Pinkerton: How We Got to 'Medicare for All' — and How It Affects 2020

Medicare for All—Or Alexandria Ocasio-Cortez for All?

Here’s something interesting: According to a new poll from the Harvard T.H. Chan School of Public Health, 68 percent of Americans believe that providing “Medicare for All” should be an “extremely important priority.”

We might note that the “internals” of that number show us that 84 percent of Democrats support Medicare for All, as well as 70 percent of Independents—and even 39 percent of Republicans.

Other surveys show similar numbers. For instance, a Reuters/Ipsos poll from August showed 70 percent supporting Medicare for All.

It’s tempting to say that this is just the glamorous handiwork of Rep. Alexandria Ocasio-Cortez (D-NY). After all, the political comet—now so well known that she is identifiable just as AOC—burst on the scene in June 2018 when she defeated an incumbent Democrat in a Bronx-Queens primary.

Since then, like her or not, she has lit up American politics. At last count, AOC boasted 2.54 million Twitter followers, and she has used them to advocate major policy changes, from higher tax rates to a “Green New Deal” (which I have written about here, here, and here). Yet Medicare for All has always been a top priority; AOC has tweeted about it often.

Okay, so what’s the future of Medicare for All? In the short run, of course, with the Republicans in charge of the White House and the Senate, nothing’s going to happen.

Yet the longer run could be a different story. That is, everything could change after the 2020 elections. Yes, less than two years from now, it’s at least possible that a Democratic president, joined by a Democratic Congress, could be seeking to enact Medicare for All.

And what might happen then? Could such an ambitious bill actually pass? It’s worth knowing that similar fights have happened before, long before anyone had ever heard of AOC. So perhaps we should take a look back at history, in search of lessons.

The Truman Show

Presidential efforts on behalf of national health insurance began with Franklin D. Roosevelt. In his 1943 State of the Union address, FDR called for economic security for all Americans, using the memorable phrase, “from the cradle to the grave.” Yes, this was in the middle of World War II, but the 32nd president believed that victory in the war depended on social solidarity on the home front. Moreover, he was looking ahead to the post-war era, when a victorious America would be “a nation fit for heroes.”

FDR died in April 1945, just before the war ended, but when the fighting was done, his successor in the White House, Harry Truman, picked up the torch. On November 19, 1945, Truman delivered a special message to Congress calling for national health insurance:

Millions of our citizens do not now have a full measure of opportunity to achieve and enjoy good health. Millions do not now have protection or security against the economic effects of sickness. The time has arrived for action to help them attain that opportunity and that protection.

At the time, the political wind seemed to be at Truman’s back. As scholars Robert Blendon and John Benson wrote in a 2001 article for Health Affairs:

In the years leading up to Truman’s proposal, 82 percent of Americans said that something should be done to make it easier for people to pay for doctor and hospital care, and 68 percent thought that it was a good idea for Social Security to cover doctor and hospital bills.

Some policy success came to Truman right away. In 1946, the 33rd president signed legislation expanding funding for mental health and hospital construction.

Yet even with Democratic majorities in both chambers of Congress, Truman was thwarted on Capitol Hill. Then, in November 1946, the opposition Republicans won a big victory in the midterm elections, thus putting the president’s proposal in the deep freeze.

Yet Truman persisted. Having staged his famous come-from-behind victory in 1948, the reelected president, bolstered by restored Democratic majorities in the House and Senate, sought to unthaw his health proposal. In his 1949 State of the Union address, Truman framed his proposal as a kind of compassionate conservatism:

In this society, we are conservative about the values and principles which we cherish; but we are forward-looking in protecting those values and principles and in extending their benefits.

Yet his opponents—not all of them in the Republican Party—were ready with their counter-arguments. The opposition was spearheaded by the American Medical Association, which was then a conservative group; the AMA warned that a national health plan would lead to “the enslavement of the medical profession.”

Indeed, as the Cold War grew colder, anything that could be labeled, fairly or not, as akin to Soviet-style totalitarianism was looked upon with horror. Thus, the AMA was able to round up support from a bevy of organizations, including the Chamber of Commerce, the American Bar Association, the American Farm Bureau Federation, the American Dental Association, the American Legion, the General Federation of Women’s Clubs—in all, 1,829 groups.

Confronted with the charge that his healthcare plan was “un-American,” Truman responded, “I put it to you, is it un-American to visit the sick, aid the afflicted or comfort the dying? I thought that was simple Christianity.”

Yet still, Truman was thwarted again; his bill died in 1949. In his memoir, Truman reflected:

I have some bitter disappointments as President, but the one that has troubled me the most in a personal way, has been the failure to defeat organized opposition to a national compulsory health-insurance program.

Part of the reason for Truman’s defeat, of course, was the hard-nosed opposition. Yet other factors were at play as well. As noted, Truman signed significant health legislation, independent of national health insurance, early in his presidency. We can conclude: In winning those partial victories, some of the steam went out of Truman’s engine.

Moreover, even as Truman’s bill was being debated, American workers, too, were gaining a partial victory—they were getting health insurance from their employers. As a history from the Social Security Administration notes, “In 1946 only one-fourth of the population had had health insurance, but by 1950, about 60 percent had at least basic hospitalization coverage.” In other words, the cause of providing national health insurance was to some extent preempted by the new coverage provided by private employers, eager to attract workers. That’s what a booming economy can do: it can create the wealth needed to pay for social goods. As John F. Kennedy would later say, “A rising tide lifts all boats.”

