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Medicare-for-all is nothing like “repeal and replace”

One’s a clear vision; the other’s a big con.

bernie sanders Chip Somodevilla/Getty Images

Medicare-for-all is a slogan that, like any slogan, underdetermines actual policy content and brushes aside some details and tough trade-offs. But the increasingly popular argument made by both Patricia Murphy in Roll Call and Margot Sanger-Katz in the New York Times that it resembles the Republican Party’s slogan-based call to “repeal and replace” the Affordable Care Act is fundamentally misguided.

It’s true that slogans are extreme shorthand for policy ideas at best, and that, as Sanger-Katz writes, the Medicare-for-all concept “papers over intraparty disagreements and wrenching policy choices.” It’s also true that Bernie Sanders’s Medicare-for-all legislation is, deliberately, a very high bid offering no deductibles, no copayments, and extremely broad coverage (including dental, vision, and long-term care) of the sort that’s unlikely to be enacted by any realistic political coalition. But it’s not true that this was the problem with repeal and replace.

Repeal and replace wasn’t just a slogan that covered up some internal disagreements. It was a lie. Repeal and replace was an effort to bridge a fundamentally unbridgeable gap between the American people’s complaints about the ACA — premiums, deductibles, and copayments that were too high — and the Republican Party donor class’s complaints about the ACA: that it levied too much in taxes. This left Republican legislators not just with some difficult trade-offs to grapple with, but with the difficult question of how to break the news to the American people that the outcome of their legislation was going to bear no resemblance whatsoever to what had been promised.

The roadblocks to a single-payer health care system are large, but they are fundamentally different from that.

Repeal and replace was a con job

Before he took office, Donald Trump was always very clear that his intention was to repeal the Affordable Care Act and replace it with something that would offer Americans more generous and more robust health insurance.

“I’m not going to cut Social Security like every other Republican and I’m not going to cut Medicare or Medicaid,” Trump told the conservative Daily Signal way back in May 2015. “Every other Republican is going to cut, and even if they wouldn’t, they don’t know what to do because they don’t know where the money is. I do.”

This was, strikingly, not a general election pivot to the center, but a commitment Trump made as a candidate in the GOP primary.

That fall, his promises got even bigger. "I am going to take care of everybody," he told 60 Minutes. "I don’t care if it costs me votes or not. Everybody’s going to be taken care of much better than they’re taken care of now."

Even after the election, Trump continued to insist that his plan was to offer patients a more generous deal than they were getting from the Affordable Care Act.

In an early January interview with the Washington Post, he said that Trumpcare would feature “insurance for everybody,” in contrast to an ACA that, while bringing the uninsurance rate to a historic low, has still left 25 million people without coverage. The plans, he said, would have “much lower deductibles.” And ability to pay, he said, wouldn’t be an issue. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.”

And though Trump took this further than other Republicans, he was not fundamentally out of step with their words.

On the January 8 edition of Face the Nation, Senate Majority Leader Mitch McConnell listed the Affordable Care Act’s shortcomings: “If the idea behind Obamacare was to get everyone covered, that’s one of the many failures. In addition to premiums going up, copayments going up, deductibles going up.”

The problem with this rhetoric isn’t just that it was vague but that the legislation Republicans have been pushing ever since Inauguration Day does literally the opposite of this.

Republican repeal plans offer worse insurance

To an ideologically sophisticated person it is, of course, obvious that whatever the merits of a Republican Party health care plan it’s not going to provide people with more generous health insurance. The GOP is the party of small government and low taxes — the party that believes social services should be less generous.

In exchange, taxes are lower — especially on high-income households — which is nice if you are rich and really nice for everyone if you believe that low tax rates substantially boost economic growth.

All the Republicans’ health care bills reflect these priorities:

  • Under the House’s American Health Care Act, 24 million fewer people have health insurance, and the remaining insured have skimpier coverage.
  • Under the Senate’s Better Care Reconciliation Act, “only” 22 million people lose coverage but the long-term Medicaid cuts are bigger.
  • The last-ditch “skinny repeal” plan skipped the Medicaid cuts but completely blew up the exchanges on which 15 million people currently get coverage.
  • The first two plans increased the maximum deductible on the individual market, and the third plan let it go up to infinity.

None of this is because the details of the bills were poorly designed (though in some cases they were). In all cases, it’s because conservative ideology says the government should spend less money and provide lower-quality services.

But most people aren’t especially ideologically sophisticated. And when politicians that these people feel culturally in sync with promise that, if elected, they will pass laws to reduce premiums and deductibles, these people are inclined to believe them.

The dilemma Republicans faced after winning the election was that their plan was actually to drastically increase the number of uninsured, raise premiums, and increase cost sharing. Those weren’t “details” to be hashed out; they were glaring up-is-down contradictions, and it’s a minor miracle of party discipline and ideological rigor that such an overwhelming majority of Republicans were willing to go along with it.

Medicare-for-all is a clear direction

Medicare-for-all, by contrast, really is a slogan in need of detail work.

Should the program be about as generous as Medicare, or should it be what Sanders wants — a program with higher actuarial value and broader scope of coverage? Will it pay doctors and hospitals about what Medicare pays them, as much as private insurance pays them, or as little as the Canadian single-payer system pays them? Will there be universal enrollment at no charge, or will individuals and employers “buy in” to the system? Will the treatments the system covers be offered free of charge like a library book or a visit to a city park, or will users need to contribute some of the money as with a bus ride or a visit to a national park?

How these details are decided will determine how much new federal revenue is needed, and then there are a host of questions about where that revenue comes from.

The total current volume of health care spending in the United States is already very high (and total taxes in the US are low by international standards), so it’s clear that as an abstract economic matter, the country could afford a Medicare-for-all system of some kind. But how you design the taxes matters, both to the people who pay and to the economy as a whole.

All that said, the basic shape of the proposed change here is clear. We know what Medicare is. We know what it would mean to make more people eligible for Medicare benefits. We know what it would mean to make Medicare coverage more generous in terms of reduced premiums and copayments. And we know what it would mean to make Medicare coverage broader in terms of kinds of services it covers.

If Democrats run on various flavors of “Medicare should be expanded both in terms of who it covers and what it pays for” and win a bunch of seats, they will face a lot of difficult policy work. But there’s no reason they shouldn’t be able to write a bill that, broadly speaking, does exactly that. The problem with repeal and replace, by contrast, wasn’t making the details work. It was that the broad strokes of the GOP plans did the opposite of what they’d promised. The single-payer push needs more wonks, but no amount of wonking could save repeal and replace.