Medium-Size Reform Creates Conditions For Big Reform

 (These caricatures of Senator Elizabeth Warren and economist Paul Krugman are by DonkeyHotey.)

Yesterday, I posted Elizabeth Warren plan to accomplish a single-payer government-run health insurance system in a two step process. She believes (and I agree) that an immediate move to force a Medicare-For-All program on the country would fail.

Instead, we must first improve Obamacare and add a public option for insurance to it. This public option would cover those who cannot afford private insurance, and would give all Americans the option to buy into it (saving them money while providing them with decent health coverage).

This first step would show Americans that public health insurance would work and be affordable -- and would save money for most Americans. That would make it possible to transition to a full Medicare-For-All system in the future.

I agree. American voters don't like radical change. They are afraid of it. They want change (especially in healthcare), but they want it in steps -- so they can be sure we are doing the right thing. While there are some people on the left who would love to see an immediate Medicare-For-All system, and some people on the right who would love to outlaw Obamacare and go back to the broken system that pre-dated it, most Americans are moderates -- and they want their change completed in moderate steps.

I am not alone in believing this. Here is part of what Nobel Prize-winning economist Paul Krugman says in his New York Times column:

Back in 2010, as Obamacare was about to squeak through Congress, Nancy Pelosi famously declared, “We have to pass the bill so that you can find out what is in it.” This line was willfully misrepresented by Republicans (and some reporters who should have known better) as an admission that there was something underhanded about the way the legislation was enacted. What she meant, however, was that voters wouldn’t fully appreciate the A.C.A. until they experienced its benefits in real life.

It took years to get there, but in the end Pelosi was proved right, as health care became a winning issue for Democrats. In the 2018 midterms and in subsequent state elections, voters punished politicians whom they suspected of wanting to undermine key achievements like protection for pre-existing conditions and, yes, Medicaid expansion.

And this political reality has arguably set the stage for further action. At this point, as far as I can tell, all of the contenders for the Democratic presidential nomination are calling for a significant expansion of the government’s role in health care, although they differ about how far and how fast to go.

Which brings me to the latest development in intra-Democratic policy disputes: Elizabeth Warren’s proposal for a two-step approach to health reform. Her idea is to start with actions — some requiring no legislation at all, others requiring only a simple Senate majority — that would greatly expand health insurance coverage. These actions would, if successful, deliver tangible benefits to millions.

They would not, however, amount to the full Bernie, eliminating private insurance and going full single-payer. Warren still says that this is her eventual intention, and has laid out a plan to pay for such a system. But any legislative push would wait three years, giving time for voters to see the benefits of the initial changes.

Sanders supporters are, predictably, crying betrayal. For them it’s all or nothing: a commitment to single-payer has to be in the legislation from Day 1.

The trouble with such demands, aside from the strong probability that proposing elimination of private insurance would be a liability in the general election, is that such legislation would almost certainly fail to pass even a Democratic Senate. So all or nothing would, in practice, mean nothing.

But is Warren giving up on Medicare for All? After all, what she’s offering isn’t really a transition plan in the usual sense, since there’s no guarantee that Step 2 would ever happen.

The lesson I take from the politics of Obamacare, however, is that successful health reform, even if incomplete, creates the preconditions for further reform. What looks impossible now might look very different once tens of millions of additional people have actual experience with expanded Medicare, and can compare it with private insurance.

Although I’ve long argued against making Medicare for All a purity test, there is a good case for eventually going single-payer. But the only way that’s going to happen is via something like Warren’s approach: initial reforms that deliver concrete benefits, and maybe provide a steppingstone to something even bigger.