Challenges Facing Medicare-for-All and Why it Might Not Pass
by Anthony Arnold
December 2019
Chances are you have an opinion on healthcare. Over the last 15 years, few topics have generated as much interest. It's no surprise then that healthcare is an important issue, as we head into the 2020 election. But among the solutions floated, (MFA) has dominated much of the coverage.
With this proposal picking up steam it's worth looking at some of the challenges it faces, and why it remains a distant dream for now.
Government Is Unpopular
Americans, almost as a rule, don’t like their government. It’s been 16 years since Congress had majority approval in the polls, and even that understates exactly how unpopular Congress has been over the last 4 decades.
This isn’t just a matter of partisan politics. Congressional approval numbers typically lag substantially behind presidential approval numbers, even when one party controls both houses of Congress and the White House. Under those circumstances it should be easier to pass legislation that is both effective and popular, which would have the effect of making government, or at least your party, more popular. But, even in those cases gridlock persists, and the public tends to assign most of the blame for that to Congress. Some of this is due to structural problems in Congress, and some of this is due to political concerns not always lining up with voter concerns.
It’s the way that this intersects with MFA that’s important. Turning over a substantial portion of the economy to the government is a lot to ask. Private sector jobs will be lost, healthcare providers will face additional workload, and a transition that large, no matter how well managed, will have its rough spots. The disastrous Obamacare rollout comes to mind, for instance. Even a popular government might think twice before taking a task like that. But asking the public to trust a largely unpopular government with that much responsibility? It’s easy to see why many voters might say ‘no’, and why many politicians may not want the headache.
Interparty Politics
It’s 2021. A newly elected Democratic president is trying to pass MFA. To that end he/she works with the House and gets a bill passed on to the Senate. And now another roadblock presents itself. Because the only way to get that bill out of the Senate will be to cut deals with conservative Democrats. They’re the swing votes, and whatever they ask for, the result will be a bill that’s further away from what’s being promised right now.
This sort of ‘give and take’ is a necessary part of policymaking. Our system of checks and balances means that even the president rarely gets exactly what he or she may want. The end result of this process is normally legislation that tends to leave most outsider observers unhappy. That’s because compromising on an issue as vital as this feels like a defeat. If you’ve been promised MFA, then anything else can seem lacking in comparison.
That’s assuming such a compromise is even possible. The last two Democratic presidents have each tackled, or tried to tackle, healthcare. And in each case, their efforts were rewarded with stinging midterm defeats. Being labeled the party of “big government” is always a concern of Democratic leaders, and that fear has historically driven them away from the most ambitious policy proposals. Coupled with the fact that there are plenty of other issues on which the Democratic party is more united, and it’s easy to see why any Democratic nominee could be encouraged to move away from MFA as we move into the general election.
Polling Isn’t Clear
If you’ve watched the debates, you may have the impression that voters are extremely unsatisfied with the current state of healthcare. And that’s true, with an important caveat. Voters are largely satisfied with their own personal healthcare, even while they’re much less satisfied with the state of national healthcare. The reasons for this can get muddled pretty quickly. The safest assumption is that most Americans are concerned with the cost of care, and concerned about the possibility of losing care, since so many people have it through their jobs.
What’s crucial here is that most Americans don’t actually want to lose access to the care they have right now. This point was one of the things President Obama had to promise when he rolled out the Affordable Care Act (ACA). The immediate impact of MFA would be to play that same scenario out on a much larger, and more politically risky, stage. And there’s simply not a lot of evidence that people want a large scale overhaul that would force them to give up the coverage they have now for something else.
Even recent polling shows that Americans are divided not just on the issue of whether or not the government should get involved, but also on the issue of exactly how much the government should do, if they do get involved. Primaries typically reward the most passionate supporters of a candidate or position. Governing is something else entirely, and opposition voices, even those from the other party, can make the politics much harder.
At the end of all this, what you end up with is something that looks a lot like the ACA. A fundamentally progressive bill, with some concessions made to red-state Democrats, that expands protections for the most vulnerable — and provides a stronger safety net for everybody else. The next step on the path to MFA isn’t a risky gamble to get there all at once, but is instead a bill focused on strengthening the ACA while attempting to tackle the exploding costs of healthcare.
None of this means that Democrats should abandon MFA. Equal access to healthcare isn’t just a matter of policy. It’s also an issue of morality and fairness. For many people, the fact that a country like ours doesn’t guarantee healthcare is deeply wrong, and that alone makes this a fight worth having. But, it’s equally important to understand the limitations of the system we have, the potential flaws in the big ideas we hear so much about, and learn how to work around those things to produce more effective outcomes for all of us.