Great ideas don’t become great things unless they actually happen. And no idea, regardless of its perceived merit, is guaranteed to succeed.
With that in mind, the point of this column isn’t about debating the pros and cons of a Bernie Sanders style Medicare-For-All system. It’s not about whether the idea is good or bad, or whether it will help or hurt Americans. It’s not about whether single-payer systems in other countries work better or worse than health care in the U.S.
This discussion is about the hurdles facing Medicare-For-All and whether it’s likely to become a reality here.
Given the political divide in the country and more importantly the political chasm between lawmakers, the passage of Medicare-For-All legislation would require that progressive Democrats win the White House in 2020 and achieve something very close to a super-majority in both houses of Congress. Single party control like that has only happened three times in the past 60-plus years, in 1965, 1977 and 2009. None of them lasted longer than a single two year election cycle.
At a minimum, Democrats will require 60 votes in the Senate in order to override a filibuster. Given that Democratic senators could be divided about Medicare-For-All, it might require an even larger majority than that.
Some single-payer supporters may recommend doing away with the filibuster. I’d ask them to think about what the last few years would have looked like from their point of view, if Republicans had eliminated the filibuster in 2017. I’d also suggest that when Republicans regain control, the first thing they’d try to repeal without the filibuster, would be Medicare-For-All.
Even with a super-majority, Medicare-For-All will face a strong and very well-funded opposition from the health care and insurance industries, among others. Multi-million dollar campaigns will be mobilized against it and that will have the potential to swing some Democratic legislators toward a “no” vote.
Then, there’s the cost. The estimated cost of Medicare-For-All varies wildly. Projections range from $13.8 trillion to $36 trillion over 10 years. And that disparity should raise concerns about just how accurate any of those projections actually are. However, even the left leaning Urban Institute estimates that Medicare-For-All could cost $32 trillion over a decade. That’s a heavy lift for a country and a population that reacts to new taxes like some kind of national disaster.
In response, supporters will argue that health insurance premiums under the existing system would be far higher than the individual tax burden imposed by Medicare-For-All. In addition, businesses would no longer have to pay for employer-sponsored health insurance, offsetting the higher tax load. But, that may be looked upon as a “just trust me” argument that a lot American voters and businesses might not buy into, especially when cost predictions vary by $22 trillion.
Sanders would help fund his health plan through progressive income tax hikes that would increase the marginal income tax rate to 40 percent for those making over $250,000 a year and up to 52 percent for those making over $10 million. He would limit deductions for the wealthy and tax capital gains and dividends at the same rate as work income. He’d also implement a one-time tax on offshore profits, increase the estate tax, establish a new wealth tax and impose a fee on large financial institutions.
So, now we’re not just passing a health care bill, we’re significantly restructuring the tax code, too. That’s sure to motivate an even more powerful and well-funded opposition from the financial sector, business organizations, chambers of commerce and other lobbies.
Even if Medicare-For-All clears all of these legislative hurdles, there’s the additional minefield of court challenges. There‘s no doubt that multiple court cases will be filed by Republican state attorneys general and other organizations to challenge the new law. And thanks to the 2016 election, the federal judiciary and the Supreme Court are more politically conservative than ever before. That doesn’t bode well for Medicare-For-All advocates.
Finally, there’s the huge problem of implementation. The Sanders plan would end private health insurance as we know it, an industry that covers the majority of Americans and employs about 540,000 people. It would massively expand the Medicare program, create a new administrative infrastructure, redesign health care coverage and fundamentally restructure the most complicated health care system in the world which happens to represent 20 percent of the U.S. economy. And he’d do all of that in the very ambitious time span of four years.
Remember the public and political reaction to the initial roll out of Healthcare.gov? The four-year-long implementation of the Affordable Care Act was a cakewalk compared to the challenges presented by Medicare-For-All.
Having said all of this, I’m not saying that it can’t be done. But, it might be wise to be especially clear-eyed about the magnitude of the task ahead.
Bob Semro of Glenwood Springs is a former health policy analyst for the Bell Policy Center, and a legislative and senior advocate. His column appears monthly in the Post Independent and at postindependent.com
