By Lambert Strether of Corrente.
Yesterday, I wrote on the politics of The Medicare for All Act of 2017 (“BernieCare”). Today, I’ll write on the policies. First, I’ll lay out, very sketchily, one or two differences between BernieCare and HR676 (“ConyersCare”) — as opposed, of course, to #LiberalsDontCare — which will have to serve as a placeholder for the full-throttle War and Peace-length post I should and will write on this topic. Then, I’ll consider the health insurance industry workers that #MedicareForAll would displace. Finally, I’ll look at the fiscal issues (or rather, how to think about them). Spoiler alert: I’ll treat worker displacement and budget issues at a very high, talking-point level; it would be nice if some good faith wonks got down in the weeds on these topics but (with the exception of Gerald Friedman) they haven’t yet.
BernieCare vs. ConyersCare
Again, I want to express my gobsmackedness at having not one, but two #MedicareForAll bills introduced in Congress, both with a serious number of co-sponsors; we have come a long way from the days of 2009, when Max Baucus refused to include single payer advocates in his hearing, and had them arrested when they protested; or when Obama sneered at “little single payer advocates.” It just goes to show that good things can happen in one’s own lifetime, which really matters to an old codger like me.
Here are two comparisons of BernieCare and ConyersCare. The first is a list from Dr. Margaret Flowers and the HOPE campaign, in mail; the second is a table from Health Over Profit. The first cites to the second. Looking at the table, this jumps out:
HOUSE: HR 676 SENATE: Medicare for All Act Providers All who meet standards and are public or nonprofit (bans investor-owned facilities and phases them out over 15 years). All facilities must meet standards for staffing and quality. All who meet standards. . All facilities must meet standards of staffing, competence, quality and satisfaction.
I’m very dubious about the unlimited inclusion of “investor-owned facilities” in BernieCare, because I’m dubious that profit-driven facilities can deliver care equitably. (See here for an illuminating description of profit vs. non-profit hospitals during Hurricane Katrina. Guess which facility triaged its patients, and which saved all of them?) Frankly, this seems to me like an open invitation for a neoliberal infestation and invasion even worse than we already have, fought out on the ground of “standards.” Less centrally than saving lives, there is the cost issue; most projections of #MedicareForAll assume that profit (and rental extraction) are squeezed out of the system as much as possible.
Reinforcing my fear of neoliberal infestation:
HOUSE: HR 676 SENATE: Medicare for All Act Operating and capital expense budgets Global operating budgets for each facility and separate capital expense budgets, cannot co-mingle. . Facilities can co-mingle operating and capital budgets. No mechanisms to control budgets.
On my cursory reading, “No global operating budgets” + ” investor-owned facilities” = Ginormous Bezzle. Prove me wrong, please!
Helping Displaced Workers
Next, we have the issue of how to help the approximately 525,000 workers in the health industry (hat tip, marym) who would be displaced by #MedicareForAll.
At the outset, this wonkish objection to #MedicareForAll is hardly ever made in good faith; in policy terms, the political class doesn’t give a rats patootie about displaced workers; look at what’s happening to retail now, or, for that matter, the deindustrialization of the Rust Belt. Please don’t try to make me believe that these suddenly expressed tender concerns — “Will nobody think of the workers?” — are anything other than tactical.
That said, if the left does in fact put workers first, then for its own reasons, it needs to come up with a solution, since the need for one won’t go away. For example, supposed we ended the empire tomorrow. What about the workers at Bath Iron Works, say? Or suppose the finance sector were shrunken from its current hideously bloated, Shelob-like size to something more manageable? Granted, Greenwich will do OK no matter what, but what happens to the office workers and cleaners and food prep people and transport workers and HVAC techs and IT workers who kept Wall Street going, before all the towers went dark?
At the highest level, a Job Guarantee is the obvious answer, but that illustrates the requirement for the left — as the neoliberals have — to think in terms of whole systems, and not merely policies. (In other words, this is not a JG thread, and not a JG v. Big thread. For further reading, see especially here, and here, and here.) But as for policy, again the two bills:
HOUSE: HR 676 SENATE: Medicare for All Act Transition for workers Displaced workers have first priority to be hired into new system, 2 years salary and training support. Temporary worker assistance for up to 5 years, capped at 1% of total budget.
