Okay, let's spend some time today talking about Medicare for all Medicare for all is
becoming a bigger and bigger, bigger
part of the 2020 democratic primary. It rightly so. I mean it makes sense. This is one of
the biggest issues. How are we going to pay for healthcare? How are we going to organize
healthcare? And there are now lots of inaccurate things that are being said about Medicare
for all proposals. And there is lots of inaccuracy also about allegations about the positions
of different candidates around Medicare for all. So what I want to do today, and I hope
that this will be useful and understood and in the good faith that I'm presenting it,
I want to go through the bad arguments against Medicare for all, but I also want to bring
up the more serious and sober critiques that are the areas in which we should be focused
because these are the stronger criticisms of the proposal. So to set the stage generally
if you're already triggered, because I might say something about Medicare for all is not
perfect.
You've got to come back to the real world. There is no political proposal that is perfect
or without caveat or risks or liabilities. This is the world we live in. Every everything
has the other side of the ledger. Everything is risk versus reward. Everything is opportunity
versus liability and what we want to figure out is what proposal or plan is on balance
the best and most efficient when it comes to healthcare for delivering the best and
highest quality and most available care at the lowest cost. We shouldn't be afraid in
serious adult conversations about discussing the pros and cons of any policy, even a policy
that we think is the best one or better than the status quo and in fact, I would make it
further argument. We want, we need to be prepared for when people argue against Medicare for
all, we need to be able to identify these are the serious arguments to be discussed
versus these are the silly, bad faith, ignorant arguments that aren't really worthy of flow
for further exploration.
My prediction is that most of my audience understands why I'm doing this and will like
it and appreciate it, but I do know that there are people who will attack me merely for talking
about here are question marks that remain about Medicare for all, which completely misses
the point. So first and foremost, bad critiques of Medicare for all. There are many of these.
One that comes up often is the countries that have programs like Medicare for all have small
populations. The U S is huge. Therefore, Medicare for all wouldn't work in the United States.
This is a bad critique of Medicare for all. Number one bigger population actually means
that you're spreading the risk across more people. There's no one small group or people
with a particular condition that can throw off the actuarial realities of what it costs
to cover people. You can make the opposite case that actually the bigger the risk pool,
the safer and more efficient and better priced.
Something like Medicare for all would be that. That's a bad argument. Now. Secondly, you
can also disprove that by counter example because there are many very large countries
that have nationalized systems of different kinds. Germany has 83 million people. Their
system is not Medicare for all, but it is a system that is far better than the one we
have and has elements of Medicare for all. Japan has 130 million people. I think you
get the point. Now that being said, you can make the case that what will make uh, the
us implementation more of a struggle or a challenge, uh, are the large rural areas of
the United States because large rural areas can be more of a concern in terms of providing
access to healthcare services. But that's not an issue with Medicare for all specifically.
That's an issue more broadly in a country that has a lot of rural areas and it has nothing
to do with Medicare for all.
Second bad argument that we hear about Medicare for all Medicare for all will lead to long
waits for services and it'll lead to rationing of care. And you know, death panels was one
of the phrases that used to be thrown around. We already have those things. There is a shortage
of dermatologists in much of the U S you sometimes have to wait three or four months as a new
patient to see a dermatologist in all, but what would be considered like emergency, you
know you might have skin cancer. It needs to be looked at. Right now there's already
rationing in our system because for profit insurance companies are deciding who's covered
what is covered when and how much. You can already see de facto rationing and it impacts
how people obtain or avail themselves of care that they would like to have. There will sometimes
be weights and there will sometimes be rationing under Medicare for all.
It will be different than under the current system, but it's not unique to Medicare for
all and it is not a unique criticism of Medicare for all whatsoever. Then you get into the
general, we can't afford it. That's a terrible criticism because we can't afford our current
system. If the barometer for affordability is people can get the care that would be medically
suggested at a price they can afford. We already have a problem with affordability. Affording
Medicare for all is a question of political will. It's a question of deciding what kind
of a system are we going to have and deciding to put in the means to pay for it. Now there
are also, we'll talk more about costs in a moment. There are also just really dumb criticisms
of Medicare for all. Like it's communism. These aren't remotely serious. I'm not even
going to waste your time with that today, but just know that if that's, if you hear
those words in a critique of Medicare for all, it's not a serious critique.
So let's now get to what are the more important and sensible critiques of Medicare for all.
We all want to know what these are so that we can be prepared. Uh, seriously, I hope
people understand what I'm doing here. I'm not attacking Medicare for all, despite the
following critiques. It may still be the best system, but this is how serious people evaluate
important proposals. We figure out what are the strongest arguments against it and then
can we still defend this as the best policy in light of those arguments, does it stand
up to scrutiny as remaining the best plan? First of all, just accepting that Medicare
for all isn't the only way to get to universal coverage. We should all be doing. That's,
this isn't a criticism, okay? It's a reality. Lots of countries have universal coverage
that people can afford without Medicare for all or something that would be equivalent
in that country, but with other plans I've talked about many of them.
Medicare for all could still be the best. It could still be the simplest, it could be
the cleanest or not, but it's important not to say that Medicare for all is the only way
to achieve healthcare for everyone because there are many examples from around the world
that are different. Second, the idea that costs will go down for everyone or almost
everyone. That is a possible truth. It is possible that you can structure Medicare for
all so that cost goes down for most people, but if you look at serious analyses, you will
see that in order for costs to go down for most people, you need either to justify drastically
reducing what healthcare costs per person in the United States beyond just what the
bureaucracy adds to the cost. I'll get to that momentarily or you need a more modest
plan in terms of what's covered and I'll explain that now.
