What can we learn from the rise of 'Medicare for All'?
Dr Adam Hannah (@adamjhannah; University of Western Australia) draws on his recent article in Policy & Politics to consider the growing prominence of Medicare for All in US politics and what lessons can be drawn for those advocating for systemic change.
For Australians, the relevance of recent debates over health care in the United States might not be immediately obvious. After all, Australia has both a state-administered public hospital system and a national public health insurance system for primary care, while the US has neither. However, for those interested in major policy change in Australia, there are several reasons to pay attention.
First, both Australia and the US are generally considered to have late-developing, ‘liberal’ welfare states, that rely on means-testing and a public-private mix of service provision. Second, both countries face several significant institutional hurdles to the passage of major reform, including a bicameral legislature and contestation between state and national governments. Third, in both countries, the pursuit of major health programs continues to be central to centre-left politics.
More broadly, recent developments in the US may also provide several lessons for those interested in large-scale policy change. The Patient Protection and Affordable Care Act (or ‘Obamacare’) is considered the crowning achievement of the Obama administration. How is it that, less than ten years later, the necessity of entirely replacing that reform with a system of universal public health insurance has become an article of faith for many Democrats?
The return of Medicare for All
Universal public health insurance is not a new concept in the US. New Deal Democrats considered including such a scheme in 1935’s Social Security Act, which established a public pension system. In the years since, Presidents, such as Harry Truman, and senior party figures, such as Senator Ted Kennedy, have argued for a national insurance scheme. However, these efforts have generally been thwarted by some combination of:
The fragmented US legislative process, especially the ability for more conservative Democratic Senators to effectively veto reform
The potential for constitutional challenge
Public campaigns and lobbying by interest groups, such as the American Medical Association
The growing entrenchment of private insurance, especially among wealthier Americans (supported by favourable tax arrangements).
As I discuss in a recent article in Policy & Politics, by the time Obama was elected President in 2008, Democratic leaders largely accepted the idea that any successful reform would need to build on, rather than do away with, the existing system of insurance. While the fact that almost 16% of Americans went without insurance in 2010 provided strong justification for change, the perceived risk of backlash meant that proposals to expand public insurance beyond programs targeting the elderly and those in poverty were taken off the table.
Photo by Vidar Nordli-Mathisen on Unsplash
When viewed against its primary aim – to expand insurance coverage – the Affordable Care Act can be considered a partial success. By the end of the Obama Administration, the uninsured rate dropped to around 8%. However, despite the extension of coverage to an additional 20 million people, progressive leaders such as Bernie Sanders and Elizabeth Warren have channelled popular frustration into support for national public health insurance, usually described as ‘Medicare for All’ (MFA). This happened for several reasons:
Many millions still remain uninsured. Moreover, many who do have insurance still face high out of pocket costs and various restrictions on access when they do need care. Health insurance coverage remains extremely fragmented, with the cost and standard of coverage highly variable.
The Obama-era reforms do not come close to living up to Obama’s rhetoric that health care is a ‘right’ and should be provided on a ‘universal’ basis. Instead, the law built on the existing system in a way that contradicted the widely held view that it was fundamentally broken.
Progressive advocates can point to a popular and effective program that does provide universal coverage to those over 65: Medicare, the program established as part of Lyndon Johnson’s ‘Great Society’ reforms.
Lessons for change-seekers
Of course, there is no guarantee that Sanders or Warren will win the Democratic nomination this year, let alone successfully shepherd major health care reform through the US Congress as President. However, it is clear that the terrain has shifted: the most radical element of Obama’s 2008 proposal (eventually dropped during the legislative process), the ‘public option’, is now considered the moderate alterative to MFA. As such, there are several lessons we can draw from this recent success.
Universality has appeal: Even in the context of liberal welfare states that tend to favour targeting and means-testing, appeals to rights and universality can generate public support. However, there also appears to be risk in making use of this language when the favoured policy response is to further embed markets and differentiated access to benefits.
Pragmatism has its place: Despite accusations that support for MFA has become a counterproductive ‘purity test’, it appears that American progressives have generally taken a pragmatic approach to health care reform. In 2009/10 they strongly supported the reform effort that was on the table, while also seeking to creatively shift the law to the left wherever possible. This has allowed Sanders in particular to claim credit for supporting Obama in 2009/10, while also pointing to the limitations of the law that resulted.
Be prepared: The return of MFA also appears to confirm an old maxim in policy studies: advocates need to be ready with solutions well before the opportunity for change arises. Pragmatism can be be a valuable approach in the context of a single legislative process over which one has little control. However, progressives have simultaneously spent years developing plans and cultivating support from friendly unions, such as National Nurses United. As such, once a movement began to build around Sanders in 2016, progressives had a well-developed proposal that they could immediately push to the centre of the policy agenda.
Don’t overwhelm with detail: Debates during the current election cycle suggest that proponents of systemic change should not bow to pressure to provide reams of detail. As Elizabeth Warren has recently found, any version of MFA will require at least some unpopular trade-offs, especially with regards to financing. By getting involved in those debates during a Presidential primary, Warren has left her proposals open to attack. Sanders on the other hand, has generally focused on the benefits that his version of MFA would provide. It is unlikely that the version of MFA Sanders currently describes would actually result from a Congressional legislative process. However, it will be mass public support, rather than the support of policy experts, that will sustain such an effort. There will be plenty of time for details after the election.