In January 2016, just days before the Iowa caucuses, presumptive Democratic nominee Hillary Clinton took a swipe at the ambitious Medicare-for-All plan proposed by her upstart challenger, Bernie Sanders, when she declared that single-payer healthcare would “never, ever come to pass.” Two years later, in the wake of Clinton’s shocking loss to Donald Trump, more than half of House Democrats and one-third of Senate Democrats (including nearly all of the 2020 presidential frontrunners) have endorsed Medicare-for-All plans offered by Sanders and Michigan Representative John Conyers.
Sanders, in short, helped make Democrats more of a single-payer party than it has been for a generation. Despite what skeptics say, this shift is nothing short of remarkable. The center of gravity in the Democratic Party on healthcare policy has shifted decisively to the left, returning the Democrats to the full-throated endorsement of government-provided universal care that they retreated from in the decades following George McGovern’s 1972 loss.
While the Democratic Party’s sudden embrace of Medicare for All is heartening, it still has a long way to go before becoming law, and many key details—especially how it will be presented to the public and financed—need to be ironed out.
For a progressive program of government-provided healthcare to make it into law, survive, and thrive, it must be popular. And to ensure Medicare for All’s appeal, Democrats will need to shake off several bad policy habits they’ve developed over the past forty years. That means prioritizing how the public will understand and experience government-provided care, not what party policymakers or centrist wonks think is the cleverest implementation.
Marketing Medicare for All
The first task for Democrats is deciding how to market their vision of government-provided, universal healthcare.
Since they took control of the White House and Congress in January 2017, Republicans’ series of manifestly unpopular healthcare plans have inadvertently boosted the prospects of progressive healthcare legislation. When Barack Obama assumed office in 2009, the percentage of the public agreeing that it’s the government’s responsibility to ensure that all Americans have healthcare was actually falling, either due to increasing partisanship or the public turning inward in response to the Great Recession. The contentious debates surrounding the Affordable Care Act’s passage did little to alter this shift. But since its nadir in 2013, this trend has reversed, with 56 percent of the public now saying that ensuring healthcare for all Americans is the responsibility of the federal government. The ACA’s popularity has recovered, too, with a slim majority now viewing the legislation favorably.
Overall, however, Americans remain deeply concerned about the state of healthcare in the United States. The public currently ranks healthcare among the top three “most important problems” facing the country today. Americans’ main concern remains the soaring cost of care and prescription drugs. Even those who say they’re happy with their current care worry about rising costs, which they believe hasn’t resulted in a corresponding increase in quality. Even with the changes brought about by the ACA, approximately one in five privately insured individuals say they skip needed care because of cost, while larger shares of Americans—particularly those with high-deductible plans—have experienced some form of financial strain paying for care.
As a result of these concerns, a whopping 70 percent of Americans say that the U.S. healthcare system needs either “fundamental changes” or to be “completely rebuilt.” While this discontent worked against Democrats while Obama was in office, potentially providing a boost to the 2010 Tea Party wave, the public’s continuing healthcare frustrations have created a political opening for Democrats. More than six in ten Americans now hold Republicans responsible for “any problems with [the ACA and healthcare] moving forward,” and Democrats are now trusted more than the GOP on the issue of healthcare.
But simply shoring up the ACA isn’t an option for Democrats when they return to power. Trump and the Republicans are hoping to inflict perhaps irreparable harm to the ACA, and already have done much damage. And even when the law was working at its best, it left 28 million people without insurance. One of the ACA’s key failings is that, despite its name, it does far too little to make coverage truly affordable for many economically squeezed Americans. Many of the uninsured—particularly those making just above Medicaid eligibility income levels—have looked at their options on the ACA marketplace, concluded that none were within their price range, and decided to pay the penalty (or obtain a hardship exemption) instead.
When Americans are presented with paths forward for healthcare in the United States, keeping the ACA in its current form is the least popular option. Roughly one-third of Americans, and a majority of Democrats, want the ACA expanded. Even more Americans—including nearly 10 percent of Democrats and nearly 40 percent of independents—would like to see the ACA repealed entirely. Despite the ACA’s rising popularity, replacing it with a new government-run system actually polls higher than reforming and expanding the ACA. Ultimately, the public’s analysis of the ACA has returned to where it was at the time of its passage, when Americans were almost equally split for and against the bill—and when almost a quarter of those who opposed it wanted a more progressive bill.
