Is the left abandoning Medicare for All?
Centrists see an opportunity in progressives backing away from single payer.
Matt Yglesias, on Abdul El-Sayed’s healthcare plan:
…leftists have absolutely savaged non-leftists who put incremental ideas on the table, including even transformative ones like Pete Buttigieg’s Medicare for All Who Want It…if El-Sayed can create a permission structure for characterizing “Medicare for All” as an aspirational statement of values rather than a specific piece of legislation, he will be doing a tremendous favor to all kinds of center-left Democrats…
There’s a reason why Yglesias specifically brings up Pete Buttigieg’s plan: that’s exactly what El-Sayed is calling for. Leftists seems surprised about this whenever I bring it up, because the Democratic nominee has been at pains throughout his campaign to highlight his support for what he calls “Medicare for All.” But if you look at his actual platform, his position is clear:
Medicare for All does not have to ban additional private insurance through unions or employers, although Medicare for All should make those choices redundant and unnecessary.
Say what you will about this plan, but it is exactly what Buttigieg eventually called “Medicare for All Who Want It.” And his logic was identical. In 2018, he was still positioning himself as a partisan of Medicare for All, and even in 2020 he spun his plan as “a very natural glide path to a single-payer environment” on the logic that even if you left private insurance in place, public healthcare would “become the…preferred means” among Americans. This is precisely what El-Sayed is arguing when he says that Medicare for All should make private insurance “redundant and unnecessary”.
And Yglesias is right: in 2020, socialists ruthlessly opposed anything short of single payer. This piece I wrote, published in Jacobin, is a perfect time capsule of the discourse during that year’s Democratic primaries: Buttigieg and Elizabeth Warren were both positioning their plans as a variation of Medicare for All, and the line of the Sanders camp was that it is not Medicare for All if it allows for private insurance. You can argue that socialists were wrong to take a hard line on this, but not without conceding that we owe Elizabeth Warren and Pete Buttigieg a big apology.
El-Sayed’s defenders usually dismiss this as a minor policy quibble (Yglesias calls it “disagreement with the extremely specific details of the Medicare for All Act”), but there are good reasons why leftists have long insisted on single-payer. Perhaps the most important is captured in Busemeyer and Iversen’s The welfare state with private alternatives:
Once private alternatives are viable and well-established, however, high-income citizens become opposed to expanding public spending on benefits schemes when these are universal or even income-dependent…Our analysis can be interpreted as indication of strong feedback effects. In a world without or with weakly developed private alternatives, income-related conflicts about public involvement are muted, documenting a strong consensus on the need for public provision. But once private alternatives are introduced, support for continued public provision is undermined by the fact that high-income citizens opt out of public schemes and in turn become more supportive of a selective rather than a universalist model of the welfare state. The public pillar is supposed to provide basic insurance to low-income citizens, but private alternatives are increasingly preferred to public schemes for the bulk of social insurance against major life course risks such as old age. The encompassing welfare state still has strong supporters in the middle class, but they can no longer rely on allies in the upper-middle classes.
Permitting private sector welfare programs also undermines confidence in government welfare programs:
Net of known predictors of trust at the individual and country level, we find that trust in government is significantly lower where the health system is financed to a greater degree by private sources. This negative relationship occurs because in countries with more private financing, low-income citizens perceive themselves to be at greater risk for not receiving needed health care. This perception of risk is associated with more negative evaluations of the performance of the health care system, which in turn is associated with less trust in government.
Argue that a keeping private insurance around is politically necessary if you must, but the notion that it is some harmless “option” that one could only oppose for the sake of ideological purity is absurd. It has clearly deleterious effects on social solidarity and trust in government programs, effects that we have seen playing out in the Nordics and that would be even more severe in the United States. The most likely outcome of offering universal healthcare with a “private option” is not that you would get “a glide-path” to single payer; it’s that rich people who prefer private insurance would ally with the private insurance industry to try to make M4A as defunded and dysfunctional as possible, which has been the right’s strategy with every other welfare program in the United States. The only way this works is if everyone buys in.
El-Sayed is not the first progressive darling to get squishy on Medicare for All. During her run for Congress earlier this year, Illinois influencer Kat Abughazaleh also declared that “we need a universal single-payer healthcare system — with an opt-out if you’re a private insurance super-fan”. To her credit, however, Kat — faced with continuous criticism from the left — eventually dropped the private insurance line and categorically endorsed single payer.
Whether leftists will hold El-Sayed to the same standard isn’t clear. Between his courageous criticism of Israel and reverse polarization against his increasingly deranged critics, it has been easy to look past some of his less appealing stances. It is hard for example to remember a Democratic politician who has been received this warmly by socialists despite his repeated criticism of socialism. Regardless, his rhetoric on healthcare, as it shifts the goalposts towards some nebulously defined aspiration towards “universal coverage,” aligns directly with a rebranding project organizations like The Center for American Progress have been pushing for years. No wonder Yglesias is impressed.
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