Elizabeth Warren's healthcare two-step

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I owe a debt of gratitude to a Jacobin writer, Tim Higginbotham, who lambastes Elizabeth Warren for a) going into what he regards as unproductive detail about the financing of Medicare for All and b) signaling that she doesn't intend to enact M4A any time soon.

It's the latter that interests me. It solves something of a riddle. And unlike Higginbotham, I approve of this message. I think there may be a kind of deep realism in it, not severable from real commitment to major structural change.

Higginbotham notes that Warren's pay-fors depend in part on enacting other major legislation, and that her language accordingly projects Medicare for All into an..eventuality:

Warren’s remaining financing methods bring us to the biggest problem with her plan: its clear lack of urgency. Warren argues that her plan for comprehensive immigration reform could free up $400 billion toward Medicare for All over ten years, while cutting the dangerous military slush fund will free up another $798 billion.

On their own these are important goals, but using major political fights like these to cobble together funding for Medicare for All is a fairly good tell that Warren’s plan is not designed to be implemented anytime soon. This is further evidenced by the language in Warren’s Medium post about her plan: she describes Medicare for All as a “long-term” goal seven times, while couching the rest of the post in similar language (such as saying she wants to move to a Medicare for All system “eventually”).

That's absolutely right. And in fact, near the end of her Medium piece introducing her M4A funding plan, Warren makes it explicit that she won't be fighting to enact BernieCare from day 1, 2021:

Of course, moving to this kind of system will not be easy and will not happen overnight. This is why every serious proposal for Medicare for All contemplates a significant transition period.

In the weeks ahead, I will propose a transition plan that will specifically address how I would use this time to begin providing immediate financial relief to struggling families, rein in out-of-control health care costs, increase coverage, and save lives. My transition plan will take seriously and address substantively the concerns of unions, individuals with private insurance, hospitals, people who work for private health insurers, and medical professionals who worry about what a new system will mean for them. It will also grapple directly with the entrenched political and economic interests that would spend freely, as they have throughout modern American history, to influence politicians and try to frighten the American people into rejecting a plan that would save them thousands of dollars a year on premiums and deductibles while making sure they can always see the health care providers they need with false claims and scare tactics.

It doesn't sound to me like Warren here is proposing to work within the confines of the four-year transition built into Sanders' bill (or the two-year transition provided for in Jayapal's House version.

What might such a "transition plan" look like? Well, this past spring Warren reintroduced her "ACA 2.0" bill, the Consumer Health Insurance Protection Act, which vastly improves ACA subsidies, reducing both premiums and out-of-pocket costs; removes the income cap on subsidy eligibility; fixes the ACA's family glitch, extending marketplace subsidy eligibility to workers whose employer plans render family coverage unaffordable; tightens provider network requirements on insurers; and raises the percentage of premium revenue that marketplace insurers are required to spend on enrollees' medical costs from 80% to 85%.

The transition plan will likely go further, perhaps much further. Given the promise to rein in costs, it may include a cap on provider payments in the marketplace or beyond. Perhaps it will include a public option, and perhaps make it available on a subsidized basis to those with access to employer-sponsored insurance deemed affordable by current standards. Those measures would bring the transition plan in line with plans put forward by Buttigieg and Biden.

The promise to "grapple" with powerful healthcare lobbies is interesting, as it places that fight in a transition plan, as if actual legislative steps to tame that political influence are a precondition of full M4A legislation.

Higginbotham notes with suspicion that "Center for American Progress — a notorious opponent of single-payer health care — is showing sudden enthusiasm for Warren’s plan." Beyond the link provided, Topher Spiro, CAP's chief healthcare policy person, has defended the financing assumption in more detail. Spiro is a chief architect of a Medicare buy-in proposal, Medicare Extra, that's the basis of the Medicare for America Act, a sweeping bill that revamps the Medicare benefit, incorporating long-term care; folds in Medicaid; auto-enrolls newborns; and mandates that providers accept Medicare rates from commercial insurers. Perhaps Warren's transition plan will incorporate aspects of his reform model, which is sometimes seen as a glide path to single payer/Medicare for all (and sometimes as a system that preserves viable private competition, as in current Medicare).

For more than two years -- beginning with Warren's cosponsorship of Sanders' first M4A bill in September 2017 -- I have noted a recurring strain of ambivalence or hesitance in Warren's backing of Medicare for All. Fairly consistently, she has endorsed it as a goal while also implying that it may be an impossible all-at-once political lift (and perhaps too big an all-at-once shock to our economy and healthcare infrastructure -- she has never specified the cause of her hesitance as far as I know).

So here we are again. There seems to be a double message in the Medium piece: Medicare for All is financially feasible and a pure win on policy grounds, but the ground needs to be cleared in various ways before a Sanders-like four-year path can be enacted. Warren explicitly presents the financing plan as part one in a two-step: let's see where we are when the next shoe drops.