Taken together, the policy and public opinion realities point to the need for Democrats to move beyond defending the ACA and promising small tweaks. However, the form and framing of the new, universal system that will replace the ACA remains up for debate.
Fortunately, Sanders’s decision to dub his plan Medicare for All—even if it’s unlikely to resemble Medicare in its current form—has pointed Democrats in the right direction. Medicare is extraordinarily popular. Despite decades of attacks from Republicans and conservative think tanks, the public opposes the privatization of Medicare. In fact, a whopping 80 percent of Americans want the government to spend more on Medicare. Likewise, 72 percent of the public supports giving all Americans the option of buying into Medicare.
Considering Medicare’s overwhelming popularity, it’s clear that presenting any new healthcare overhaul as an expansion of Medicare is the best path forward for progressives. Medicare for All polls significantly better than alternative brandings of government-provided universal coverage. For example, while single-payer polls better than many skeptics might imagine, only a plurality of the public has a positive reaction to the term, compared to the 60-plus percent of Americans who react positively to Medicare for All.
While keeping in mind that Medicare for All is a more popular framing, it’s nonetheless worth examining the nature of public support for single-payer, which has been more widely surveyed than Medicare for All. A series of surveys by YouGov reveals strong majorities of self-identified Democrats and liberals in support of single-payer and majorities of Republicans and conservatives in opposition. Falling in between are independents and moderates. A plurality in each favors single-payer, but more than 30 percent of both remain undecided. Progressives must win over this group, and their support for both Medicare itself and a possible Medicare buy-in suggests that casting universal government-provided care as an extension of Medicare should aid in winning over these key independents.
Organizing support among low-income Americans and people of color is also essential to creating the public pressure necessary to pass Medicare for All. As on many policy issues—including the GOP’s recent, massively unpopular tax bill—between 30 and 40 percent of people making less than $50,000 per year, African Americans, and Latinos say they’re “not sure” when asked about single-payer. However, among those who do offer an opinion, support is strong. Once again, the “Medicare-for-All” branding should help. While prospective, relatively unknown policies—such as the GOP tax bill and single-payer—yield large differences in responses between upper-income and lower-income respondents, and between whites and people of color, such gaps vanish in questions about Medicare, which show that Americans making below $50,000 per year, African Americans, and Latinos all value Medicare as much, or more than, other groups.
Ironically, one final public opinion landmine that proponents of Medicare for All must watch out for is potential opposition among Americans already on Medicare. People over age sixty-five are less favorable toward single-payer than any other age group. While some of the opposition among older Americans undoubtedly is due to the overall conservatism of that age group, some of it is also likely due to fears that a switch to a new national system would somehow leave those already on Medicare worse off. Making clear that the new program is an expansion of Medicare should help alleviate those fears. But given the voting power of seniors and the political sway of their lobbying groups, Democrats must also make sure that any version of Medicare for All is not only harmless to people over sixty-five but also provides them with better coverage. A strength of both the current Senate and House bills is that they would do exactly that—improve Medicare as it currently exists, by reducing out-of-pocket payments and expanding benefits.
Keep the policy simple, stupid
For decades, Democrats have studiously avoided both visibility and simplicity in policy. Instead, they’ve worked to hide expansions of the welfare state from the public due either to the belief that covert initiatives would be more economically effective or to the fear that visible programs (and the taxes needed to fund them) would generate an anti-government backlash. Not only has this desire to hide programs from public view created an unwieldy “submerged” or “hidden” state, it’s also had the unintended effect of undermining support for the welfare state by making government programs seem like natural outcomes of the market.
Thanks to the complexity of much modern U.S. policy, many Americans don’t realize that they’re recipients of government largesse, and progressive politics has paid the price.
For example, Obama’s stimulus package, the American Recovery and Reinvestment Act of 2009, cut taxes for nearly 95 percent of workers. Yet only 12 percent of Americans said they’d received a tax cut, while 24 percent thought their taxes had gone up. The public’s lack of appreciation “frustrat[ed]” the White House, as press secretary Robert Gibbs put it. But the administration had itself to blame. Obama’s advisers believed that small tax cuts hidden in each paycheck would have a greater economic impact than a single lump-sum payment like George W. Bush’s 2008 “rebate” checks. It’s debatable whether this was smart economic policy; it’s clear it was disastrous politics. Unlike Obama’s hidden cuts, Bush’s checks were highly visible. As a result, Americans were much more likely to report receiving the Bush check than the Obama cut, despite the fact that Obama’s cuts were more generous for most taxpayers.
