Thursday, the Center for American Progress released a single-payer health plan (or thereabouts), planting a significant marker in the evolution of the Democratic Party, and eventually perhaps the American health-care system.
And we have President Trump and the Republicans to thank for it.
CAP calls its plan “Medicare Extra For All.” That’s a little unwieldy but seems meant to distinguish it from “Medicare For All,” which is what Bernie Sanders called the plan he proposed in 2016 and what others have called for. It isn’t a true single-payer plan because it envisions a continued role for private insurance. But it greatly expands government coverage, both for anyone who doesn’t have insurance and, critically, anyone who simply would prefer the government’s plan.
It’s significant that this plan is coming from the heart of the Democratic establishment, a think tank that is the closest thing to a Democratic government-in-exile. When it has officially put its imprimatur on a sort-of single-payer health plan, that means the general principle is now all but consensus among Democrats, something that wasn’t true even a year ago.
While this evolution has been in-process for a while, the fact is that as of now, the Democratic Party is converging on consensus around the goal of universal coverage with a much stronger role for government. You may recall that in the last presidential election, the party’s candidate wasn’t willing to go that far. Today, nearly every Democrat considering a run for the White House in 2020 has endorsed the idea of universal coverage.
It’s possible that this movement would have happened no matter what Republicans had done in the past year. But it’s hard to argue that the GOP hasn’t helped push the Democrats in this direction, and thereby helped accelerate the arrival of a universal health-care system.
First, Republicans attempted to repeal the Affordable Care Act, which had the effect of reminding everyone how many people have benefited from it. In particular, the prospect of tossing millions of people off Medicaid revealed that government insurance is actually quite popular with the public, encouraging Democrats to go ahead and advocate a further expansion of the government’s role.
The dynamics of opposition have also played a part. When you’re out of power, not only do you have to draw a stark contrast with the party in power, but also your frustrated and angry base encourages you to eschew half-measures. “Like the ACA, but a little better” is no longer a tenable position to take to Democratic voters.
That’s particularly true given what the administration and Republican states have been doing on health care. To sum it up, they’ve engaged in a concerted effort to make sure that fewer people have health coverage and that the coverage that exists is worse. The administration has encouraged states to force Medicaid patients to navigate cumbersome bureaucratic requirements, including logging their work hours and paying small premiums, with the plain goal of kicking as many people off the program as possible. They’ve promoted junk insurance that doesn’t cover essential health benefits. They’ve moved toward abandoning the payment reforms in the ACA, which attempted to transition from the fee-for-service model that has helped drive spending so high and toward a system that encourages keeping patients healthier.
That’s all in line with their philosophical perspective, which is that government should cover as few people as possible and if the market doesn’t provide you with affordable coverage that actually covers you, then it’s just too bad. But is there a single person willing to predict that by 2020 - when we have more uninsured, costs are higher, and coverage is less secure - the American public is going to say, “Gee, the Republicans have done a terrific job on health care”?
Even if Republicans in Congress have largely shelved their attempts to destroy the ACA, their party is still working to fulfill its extremely conservative health-care vision. Meanwhile, the Democratic Party has decided that it’s both morally right and politically advantageous to move to the left.
The CAP plan, like what most Democrats are now advocating, is not a strict single-payer plan. But it would achieve universal coverage, which is the core goal of single-payer. And as we’ve seen before, it’s the role of groups like CAP to do the work of policy development on behalf of their party’s politicians so they have a starting point for change when they retake power. Don’t be surprised if some of the 2020 candidates essentially adopt this, or something very much like it, as their own.
So here are some key features of the CAP plan:
--Everyone would be eligible for Medicare Extra. If you have employer coverage, existing Medicare, VA coverage or anything else, you’d have the option to stay with what you’ve got or enroll in the new plan.
--Anyone without insurance would be automatically enrolled as soon as they show up at the doctor or a hospital; children would also be automatically enrolled at birth.
--A wide range of benefits would be covered, including preventive care, hospitalization, dental and vision, and mental health treatment.
--Those with incomes below 150 percent of the poverty level would pay no premiums; above that premiums would rise on a sliding scale capped at 10 percent of income.
--Deductibles, co-payments and out-of-pocket costs would also vary by income.
--Employer-provided coverage would remain, but employers could choose to enroll their employees in Medicare Extra instead. Individuals could also choose to leave their employer plan and enroll in Medicare Extra.
--Medicaid and CHIP would be integrated into the new plan.
--Costs would be brought down by paying something similar to current Medicare rates to providers, negotiating lower drug prices, implementing payment reforms and streamlining the health-care bureaucracy.
--Premiums would be collected through the tax system, and new excise taxes and taxes on high earners would pay for the costs that remain.
It’s an ambitious plan, but it’s also politically savvy. First, unlike the ACA, it’s easy to explain. You can say, “Anyone who wants Medicare can get it,” which may not be 100 percent accurate (it would be similar to existing Medicare but not identical), but it basically describes the idea. Second, the only easily identifiable losers are the rich, who’d see some tax increases - and that’s something most Americans were in favor of even before the GOP passed a ginormous tax cut for corporations and the wealthy. And it incorporates plenty of free choice for both individuals and employers.
That doesn’t mean Republicans won’t hate it (Big government! Washington getting between you and your doctor!), but they’ve got no one to blame but themselves. If they had left the ACA alone and not been working so hard to make American health care worse and less secure, the Democrats might not have been pushed this far this fast. But that’s where the Democratic Party is now, and it’s not going back.
Paul Waldman is a contributor to The Plum Line blog at the Washington Post and a senior writer at The American Prospect.