I recently had a conversation with a friend that likely mirrors one many Americans are having with friends and family members.
“Aren’t most people pretty happy with their existing health insurance?” the conversation began. “Why disrupt such a large chunk of the economy — 18% of GDP — all at once?” the questioning continued. “Passing Medicare for All just isn’t realistic,” my friend concluded. “Even if Elizabeth Warren wins, the policy would be dead on arrival in the Senate.”
I acknowledged the ambitiousness of M4A and promised my friend I’d do some more research into the state of public opinion. After doing my diligence, here’s how I responded over email.
Is it popular?
Let’s say you agree M4A might be good policy in theory. You just think it’s not good politics. Let’s focus on electability, you’re telling yourself and other Democratic friends weary of losing to President Trump in 2020. You listen to Kaiser Family Foundation (KFF) President and CEO Drew Altman say public support for M4A “may have crested.”
If you want to be guided by numbers, I believe the KFF’s own polling shows that M4A is currently a toss-up. Maybe not the most obvious ground to stake your campaign on. But if you look beneath the surface, polling actually reveals M4A as an excellent campaign pillar. It has the makings of both a base mobilizer and swing vote pusher in 2020.
Health insurance reform will be pivotal, just as it’s been in every election I can remember in detail. In 2008, I recall talking to thousands of Iowa, Colorado, Ohio and North Carolina voters about the importance of a ‘public option’ while campaigning door-to-door for Barack Obama. A long line of progressives (thanks Obama and Bernie) have made tremendous progress moving this concept forward. M4A’s time is now.
As we head into the holidays, though, the majority of Americans admit they do not understand existing health insurance policy, let alone the mechanics of Elizabeth Warren’s latest plan. Indeed, it’s hard to feel educated when the system has become so convoluted. Our upcoming Thanksgiving feasts will be prime opportunities to dig into the details of what’s next, or at least allow time for some banter between turkey legs and Beyond burgers. That’s why I believe Senator Warren’s focus on explaining how her M4A plan will work is worth the early effort.
Right now, the American people aren’t aligned around M4A implementation: 78% think taxes for most people would increase; 69% think they’d continue to pay co-pays and deductibles; 55% think their employer-based insurance would continue. That’s a lot of FUD.
So, how we talk about health insurance reform matters. Warren — the best policy communicator in today’s Democratic presidential field — has attempted to frame the conversation around values and big ideas: total costs, total quality, and simplicity. She has rejected the false narrative and political third rail: higher middle-class taxes.
The goal, as she explains, is better quality, at lower cost, for ALL. Only M4A, which drastically simplifies insurance, can drive a long-needed shift in health care focus towards outcomes. Private, employer-based insurance has failed to move aggressively in this direction. One reason is that the legacy, billing-based tech that surrounds our current mode of procuring care has been engineered to squeeze out profit, without excessive care for quality.
The tag lines and Twitter hash tags that lie in waiting have been shown to drive public perception of M4A, so let’s take a closer look at the words that matter most. “Universal health coverage” and “Medicare for All” poll the best, bumping support to 63%. The phrase “socialized medicine” drops support to 46%. But none of these refrains clearly describe the insurance reform envisioned by Senator Warren.
For historical context, between 1998 and 2016, the percentage of Americans who prefer a national, single-payer health plan steadily increased from 40 to 50%. A high-water mark (59%) was reached in March 2018, shortly before GOP messaging began to pound away in the lead-up to midterm elections. Support today hovers in the low 50s — a national majority, in spite of years of GOP bashing.
That nervous fever has recently spread to leading Democratic presidential candidates, many of whom have watered down M4A, changed its meaning, and even begun echoing GOP talking points. Somehow “building on ACA” became an alternative to “ripping it apart” through M4A, even though M4A builds on ACA’s chief accomplishment: getting more people covered, whether thru elimination of pre-existing condition-based restrictions, allowing kids to stay on parents coverage, or opening of exchanges.
Leading Democrats have confused voters by embracing the notion that M4A will be “too expensive to implement.” It’s no coincidence that this is the second most popular reason, according to KFF, for opposing M4A. This may be an effective scare tactic, but it’s not a good reason to oppose M4A.
Warren’s projected cost, $52 trillion over ten years, may cause initial sticker shock. However, the bill carries the same price tag as The Urban Institute’s projections for our current system — only Warren’s plan would offer higher quality coverage for all Americans. How does that work? you may be wondering. When you add up co-pays, deductibles, premiums, state and federal payments, as well as the hidden employer insurance contribution, you arrive at the full cost of “national health spending.”
So what is crazier — spending more for less, or driving a hard bargain on behalf of consumers? Enabling a limited set of special interests, or attempting to correct clear market inefficiencies?
Today, American hospitals cough up 25% of expenditures on administrative costs, with 8.5% revenue spent handling billing and insurance-related transactions, which are brought on by our complex multi-payer system. Today, America spends $1,200 per capita on pharmaceuticals, in large part because we are saddled with rates between 4 and 60 times as much per drug as citizens of other countries. Less profitable, vastly useful drugs are disincentivized. The pharmaceutical industry, meanwhile, rakes in nearly half a trillion dollars in revenue each year.