The ACA suffered from many of the same design failings. Its defenders have pointed to studies showing that approximately 6 million still-uninsured Americans would be better off financially buying a “Bronze Plan” on the ACA marketplace than paying the penalty. In fact, the Kaiser Family Foundation found that a majority of those 6 million are actually eligible for free Bronze Plans, after accounting for subsidies, but don’t seem to know it.
But this reality actually underscores one of the ACA’s signal flaws: it’s too complicated.
Economists who’ve studied how Americans select health plans marvel at the preponderance of supposedly “irrational decision making.” But we shouldn’t be surprised. Health insurance is incredibly complex and confusing. The ACA—with its maze of Medicaid expansion, private coverage, means-tested subsidies, and Olympic medal-coded plan levels—did little to fix this problem. Instead, it merely added to what political scientist Steven Teles has dubbed the vast American policy “kludgeocracy.”
Much of the press coverage of the ACA’s enactment focused on the technological woes that hampered Healthcare.gov’s rollout. But even after the site was fixed and even after the Obama administration added a “shop and browse” feature, the site remained incredibly confusing due to the nature of the ACA itself. Not only did shoppers need to understand the already-esoteric language of health insurance, they also needed to learn a variety of new terms introduced by the ACA. Moreover, numerous reports found that the subsidy estimates provided by Healthcare.gov often badly missed the mark. Even when everything went smoothly, the pre-paid nature of the ACA tax credit made recipients’ tax returns the following year even more complex.
Like the Earned Income Tax Credit, the ACA’s structure virtually ensured that many Americans would fail to claim benefits to which they were entitled and that many others aided by the ACA would fail to notice the assistance. Particularly when the huge tax break for employer-provided health insurance is considered, the federal government is helping to provide health insurance for most Americans, but almost none of them know it.
This invisible policy paradigm is not only expensive in budgetary terms, it’s incredibly costly for progressive politics. When Americans mistakenly believe that they alone (or their employer) are paying for their families’ healthcare, it buttresses conservatives’ anti-government nostrums. The right’s attacks on Medicare for All will inevitably play upon the individualist misapprehensions created by the “submerged” state and the confusion engendered by the kludgeocracy.
Deterring the inevitable Republican counter-attack
Once Democrats begin pushing Medicare for All in earnest, Republicans will claim that it’s too expensive, argue that it’s too disruptive, and portray it as vaguely “foreign” and “socialist.” The plan’s advocates should be prepared well in advance for the right’s inevitable counter-attack, which will assuredly be generously funded by conservative billionaires and powerful corporate lobbies.
The “Medicare-for-All” branding is designed to blunt the last “socialist” branding by making what is, in fact, socialized medicine “speak American” by tying it to one of the most beloved pieces of social policy in U.S. history.
But Democrats will need to confront head-on the inevitable GOP fear-mongering about the massive turnover that a switch to Medicare for All will cause. In doing so, they will need to avoid the Obama administration’s mistakes in selling the ACA. Obama misled the public by repeatedly promising Americans, “If you like your health care plan, you can keep it.” When the ACA’s rollout demonstrated that this was untrue, PolitiFact dubbed Obama’s line the “Lie of the Year.” It was an unforced error born of bad framing.
Instead of denying the turnover that the ACA would cause, the Obama administration should have repeatedly pointed out how neither employer-provided nor individually purchased insurance guarantees healthcare continuity. Americans already experience an enormous amount of churning in their coverage, and this problem has been imported into the ACA marketplace, where buyers often switch plans every year. Proponents of Medicare for All need to flip “loss aversion” on its head by relentlessly reminding Americans that the plan will end churn once and for all. Medicare for All will also relieve Americans from the “hysterical misery,” as political scientist Corey Robin put it, of shopping for healthcare year after year and learning to navigate new plan after new plan.