This is not my opinion. If you look at the work of the urban Institute which is left
leaning, they say that to do exactly what Bernie wants to do. Overall healthcare spending
might actually go up. I'm just the messenger here. If you do what Bernie wants to do in
terms of taxation level, but with more modest covered benefits, then the cost might go down.
For most people now, this is not an attack. Let's be adults. No system is perfect. There
are many ways to set up a plan. There are left leaning analyses that say it is not as
cut and dry as Bernie's numbers make it out to be. Now that's okay. It might still be
the best proposal we have and it would definitely be better than what we have right now, but
we're doing an analysis so let's stick with this issue of cost for now.
The argument is right now we have all these different costs. We've got employee paid health
insurance premiums, employer contributions to health care premiums. At many employers
you've got your copays, some people have co-insurance, you have an annual deductible you have to
meet. There is a maximum yearly out of pocket. Ah, it all adds up and the idea is Medicare
for all gets rid of all of that stuff and it gets replaced with a payroll tax that is
shared by employees and employers and overall the cost comes down. This is in total a claim
that has some controversy around it. Even when you look at nonpartisan and even left-leaning
leaning economists, it's possible that that's the way it would work. It's not guaranteed.
Okay. There are dense economic papers which I encourage you to read from good economists.
For example, Robert polling from the university of Massachusetts who has consulted for Bernie
Sanders who says, the truth is we don't yet have all the details to say for sure that
the middle-class is definitely going to save.
Let me again be clear. Costs might go up slightly. They would cover more so it might still be
a trade we want to make and it still could be the best proposal for most people, but
serious economists say w it's a little early. We don't really have the data to say that
a costs are going to go down for almost everyone. The way that Bernie and Warren and others
have been saying, it's not an attack or a defense on any candidate. This is just the
reality about these proposals. Let's do one more thing related to the cost piece. Bernie
has said you raise the money from an employee tax and an employer tax. The employer tax
is only going to hit companies that have payrolls of 2 million or more per year. If you look
at that, economists generally believe that that tax, that the employers pay will be passed
along to workers as either wage cuts or will delay future wage increases or we'll lead
to companies maybe not hiring as many people.
That doesn't mean it's a bad plan. That's something that economists say is not being
accounted for in the broader economic impact of the proposals. That's a serious question.
Now again, this might still be the best plan, but we don't want to pretend that every question
is answered by the proposals that we have so far. Now there's one other detail. Uh,
Bernie and Elizabeth Warren haven't made clear who counts as middle-class. A big part of
what they say is middle-class. Total costs will go down. We need to know who counts as
middle-class in order to evaluate that. So far we haven't gotten, that doesn't mean anything
is dishonest, doesn't mean anything is an under the, you know, uh, untoward. But we
need to know that next, aside from who pays, there is the issue of total cost. And this
is what I alluded to earlier. There are left wing economists, serious economists who say
proposals for Medicare for all are drastically understating the cost to deliver care.
Uh, one example is an economist named Kenneth Thorpe. He was hired, remember when Vermont
was going to do state single-payer a, he's not a right wing bomb thrower. He was hired
by, by Vermont to help implement state single payer, which ultimately didn't happen. Thorpe
has said that as proposed, if we look at Bernie's 2016 Medicare for all plan, which is very
similar to the one we have today, uh, 71% of households overall who currently have private
insurance might end up actually paying more in total. When you account for the tax increases.
Now they may have better access, they may have more covered services, we still might
want to do it, but the claim that everybody's costs will go down. This left wing economist
says there is a question Mark around that. That's just one analysis, but it's an important
one and it's really important to understand where the discrepancy comes from.
Thorpe says that Bernie's plan, the numbers Bernie uses, they uh, change out when they
change out from a private insurance system to a single payer system. They assume that
our per person healthcare spending will drop to the healthcare spending per person in countries
like Canada and Australia. This is an assumption that may never happen and it could take a
long time. What I mean by that is Canada spends 48% less per person in the United States on
healthcare. Australia spends 56% less per person than in the United States. Part of
that discrepancy is the bureaucracy built into the system that we have. And when you
get a more efficient system for paying like Medicare for all, there will be a savings
but there has not been a good answer to why are we assuming total costs will go down to
what they are in, in uh, Australia and Canada.
Because there are many other reasons including just how things are priced here in the United
States that will keep costs higher and that throws the numbers of most of these Medicare
for all proposals out of line. Now you can make the case. Once it's a single payer system,
the government is going to be able to negotiate costs of all services all the way down to
what Canada and Australia have. That is a bit optimistic by serious analyses. So like
that's a question Mark. So does this mean Medicare for all is bad? No it doesn't. Does
this mean Medicare for all is worse than what we have now? Definitely not. It would be better.
Does it mean we should abandoned Medicare for all as a platform? Absolutely not. Especially
because remember a lot of Democrats already oppose it and it's going to be a negotiation
no matter what happens in November of 2020 but we need to understand the details because
there are good faith questions about Medicare for all that smart people on the left are
bringing up and they're being brought up because we want the best system, we want to anticipate
what arguments could be made against it and we want to be able to distinguish bad arguments
like the U S has too many people for this to work.
Terrible argument or it's communism, not even an argument versus listen, if you look at
the cost assumptions in most of these proposals, they seem idealistic and potentially beyond
what the facts support. That's the important thing here and if we go through that, we might
still decide Medicare for all is the best system or we might say Medicare for all is
a great system that has these problems and here is another system, not the lame public
option, but serious other ways of getting to universal coverage that have other issues,
but resolve some of the issues of Medicare for all. This is how we have to think through
these serious problems
and I think that's why it's worth taking the time to go through it. Let me know what you
think. I'm on Twitter at the Pacman. The show is on Twitter at David Pakman show,