Wednesday, June 19, 2019

Voters understand Medicare-for-all better than Bernie does

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I would think long and hard about contradicting Larry Levitt (of the Kaiser Family Foundation) and Jonathan Cohn (of HuffPost) together on anything but semantic grounds.  But on semantic grounds...I don't think their framing of the results of a Kaiser poll voters' understanding of "Medicare-for-all" is quite right.

Kaiser asked some 1200 voters what the healthcare system would look like "under a national health plan, sometimes called Medicare-for-all." Majorities, varying moderately by partisan affiliation, assumed:
  • Taxes for most people would increase 
  • People would continue to pay premiums, deductibles and copays for medical services
  • People with private insurance would be able to keep their plans
  • Private health insurance companies would not be the primary way Americans can get health coverage*
  • All U.S. residents would have health insurance coverage
On Twitter, Larry Levitt alluded to "how confused the public is about Medicare-for-all based on our new poll." Jonathan Cohn, who wrote about the results, tweeted, "Voters like Medicare for All, but there's a catch: They don't understand what it'd do."

I don't think the survey respondents and focus group participants were collectively confused, though they're not informed about current bill specifics. I think they're realistic about the furthest likely extent of next-gen Democratic healthcare reform. Their responses lack coherence only to the extent that "Medicare-for-all" can't be understood to encompass "Medicare access for all," particular in the refracted context of a "a national health plan, sometimes called Medicare-for-all."

Bernie Sanders' bill (in most recent form) is called The Medicare for All Act of 2019 (S. 1129). Kaiser survey respondents were not asked about this bill per se, or about its similar but not identical House counterpart of the same name (H.R. 1384), introduced by Pramila Jayapal.  That was deliberate, according to Kaiser's director of public opinion and survey research:

Be that as it may, respondents' expectations point toward a reformed system in which Medicare is available to all, while employer-sponsored insurance and private individual market insurance continue to exist alongside it. The public plan covers most but not all of the population, and it includes deductibles and copays.

That's an accurate description of the Medicare for America bill introduced in the House by Reps Rosa DeLauro and Jan Schakowsky. That bill would allow anyone to buy into a revamped, comprehensive "Medicare" program on a sliding scale requiring premiums ranging from 0-8% of income ($0 for anyone with income up to twice the Federal Poverty Level). They could also buy into tightly regulated private alternatives, and employers could continue to offer insurance, required to meet a standard close to the current employer norm. People with incomes over 200% FPL would have to pay coinsurance for many services. It's true that deductibles have been eliminated in the bill's latest version, but annual out-of-pocket maximums can go as high as $3,500 individual/$5,000 family.

This is not to suggest that Kaiser survey respondents are any more familiar with the Medicare for America bill than they are with the Medicare for All bills (doubtless they are less so).  But a lot of presidential candidates are talking up Medicare buy-ins, and by whatever osmosis, the majority expectation for a Democratic administration/Congress (who else would try to put over a national health system?) lands quite close to the Medicare for America design. Perhaps that's not so surprising, as Medicare for America is only the latest iteration of a basic healthcare reform architecture that predates the Affordable Care Act.

Maybe the takeaway from the Kaiser survey has been inverted. The point isn't that voters misunderstand the Medicare for All bills introduced by Sanders in the Senate and Jayapal in the House -- but rather that the particulars of those bills haven't registered because voters don't consider them realistic or desirable.

These survey responses reflect reality. Democrats are not going to pass legislation that offers more comprehensive coverage than any national health plan on the planet. They're not going to pass a bill that requires more than doubling federal tax revenue. They're not going wipe out the private health insurance industry in 2-4 years, and they're not going to subject providers exclusively to Medicare payment rates within the same time period. They are not going to take on every segment of the mammoth U.S. healthcare industry and concede nothing to any of them.

The focus groups doubtless did exhibit confusion as to what Democrats are offering in specific bills, as Jonathan Cohn explains here:

I'm sure that that Liz Hamel and Larry Levitt, at close range to the results, know whereof they speak with respect to respondents' confusion concerning bill particulars. At the same time, the focus group responses cited in Kaiser's survey report strike me as  realistic -- reflecting realities in universal healthcare systems abroad (alternatives for the wealthy), in U.S. governance, particularly in healthcare (private administration of public benefits), in federal finance, and in current practice:
[Moderator: Do you think Medicare-for-all means that private health insurance companies will go away?]

“No, because they’d be running Medicare-for-all.” (Houston, independent)

“Or even those individuals who can afford to have the type of coverage they want, they wouldn’t want a basic burger. No, they want to add all of the extra fixings because they can afford it.” (Houston, independent)

“They’re going to take a hit obviously but I don’t think that they’re really going to go away. They’re too powerful.” (Harrisburg, Democrat)

“I don’t think for a second that private insurance would go away, even if you implemented this. There will always be the Cadillac plan that is available, because as long as somebody—the market will react.” (Orlando, Democrat)....

[Moderator: Do you think Medicare-for-all means that there would be no more co-pays or deductibles when people use care?]

“No, I think there’d probably still be co-pays and deductibles, but just be affordable.” (Houston, independent)

“It wouldn’t make sense to you that you wouldn’t have to pay [co-pays and deductibles] because it wouldn’t feel sustainable.” (Houston, independent)

“My mom is on Medicare and she has to pay co-pays.” (Houston, independent)
Personally I doubt that in the best case for Democrats, in which they win the presidency and a narrow Senate majority in 2020, they'll have the bandwidth to do more on the healthcare front than patch the ACA: improve the subsidies and cap premiums as a percentage of income for all who lack affordable access to other insurance. At the outer edge, perhaps introduce a strong public option (with a higher benchmark actuarial value than in the present marketplace) and open it in phases to small employers, then all employers, and at some point on a subsidized basis to those who have access to employer insurance. I don't think they'll venture to fold in Medicaid and revamp senior Medicare, as Medicare for America does, in the near term. They'll have too many other mammoth problems to address and fires to put out.

I think the Kaiser survey respondents display a pretty good sense of what's possible in the best case.

* Seems to me this question could be read two ways: most people would be covered primarily through a public plan, or private insurers would be relegated to providing supplemental coverage (or both). 

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