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Faux Flip Flops

I realize that many of my readers also read Electoral Vote, which I have always encouraged. I still want to mention that they published another letter of mine today.

My letter was a response to a question asked by D.A. from Brooklyn, NY yesterday. His letter took Elizabeth Warren to task for her shifting rhetoric on health care:

I’m curious: Which version of Sen. Elizabeth Warren (D-MA) is he talking about? The one who was rock-solid behind Sen. Bernie Sanders’ (I-VT) Medicare-For-All? Or the one suggested that the latter was an end goal that we needed to move gradually toward? Or the one who says that we just need the public option added to Obamacare?

When Electoral Vote published my response, they edited it down quite a bit. I have no complaint about that, but I feel like they deleted something significant, and that is the reasons I would prefer having a public option to actually implementing “Medicare for All”.

What follows is my letter as I submitted it to them (the last three paragraphs were not published):

Regarding D.A. from Brooklyn’s question about Elizabeth Warren’s seemingly changing stance on “Medicare for All”. Why do liberals seem to be so hung up when Democratic candidates’ opinions evolve over time? As someone who works with startup companies, I know that one of the hallmarks of excellent leaders is the ability to adapt to changing realities. I’ve worked with so many young companies, and I can’t think of a single one that ended up producing the same product as the idea that caused them to originally start the company. In Warren’s case, perhaps she noticed that Sanders was soundly rejected by primary voters, and that this rejection probably was not because of Sanders’ goals, but because of his tactics.

Consider the tactics of Barack Obama. It is clear that his goal was to get the country to single-payer health care. But as he often said “Do not let the perfect be the enemy of the good”. Obama is a pragmatist. The Clintons had previously tried to push through a single-payer system, and it failed. Obama tried to push through a public option, which I think was a better strategy. I have lived in three different countries with single-payer systems, and it is obvious to me that if people had a choice between for-profit heath care or a public option, they would (eventually) pick the latter. So a public option is a significantly more pragmatic way to get the US to that goal. But even Obama’s public option failed (likely because the health insurance industry understood that they could never compete with a public option over the long term).

Pragmatism is one of the things I loved about Barack Obama. It allowed Obama to enact actual health care reform, which had eluded many past presidents. Likewise, as a pragmatist, Elizabeth Warren has also been able to get things done, even things opposed by powerful interests (e.g., consumer protection). I see Bernie Sanders as more of an ideologue, and while this may excite his base, it doesn’t help in actually getting things done (consider that his home state wasn’t able to actually create a single payer system). So even though I tend to agree with many of Sanders’ goals, I never supported him.

As a side note, why would anyone complain about Warren’s smart pragmatic tactics in comparison with the alternative? Trump seems to be happy to contradict himself all the time (occasionally in a single tweet!) and his base doesn’t even notice.

Finally, the term “Medicare for All” actually bothers me. I know that Medicare is popular in the US, and that politically “Medicare for All” might be a reasonable name to promote a single-payer system. But I don’t see “Medicare for All” as much different than a public option. In fact, now that I’ve experienced the US Medicare system for almost a year, I find it is NOT really a single-payer system at all. Part A is single-payer, but that’s the extent of it, and Part A pretty much only applies to hospital stays. And because in the US, public hospitals — and private hospitals in an emergency — are already required to treat patients regardless of their ability to pay, this is not a huge benefit. Plus even Part A has a deductible, currently $1408/year. On top of that I have to pay at least three different organizations to get similar health coverage to what I got in other counties: the government for Part B, a company for a Medigap plan (or a Medicare Advantage plan), and a different company for Part D (prescriptions). If I had vision coverage or dental coverage, I would have to pay additional insurance companies.

Medicare is complicated and confusing. I have no idea how older seniors can even deal with it. If “Medicare for all” simply means extending our current Medicare system to all ages, then I would prefer a public option that is comparable to single-payer systems I have experienced in other countries. Especially if that public option also guaranteed that employers would pass on the huge amount of money they currently spend on health insurance for their employees as salary, to make up for the extra taxes we may have to pay to finance the public option. Then Americans would have a choice.



  1. William wrote:


    I saw your letter, and am glad to get the full version.

    I note that both “A Public Option” and “Medicare for All” are vague terms, meaning different things to different people. For politicians, that’s likely a feature, not a bug.

    I suspect insurance companies would object less to a “Public Option” that looks like universally available insurance, with the same sort of pre-approval of procedures, coverage arguments, etc. that are part of the current “system” than to a “flat fee and you’re good” system. People might prefer the latter, but what does a given politician mean by whatever term the use? Understanding that would require subtleties, nuance, and attention to details, none of which are features of our present political system, news organizations, or citizen behavior.

    I see several characteristics of a potential system:
    1) Nobody excluded, no qualifications. If you want the coverage, you can get it.
    2) Predicable payments, whether through taxes or otherwise.
    3) Elimination of the present process of “coding” of procedures, approval, disapproval, etc. that forces health care providers to retain staff for the sole purpose of finessing insurance payments.
    4) Elimination of the profit motive from both coverage providers, whether company executives or stockholders, and from health care providers themselves.

    The above doesn’t sound like “Medicare for all” as you describe it, but also sounds like something beyond “A Public Option.” I also don’t know how we’d get to such a system as I described. Insurance companies would surely oppose it, and opponents could easily raise concerns about efficiency or waste.

    What we have at present isn’t a health system, it’s a system of profit and loss, but one which affects people’s lives.

    Monday, June 1, 2020 at 8:42 am | Permalink
  2. Iron Knee wrote:

    I remain extremely hopeful that the double whammy of a horribly deadly pandemic along with people losing their jobs — and thus their health insurance — will dramatically improve the chances of us finally getting some form of universal heath insurance that does not involve employers.

    What form that solution takes is up to us. Thanks for your analysis.

    Monday, June 1, 2020 at 8:57 am | Permalink