Hi It's Stupid: Medicare For All

The Doctor's Visit. Jan Steen, 1663-65, via Hetkoen International.

Hi, it's Stupid to say you shouldn't call it Medicare For All just because it isn't Medicare. Or at least that was the upshot of a conversation with Nathan Newman, probably the smartest person I know on Rose Twitter, who was rosesplaining why I was wrong until I had to give up and come over here before he decided I was stupid for real.

So why use the brand name "Medicare"? This has bothered me from the start.

— Purview From the Bridge (@Yastreblyansky) July 31, 2019

That's why it gives me the willies. "Smart" isn't the first word I'd choose.

But seriously people are going to find out it isn't Medicare long before they get a chance to find out they like it.

— Purview From the Bridge (@Yastreblyansky) July 31, 2019

People expect Republicans to lie and think it's funny. They expect Democrats to tell the truth. I think deception loses for us.

— Purview From the Bridge (@Yastreblyansky) July 31, 2019

Especially since the program is free of the worst thing about Medicare (forcing people to buy supplementary Part D insurance)

— Purview From the Bridge (@Yastreblyansky) July 31, 2019

But beyond the label, Bernie and others are clear that it's an improvement on Medicare, eliminating copays, covering long-term care, covering abortion and so on.

Using a label that actually undersells what your offering is a pretty tame "lie."

— Nathan Newman 🧭🌹 (@nathansnewman) July 31, 2019

The rub, to my way of thinking, is that we don't know in fact whether it's an undersell because we don't know exactly what it is that people love about Medicare. At least I don't, and I don't know why I should assume that Nathan does. One thing that strikes me is that most Americans don't have any direct experience of Medicare because they aren't old enough (or disabled) to be enrolled—many have an idea vicariously through their parents. A broad look at the data (from the American Society on Aging, 2015) doesn't yield a lot of specific ideas:

in addition to thinking Medicare is important, a majority of Americans (including about eight in ten older adults) think it works well (Kaiser Family Foundation, 2012). This sense that Medicare is working well is borne out in surveys examining the experiences of people enrolled in the program. Compared with adults younger than age 65 with private health insurance, older adults enrolled in Medicare are more likely to rate their health insurance as “excellent,” and more likely to say they are very satisfied with their insurance deductibles, co-pays, and choice of providers (Kaiser Family Foundation, 2014b). Older adults with Medicare also are less likely to report having experienced problems paying medical bills in the past year compared to younger adults with private insurance (14 percent versus 22 percent) (Kaiser Family Foundation, 2013a). 

One possibility, the one that worries me the most, is that what users really like is the angle that comes up in the monthly bills, the very low monthly premiums compared to the huge amounts we see pulled out of our paychecks for employer-supplied insurance. Of course they can be, as you know, because we've been paying for it in advance for 40 years through payroll tax. If that's what you like Medicare For All isn't going to thrill you if you're under 65, because those monthly bills aren't going to get significantly lower (I think the number will still be on the pay stub in the Sanders plan). If you're over 65 I can't imagine, because nobody knows exactly how or what seniors are going to pay.

But what should be thrilling people about any of these proposals is the ways in which it's different from Medicare, the absence of deductibles and copays and coverage of dentistry and mental health and drugs, the freedom from doughnut holes and supplements. These are the things I long for in a healthcare system, not the opportunity to pay a lower premium (presumably it really will be significantly lower for lots of people, with payment on a sliding scale keyed to income, but I hear it you'll be paying something with an income as low as $29,000, which sounds just vindictive to me), but the freedom from having it bled out of you at the point of service, the freedom from being robbed by an insurance company at the moment when you're sick or injured and most vulnerable.

The brand name "Medicare For All" isn't saying that.

And it's poll-tested that people like it until they find out it isn't Medicare in the sense of not lightening your monthly bills, as libertarian P. Suderman gleefully reported in January:

The survey was conducted by the Kaiser Family Foundation, which regularly asks Americans about health policy issues as part of its Health Tracking Poll series. It finds that 56 percent of the country supports a “national health plan, sometimes called Medicare for All” and an even larger percentage – 71 percent – supports the idea when told that it would “guarantee health insurance as a right for all Americans.”

When told that such a plan would eliminate health insurance premiums, 67 percent say they’re in favor.

One way to look at these numbers is as strong public approval for the broad outlines of a single-payer health care system, which would create a single national health insurance plan run by the federal government and financed through taxes. That public is support is why so many 2020 Democratic presidential contenders have been warming up to the idea.

But the more revealing part of the survey, I think, comes from the questions focused on the costs of single payer, all of which caused support for Medicare for All to drop below 40 percent. Told that it would eliminate private health insurance and require people to pay more in taxes, for example, support fell to 37 percent.

Everybody recalling this poll focuses on the weirdness of people saying they don't want to eliminate private health insurance even though they don't want to pay premiums, but I think what those respondents were saying was a lot simpler, as indicated by my bolding: if it's Medicare, why would I still be shellng out the same amount of money as I am now?

In general I meant what I said about truth in branding, especially for Democrats. It ought to be the way we work, because it's the way we are, making a point of trying to be honest because we aim to be the party of honesty, and that's in fact what voters expect, but it also ought to be a point of strategy, because it's easier to work up and defend—we're seeing a sign of that right now in the difficulty even Warren is having in explaining the tax aspect, because she doesn't want to say that the impact of this aspect will be trivial.

If it's better than Medicare, and it certainly is in these respects why not brand it that way? Why not call it Medicare Plus, or Everybodycare for universality, or I don't know. Why not market test it?

Why not talk about a health care system where the first thing they ask you isn't "Do you have insurance?" but "What's up? How are you feeling?" and where you never go bankrupt?