One problem with HR676 is that retraining is a crock; it always comes up in the “skills mismatch” debate, and it turns out in practice that the only jobs retraining programs create are for professional trainers (which is why the Democrats love the idea). Other than that, both programs seem reasonable to me, especially giving displaced workers first priority; displaced workers please chime in! (I’m also assuming that the liberals Ladies and Lords Bountiful don’t sneak in their usual complex eligibility requirements, especially means-testing. For example, people should be able to cover their moving expenses to a new job without going through some sort of ritual to prove their worthiness. Or child care during a job search. And so on and on.)
One point that I don’t see made very often: Medical coding is currently used to figure out how to bill for health care services. This is, however, an insane perversion of the coding taxonomies, which were originally designed to classify health care delivery as such, not billing for health care. (If you don’t see a distinction here, you may be a neoliberal.) If we could re-engineer medical coding by using its taxonomies for the purpose for which they were originally designed, we might learn a lot about how to deliver health care, besides saving a large number of skilled and well-paying jobs.
“How Are You Going to Pay For It?”
Unfortunately, as most NC readers know, the political class is brain-damaged about taxes (and in the sort of way that markets-first neoliberals like, since one effect of the brain damage is horror and repulsion at the concept that government — or even associations of volunteers assisted by government — can or should do anything). So, “The Federal government, as the currency issuer, would write a check for whatever Congress authorized” isn’t an answer that the political class can (as yet) process, at least without sparks and smoke coming from their ears.
Once again, and at a high level, here’s how the Swedes think about taxes:
Blyth: “Guess what the most popular government institution in Sweden is, year after year after year in surveys: The tax office.” Blyth then goes on to explain the policies that brought about that outcome. Obviously, we’re not at that point yet, and if it’s a prequisite for passing #MedicareForAll, that policy is in trouble. Nevertheless, we see what can be done. (My father, for example, always paid the maximum in taxes, in graitude for the New Deal and his service in World War II, followed by the GI Bill.)
Failing a revolution in attitudes toward tax, and failing an understanding by the general public that Federal taxes don’t fund Federal spending, we might try something like this (making up the figures):
Q: “How Are You Going to Pay For It?”
A: “Out of my right pocket, instead of my left.”
Q: [expression of bewilderment]
A: Right now, I pay $6000 a year for health care out of my left pocket, to the health insurance companies. Under #MedicareForAll, I’d pay $4000 a year for health care out of my right pocket, on April 15.
There’s no difference. I mean, except for the $2000 I’d save.
And no tax on time, a doctor of my choice instead of effing narrow networks, no co-pays, no [family blogging] paperwork when you’re coping with your diagnosis, and so on. A strategy like this might work as a sorely-needed conversation starter, at least. (Hat tip for pockets metaphor to you-know-who-you-are.)
Obviously, there’s much more to be said about #MedicareForAll. But what amazing progress in eight years, and against massive opposition, not only from conservatives, as we might expect, but especially from the liberal Democrats whose policies, politics, and persons were discredited in 2016. Hopefully, it won’t take another eight for the political class to do the right thing.
 One topic I need to understand, and do not, is the institutional imperatives and constraints within which Sanders and Conyers are working. The West Wing retells this famous story (so famous I can’t find the original):
There was a freshman Democrat who came to Congress 50 years ago. He turned to a senior Democrat and said, “Where are the Republicans? I want to meet the enemy.” The senior Democrat said, “The Republicans aren’t the enemy. They’re the opposition. The Senate is the enemy.”
(In other words, our bicameral legislature is working as designed; see Federalist Papers 62.) Both Conyers and Sanders, in addition to their personal visions of what #MedicareForAll should look like, will have had to write their bills to acquire co-sponsors in their respective Houses. For example, I’d speculate that the long phase-in for Sanders care is about sponsor acquistion, and the same for the inclusion of for-profit facilities, as long as they meet standards. ‘Twas ever thus.
 It’s dangerous to assume that our body politic is healthier than it is, and our political class less corrupt. Like it or not, breaking the political power of the health insurance industry is central both to passing #MedicareForAll, and to keeping it (and us) healthy after its passage. If the health insurance industry is still in a position to bribe its way back into power after #MedicareForAll is passed, we might as well not have passed it at all, because the same logic of making profit by denying care will still drive the system.
 I wish I knew how health insurance back office operations are geographically distributed. Partly to know how eliminating/repurposing them would affect the 2018 and 2020 elections — “First, the mill closed; then, the Aetna call center closed….” — but also to know how often health insurance jobs are the only good jobs, or the only jobs, in their communities.
 Another reason to make for-profit entities go away.
 And even some of them are willing to throw in the towel.