President Joe Biden has said he doesn’t support Medicare for All, citing the program’s high price tag of $32 trillion. But by reopening ACA enrollment on February 15, boosting ACA subsidies (potentially in the next coronavirus package), and calling for a so-called “public option,” Biden essentially supports moving the U.S. to single-payer health care on an incremental installment plan.
How? There’s a key metric that too few policy wonks and political commentators watch: the number of Americans who depend on the government to pay for their health care. With more than 61 million seniors in Medicare, and more than 77 million low-income people in Medicaid, these two behemoth programs cover approximately 44 percent of all Americans.
This makes reforming these entitlement programs politically difficult.… Just ask former Speaker of the House, Paul Ryan.
Affordable Care Act or “Obamacare” plans are similarly politically untouchable, but they are a little different: While they are government-prescribed and shoppable in government-run exchanges, they aren’t truly public insurance plans. They are offered by private companies. But those private insurance companies benefit from taxpayer-funded subsidies that increase with enrollment (and might increase even more if lobbyists get their way).
Democrats hope to continue to add to the rolls of public programs, although they vary in the degree to which they are transparent about this as a strategy to get to single payer. Some are very transparent, for example, like Pete Buttigieg and Elizabeth Warren. They’ve suggested two steps: They would start by offering a public plan alongside private insurance—the so-called “public option”—with the goal of moving all the way to single payer next.
In contrast, President Biden says he supports a “public option” but opposes Medicare for All. So do 17 percent of Americans, according to polling from Kaiser. This position sounds moderate, but it’s really not. You might just as well say you support getting off a rollercoaster halfway through the ride.
On the other hand, one could argue, we stepped on the rollercoaster in 1965 with the establishment of the Medicare and Medicaid programs. In his famous radio address about socialized medicine (in 1961), Ronald Reagan pointed out that Members of Congress (and unions) supporting Medicare were using a “foot in the door” strategy to create “a mechanism for socialized medicine capable of indefinite expansion in every direction until it includes the entire population.” How right he was.
This is why another policy strategy favored by Democrats involves significantly expanding eligibility for Medicare and Medicaid or creating a “buy in” to these programs for people who aren’t eligible. This is just the public option by another name.
For Medicare, the focus has been dropping the eligibility age to enroll more people. But even without lowering the eligibility age, Medicare’s enrollment will balloon in coming years as the American population continues to age and Baby Boomers continue to retire.
For Medicaid, the focus has been on changing the eligibility requirements via the Affordable Care Act’s Medicaid expansion. Here Democrats have already had great success: The ACA offered states generous federal subsidies to enroll childless, working-age, nondisabled adults earning up to 138 percent of the federal poverty limit, and most states took the bribe.
In fact, the overall coverage impact of the ACA is best understood as a huge expansion of government health insurance programs, more than any expansion of private insurance coverage. While proponents of the law often boast that it initially increased the number of insured Americans by 20 million or so, they often fail to point out that about 15 million of those were Medicaid enrollees.
And like any safety net program, Medicaid fluctuates with the economy: Sadly the first 7 months of the COVID pandemic saw an increase in Medicaid enrollment of 5.8 million people or 8.3 percent. In other words, a bad economy also steepens the slippery slope to single payer.
Democrats don’t need to make a big push to get Medicare for All, which might alarm Americans who don’t want socialized medicine. Rather, all Democrats need to do is continue to load the rolls of Medicare and Medicaid and subsidized ACA plans.
The private health insurance market has already witnessed—thanks to the ACA—a high degree of consolidation. Few small health insurance companies could weather the ACA’s requirements and the market volatility it caused. Many were swallowed up by larger insurers, so Americans seeking private insurance have few options left. It’s almost as if the remaining large insurers are simply competing for the government contract to manage a single-payer program, whenever that might one day be enacted, likely as a response to “dwindling market competition.” A government solution for a government-created problem.
The Democrats’ strategies to get to single payer—whether by allowing people to buy into government programs or expanding eligibility—all continue our march in this wrong direction. Americans need to recognize this. If they want to keep any private options, they need to oppose any and all expansion of government health programs, even though, as Reagan warned, these expansions can so easily be disguised “as a humanitarian project.”
Otherwise, all these roads reach the same destination, and that’s a single payer system, where the government is fully in charge of American health care.