. On the other hand, some kind of restructuring of her profession that involved forced pay cuts would also force us out of our home and probably require us to relocate. Tricky! Too bad that student debt relief plan didn't work out. Sure do hope I don't get sick.
I misspoke. Having health insurance should NOT be optional; having private and public options available is, initially, the point.
So, according to everything I’ve read over time, the biggest argument against Medicare for All is that people who get health insurance through their jobs are reluctant to lose it. So why mandate M4A and force them off their preferred providers? Wouldn’t it be smarter to provide a robust, optional PUBLIC option as the solution for everybody else, and then let the benefits of the public option erode people’s commitment to employer-provided coverage? We’d get to Medicare for All eventually, if the public option is properly designed.
Yes indeed! That’s what the piece proposes!
Absolutely! Call it what you will…
Republicans are facing the worst conditions I've seen since 2008, but my huge fear is Democrats will gain power, spend that victory to pass Medicare for all and incur a face a massive backlash instead of reforming any guard rails to protect civic democracy.
I honestly don’t believe you need to worry about Democrats passing M4A. You need to worry about them holding one hearing on Trump’s abuses and then wanting to turn the page and do nothing.
Regarding one of your comments on climate policy, a carbon tax is thoroughly out of fashion amongst climate policy types. It is seen as a political loser. A carrots approach (like the IRA) had is seen as much more effective.
Indeed, but GND works around this with mandates that would raise prices; and in the current fiscal environment, a purely spending-based clean energy program would be inflationary. Almost invariably we’re talking about “people pay more for stuff.” Personally speaking, I’d go with the carbon tax but my point was that GND has real (as in, non-denial based) political vulnerability and doesn’t substitute well as the organizing policy of the movement.
Brilliant
“Medicare for Anyone” not “Medicare for All Who Want It”
Seriously the only difference between a 1990’s vintage doodoo-lib and a Republican of that era is whether their Mrs brought in and liked a gay interior decorator.
That so many Dems prefer to fight others within their own party rather than the disaster that is the GOP is both infuriating and pathetic. But I guess if self preservation is what it takes to move the Dem establishment and “centrists” to support MFA, great!
That said, I don’t think that would slow down the rise of the left flank and/or their supporters but it would be good policy and something the party could rally behind. That would be inherently good.
Centrists in control of the party would rather it fail and rule over the ashes than compromise their core hatreds and win.