Democrats can also lessen transition fears by making sure that Medicare for All provides an improvement in coverage for the vast majority of Americans. This shouldn’t be hard. Surveys show that Americans on public plans—such as Medicare, Medicaid, and military-provided care—are more satisfied with their coverage than those with individual or employer-provided plans. Indeed, the ACA showed that many people preferred to be on public plans, as those just above the Medicaid eligibility line evinced “Medicaid envy.” This is another area where politics must trump mainstream wonkery. Health policy experts often want to herd people into high-deductible plans. However, Americans generally prefer plans with higher monthly premiums and lower out-of-pocket costs. Democrats should prioritize the views of potential recipients, not the advice of centrist policy experts, and give Americans a plan without cost-sharing. Both the Senate and House bills avoid co-payments and deductibles (with the limited exception of prescription drugs in the Senate bill), a feature that public opinion makes clear is a strength.
The GOP’s final line of attack will be on cost. Proponents of Medicare for All shouldn’t let themselves get bogged down in competing estimates of the plan’s price tag, particularly given that some think tanks and centrist economists have made unrealistic estimates of costs on the basis of faulty assumptions (and will probably do so again). Instead, Democrats should make the fact that the United States currently spends more on healthcare than any other country their mantra. Just as the GOP treats economic growth as a panacea, proponents of Medicare for All should brush aside cost concerns by noting that single-payer saves money and that Medicare is already more efficient than private insurance. When it comes time to cite specific numbers, they should also follow the GOP’s example by highlighting favorable estimates.
Democrats likewise should ignore the inevitable GOP deficit fear-mongering. Time and time again, Republicans have made clear that their deficit concerns are disingenuous. As North Carolina Republican Mark Walker admitted recently, “[The deficit is] a great talking point when you have an administration that’s Democrat-led. It’s a little different now that Republicans have both houses and the administration.”
Decades of “fiscal responsibility” by Democrats only have served to fund the next GOP tax cut for the rich. If Medicare for All creates a deficit, that’s okay. In fact, Democrats should end the filibuster to pass Medicare for All, if necessary, since Republicans have shown they are willing to manipulate Senate rules to pass their tax cuts. Any long-term deficits created by such a plan will only serve to make it harder for Republicans to push the next regressive tax cut. And if Republicans decide they actually do want to reduce the deficit in the future, the Democrats can win a fight that pits tax hikes for the rich against cuts to popular programs, including Medicare for All.
Beyond the GOP, the most significant sources of opposition to Medicare for All will come from the healthcare lobby and big business. The former will need to be overpowered, while the latter could be played to the Democrats’ advantage. In order to avoid a replay of the “Harry and Louise” ads that sunk “Hillarycare” in 1994, the Obama White House chose to make deals with the insurance industry and big pharma as it crafted the ACA. But this meant dropping several key provisions that would have made the bill more popular and more effective. With Medicare for All, there will be no compromising with the healthcare lobby, and it’s unlikely that anything beyond dropping the plan entirely could blunt its opposition, anyhow. However, Democrats can divide and conquer business, more broadly, by leveraging the fact that many businesses will be better off in the long run under Medicare for All, since they’ll no longer be responsible for constantly escalating healthcare costs. Wooing key business allies needn’t mean ceding control of Medicare for All, either substantively or rhetorically. But it could be the difference between a united corporate front against the plan and a more favorable political landscape.
How to fund Medicare for All
Notably, both the Senate and House Medicare-for-All bills do not include funding mechanisms, a key aspect of program design that was reasonably pushed off to the future, but that will have to be fleshed out sooner or later. When it comes to designing such a mechanism, proponents should keep one eye on progressivity and the other on political sustainability. The ultimate goal for Medicare for All is to leave nearly all Americans, except for the richest few percent, better off financially than they are under the country’s current healthcare and tax systems.
The U.S. tax system is not as progressive as many people imagine, and it’s become less progressive over the past half-century thanks to a series of tax cuts for the rich. Making the tax code more progressive by increasing tax rates on the very rich should be one of progressives’ top policy goals. Doing so will both fight inequality and reduce the political power of the rich. Increasing taxes on the rich is also incredibly popular. Therefore, many of the tax hikes on the rich proposed by Sanders during his presidential campaign, including introducing a new top individual income-tax bracket and taxing capital gains as ordinary income, should be a part of any Medicare-for-All bill.
Medicare-for-All proponents also should consider FDR’s wisdom in creating a dedicated funding source for Social Security. Even if federal revenue is fungible, nominally tying taxes to a popular program can make both that revenue source and the program itself more sustainable. The Social Security tax is one of the least unpopular taxes, despite its regressivity, precisely because it’s linked to a popular program.