Johnson, Clinton, and Obama

The crusade for national health insurance came up again under three subsequent Democratic presidents: Lyndon B. Johnson, Bill Clinton, and Barack Obama. In all three cases, the chief executives enjoyed big Democratic congressional majorities when they came into office, and so they all argued for bold healthcare expansion.

Johnson enjoyed substantial success in 1965, when Congress enacted Medicare and Medicaid; today, these two programs enroll 118 million Americans.

Yet three decades later, Clinton, famously aided by his wife, was not successful. He was rebuffed by his fellow Democrats on Capitol Hill in 1993, and then his party lost Congress in 1994. (Still, in 1997, the bipartisan Children’s Health Insurance Program was enacted; today it covers 9.5 million Americans.)

As for Obama, in 2008, the year he was elected, 64 percent of Americans supported national health insurance. The following year, Obama put forth his bill, soon dubbed, of course, Obamacare.

Yet then, interestingly, public support started to decline. That is, as the prospect of Obamacare actually becoming a law came into focus, approval fell away. Indeed, it had fallen to 47 percent in 2010, the year that Obama signed the Affordable Care Act into law—and it bottomed out at 42 percent in 2014. In the years since, support has been rising again—although intriguingly, support for Obamacare is lower than support for Medicare for All.

Lessons Learned

So now, having reviewed the healthcare efforts of five Democratic presidents, we can look ahead and ask: What have we learned? Two lessons leap to mind.

First, there’s a value in opposition research. The AMA did its homework in the 1940s, and it paid off. So now today, opponents could start by asking: What will Medicare for All cost?

In the absence of an actual bill on the floor, it’s impossible to pin down numbers; however, the libertarian-leaning Mercatus Center has jumped in anyway, assaying the cost of Sen. Bernie Sanders’ plan at $32 trillion over ten years.

Needless to say, Sanders and his allies, including AOC, dispute those numbers; they argue that they will be able to squeeze out cost savings. Of course, it’s worth remembering that national health insurance advocates always say that they will hold down costs—and yet they aren’t often successful.

For instance, during his 2008 campaign, Obama said that he could reduce the average family’s healthcare bill by a third, and yet the opposite has happened. A look at the numbers tells the tale: When the 44th president signed his Affordable Care Act into law in 2010, the national health expenditure was $2.6 trillion; today, it’s $3.5 trillion—that’s a 34 percent jump. In other words, what was supposed to go down by a third instead went up by a third.

Second, it’s worth understanding that another wrinkle in Medicare for All is that it wouldn’t really be for all. That is, the rich—including, one supposes, the Democratic National Committee’s finance leadership—would inevitably always seek the best healthcare wherever they could find it. And this would be doubly true if the enlarged Medicare system necessitated rationing, as has been endemic to national health schemes.

For instance, in Canada, which has a single-payer system, the dreaded queue to see a doctor has created a parallel private system for those who can afford it. In fact, Canada’s private system accounts for more than a fourth of that country’s healthcare outlays.

In other words, here in the United States, Medicare for All would still be a two-tier system; it’s just that the lower tier would be state-run, and a lot slower—and a lot more expensive.

What’s Next

Some on the right will say, of course, that the correct answer is to simply call a halt to this whole business. That is, block Medicare for All, repeal Obamacare, and, who knows, maybe even get rid of Medicare and Medicaid. This vision of “rollback” is enticing to some, but it’s not likely to happen. For instance, that Harvard Chan poll we saw earlier showed that a thumping 88 percent of Americans say that “making sure Medicare benefits are not cut back” is an extremely important goal. In that vein, we might further recall that Republicans failed in their 2017 effort to repeal Obamacare. Then, in 2018, the voters—believing that healthcare was the most important issue facing the country—handed the Democrats a big majority in the House.

So today, the issue on the table is healthcare expansion, not contraction, and each Republican officeholder has to think about those big majorities in favor of Medicare for All.

Inevitably, many, if not most, GOPers will look for some sort of middle path—an October poll from Survey Monkey might prove to be particularly valuable because it illuminates a possible nuanced approach. It found that 34 percent of Americans support outright single-payer, and another 33 percent support an optional public plan alongside private insurance (30 percent wanted neither).

In the summarizing words of Axios’ Sam Baker:

Most people—67%—seem to be on board with either single-payer or a public option, suggesting that “Medicare for All” is popular, but that’s partly because of its multiple meanings.

So, as they think about that 67 percent mountain, what will Republicans do?

Will they go all-out in opposition, as they have in the past? Yes, that approach worked in the 1940s, but unlike the ‘40s—or even the ‘90s—employers are now determined to reduce their healthcare commitments, not expand them.

Or, will GOPers seek some sort of compromise, preserving private health insurance as part of an overall comprehensive system? After all, the Republican Party has changed in recent decades. If it wishes to embrace its new role as be the protector of the working and middle classes—which have, healthcare-wise, increasingly been cut adrift—then perhaps it needs to rethink its automatic opposition to assured healthcare.

Only this much is for sure: Every Republican running for anything in 2020 will be asked about his or her position on Medicare for All. Many times.