As Bernie Sanders most effectively points out, under our current system, we spend more per capita on health care than any comparable nation. If ‘Medicare for All Who Want It’ is implemented, we’ll increase government spending. Yet without the opportunity to create economy of scale efficiencies, this alternative won’t lower costs to the same degree as M4A.
Furthermore, when you drill into KFF’s numbers more closely, you find that the top two reasons why people might come around to supporting M4A are that it “covers all” and “simplifies the system.” But if M4A morphs into “for all who want it,” both of these arguments will be neutered. By keeping in place our bloated insurance structure, we’ll compound complexity, while failing to necessarily cover all.
Another poll-tested attack line which you may hear this fall is that M4A will “limit competition.” This affront can be effectively countered by explaining that M4A will actually do the opposite, increasing choice instead of locking patients into HMOs or sticking them with doctors who are in-network. M4A expands the pie, brings the majority of doctors into network, gives everyone choice. Warren’s plan gives middle-class Americans still another choice — what to do with their ‘Warren Bucks,’ as she returns the $11 billion out-of-pocket expenses consumers currently contribute.
In spite of M4A critiques, KFF studies show that more than a quarter of Republicans (28%) support universal health care. Show me another high profile issue that gets this much support from Republicans. Oh right, gun control…
Finally, remember that Warren has yet to run national television ads. She’s yet to give a big Washington Square Park speech centered on health care inequity, personifying her policy. She’s yet to truly take the case to the nation. That will come, alongside more positive phrases like “Warren Bucks.” Perhaps she’ll encourage Americans to “Say Hello to Doctors and Goodbye to Co-Pays, Deductions, and Premiums.” Maybe she’ll remind us we can see “Any Doctor, Anywhere.” After all, “Health Care is a Basic Human Right.”
Why is there support?
I believe there is a groundswell of M4A support due to two key reasons. First, people who have Medicare currently like it; there’s nothing like testimonials from happy customers! In fact, the percentage of Medicare recipients who like their plans (77%) is MORE than the percentage of non-Medicare recipients who like their private, employer-based insurance plans (69%). This seems like the closest apples to apples comparison. It’s like comparing the percentage of Apple users who are satisfied with their iPhone to the CSAT scores for Samsung phone users.
The second reason is that most Americans are not happy with key aspects of healthcare delivery. 67% Americans are dissatisfied with their availability of access to healthcare; 49% dissatisfied with the quality of healthcare; 79% dissatisfied with the cost. These Americans may be uninsured. They may be watching their rates and premiums increasing. Perhaps they may sense quality decreasing. And it is important to think of this sentiment in the broader context of how other people around the world consider their health situation. Americans are less satisfied than Europeans. Only in Portugal, Japan, and the Slovak Republic is the citizenry less satisfied.
Americans want change.
But I admit, change is uncomfortable. The present we know is more familiar than the future we can only imagine. For this reason, we shouldn’t expect to see overwhelming poll support for M4A at the moment.
But as a leader, especially one campaigning for Democratic party leadership in 2020, you have to think about what matters most, as Yale’s Jacob Hacker has argued, and guide people towards the change you believe in. The vision must be bold and ambitious. Warren says it means galvanizing the nation to “dream big and fight hard.”
Will it be better?
I’m just a taxpayer and a patient, not an administrator, bureaucrat, pharmacist, physician, surgeon, nor nurse. I don’t think M4A is a panacea. I suspect that details around the edges of Warren’s plan, such as her yet-to-be-announced “transition plan,” which Ezra Klein hints at in his Vox post, will evolve. She’ll need to work with employers to determine how to equitably normalize their per employee M4A contribution. Perhaps her administrative management target — 2.3% — is overly aggressive.
Still, Elizabeth Warren’s M4A proposal provides the most clear and simple framework on the table for discussion this Thanksgiving. Her plan gives us a shot at achieving our stated goals as a country and a concerned public: better care, at lower cost, for ALL. Perhaps most importantly, it challenges conventional thinking, helping us consider our core values.
With M4A, government will be positioned to increase oversight and negotiating potential over Big Medicine, reduce price gauging stemming from the outsized role of pharmaceuticals and insurance industry middle men, and thereby lower costs for consumers.
With M4A, government will incentivize doctors, nurses and other care providers to obsess over social determinants as well as outcomes, holistically including a patient’s post-visit care. We can simplify records administration and data sharing, and return the patient to the center of the care experience. But providers will need to meet patients where they are (using smart phones and connected devices, via telemedicine). This desire will demand increased competition amongst tech solution providers. Personally, I can’t wait to see a new generation of open and intelligent systems. There should be human-centered, consumer-grade applications at every level in the health care enterprise software segment. These evolutions should improve decision support and care quality.
Finally, M4A will create a more equitable relationship between employers and employees. Today, millions of Americans spend time uninsured each year due to changes in their work status. Warren’s plan will usher in more worker mobility and more economic risk-taking. M4A will do this for all Americans, not just the privileged.
So as we head into 2020, now is our time. We can dream big, fight hard, and we can win.