Following FDR’s example, Sanders’s slim healthcare proposal, released during the primary campaign in 2016, wisely included new payroll taxes linked to Medicare for All. Crucially, though, that plan avoided the regressivity of the Social Security tax by scrapping the latter’s earnings cap and exclusion of capital income. But an even better Medicare-for-All financing plan would go further by including a progressive rate structure in the new payroll tax or by adding a progressive Medicare-for-All surtax to existing federal income tax.
A maximally popular Medicare-for-All proposal should invert the “submerged state” problem by making the benefits visible and hiding the taxes. The largest payroll tax increase in Sanders’s plan was on the employer side. Conservatives strongly dislike employer-side payroll taxes because they’re “hidden from workers.” But that’s why progressives should favor an employer-side payroll tax if one is to be part of a Medicare-for-All plan.
Without careful policymaking, Medicare for All could provide businesses with a huge windfall, because they’ll no longer be paying for their employees’ health insurance. While in theory those funds should shift to employees over time, since they’re already part of their compensation, it’s easy to see how they could keep some of that windfall, at least in the short-term, especially in the absence of a tight labor market. An employer-side payroll tax could take away part of that problem by shifting what businesses currently spend on workers’ private healthcare to the new Medicare-for-All program. Medicare-for-All legislation should further mandate that any money previously spent on employee healthcare not captured by a new payroll tax must be turned over to workers in the form of higher wages. This is especially important for unionized workers, a key Democratic constituency that has fought hard to provide their members good health coverage.
A truly progressive Medicare-for-All plan must avoid regressive funding sources at all costs. Some experts have floated a Value-Added Tax (VAT) as a possible mechanism for funding national healthcare reform. But using a VAT to pay for Medicare for All would be both misguided policy and political suicide. The U.S. tax system needs to be more, not less, progressive, and Republicans have made clear—both with December’s tax bill and throughout recent decades—that they intend to raise taxes on the poor to fund cuts for the rich. Democrats shouldn’t hand them a tax that will make doing so easier. Moreover, the VAT is incredibly unpopular with the public. Linking Medicare for All with a highly visible, highly regressive new tax is a sure way to guarantee its failure.
Regardless of the specific (progressive) revenue source, the plan’s supporters will need to make clear that any new taxes are replacing Americans’ existing premiums and out-of-pocket expenses. While some observers have claimed that the public doesn’t want to pay for Medicare for All, the questions in surveys that purport to prove this obfuscate the difference between additional taxes and taxes that merely replace existing private healthcare spending. If citizens understand that they’re trading their private health expenditures for new taxes—while saving money, gaining more comprehensive benefits, and ditching their unpopular co-pays and high deductibles—then Medicare for All’s backers can win the fiscal debate.
To buttress the appeal of Medicare for All, Democrats should also consider bundling it with other popular policies. For example, Medicare for All could be paired with another health-related policy, such as a carbon tax. A carbon tax polls well, and it could be made even more popular if a substantial chunk of its revenue is used to fund a yearly lump-sum rebate. Such a rebate would render a carbon tax progressive, and it could be structured like the Bush stimulus checks so that it’s highly visible. Pairing Medicare for All with carbon tax–financed “health prebate” checks could kill two policy birds with one stone, while making both more popular.
Finally, Democrats should think hard about how they can use marginal portions of the Medicare-for-All bill to reward key constituencies and shore up their political fortunes. Many commentators correctly noted how the GOP used its recent tax bill to punish blue states and reward Republican voters. A Medicare-for-All bill could do the same for Democrats, albeit in a less crass fashion. Any such bill will not only need to provide assistance to displaced insurance company employees, it will also need to hire new workers to help administer the program. Given that, why shouldn’t Democrats help their constituents and improve their political fortunes in key electoral states by siting new Medicare-for-All support and processing centers in deep blue, economically depressed areas, such as Detroit or Cleveland?
The window for enacting progressive, government-provided healthcare is open wider than it’s been in decades. Democrats need to make the most of it by learning from their past mistakes, ignoring the centrist wonks, and crafting a popular, durable Medicare for All that can withstand the inevitable attack from the right.
Josh Mound is a postdoctoral fellow at the University of Virginia. He holds a PhD in History and Sociology from the University of Michigan. His work has appeared in Jacobin, the New Republic, Salon, and Chronicle Review.