Medicare For All Vs. Medicaid For More

Reform is real, revolution is fantasy

I don’t want to discourage the people agitating for Medicare For All. They are planning a national conference. By all means, support it. It’s also a focus for Democratic Socialists of America. I’m all for it. In fact, I’d be for something resembling the U.K. National Health Service, where everybody works for the Gov. Or even our own Veterans Administration. What I don’t get is the inattention to our other huge, national health care program, Medicaid.

The VA gets a lot of flack because it is prey to the perennial right-wing dodge of under-funding a public effort, then criticizing it for its inadequacies, justifying further cuts. Rinse, repeat. We honor the troops until one of them is injured or ill. But thank you so much for your service! Sadly, this is an old story.

There is a fundamental political difference between Medicare and Medicaid. Medicaid expansion need not happen in every state, all at once. Individual states can and do add (and subtract) from benefits. Obama’s Affordable Care Act incentivized states to majorly expand with Federal dough. If it wasn’t for our shit-for-brains Supreme Court, the expansion would have automatically covered every state. Instead the decision was made optional to state governments. Even so, by now most states have picked up the expansion. Here is a map from Kaiser Family Foundation showing the current state of play.

The non-expansion states include some choice political opportunities for Democrats. Wisconsin is the most obvious, but I wouldn’t sleep on Florida, which Obama won not all that long ago. Georgia’s recent election results also make it interesting. Note that many reliably Republican states have accepted expansion. Thanks, Obama!

Of course, Medicaid targets the lowest income families. An old chestnut is that poor programs are poorly funded. But Medicaid spending has blown up over recent decades. Perhaps it is the exception that proves the rule, though “food stamps,” now called Supplemental Nutrition Assistance Program, has been dinged periodically but has also held up reasonably well.

Meanwhile, Medicare still entails big coverage gaps, such as only paying for 80 percent of medical expenses. For those who have never been able to work in covered employment, there is no Medicare, just Supplemental Security Income, a very poorly-funded program.

Now 20 percent of a huge expense is still beyond the reach of most families, so really-existing Medicare leaves much to be desired. It’s not quite insurance. We buy insurance to shield our families from financial catastrophe. 20 percent of a huge amount can still be catastrophic for families with no financial cushion against emergencies. “Medicare For All” is really an empty box, leaving to the imagination what a different Medicare would be.

It’s find to have ambitious goals like M4A, but even Bernie Sanders, the person more responsible than anybody for making Medicare For All a thing, has accepted current political limits and chosen to focus on adding dental and vision benefits to existing Medicare.

Many families have decent insurance. They pay an arm and a leg for it, but going by polling and recent history, they prefer it to the unknowns of a wholly new, national program that eliminates their private insurance and entails new taxes.

M4A in this context is directly and immediately relevant only to the minority of the population stuck between Medicaid eligibility and private insurance. Raising the ceiling on Medicaid income limits is the simplest way to capture more folks. So is juicing up ObamaCare, which has also been accomplished when Democrats controlled the Congress.

When I worked for the Gov around 2009, we at GAO (Government Accountability Office) devised ways to expand Medicaid funding that would amount to fiscal stimulus. Medicaid is the biggest expense for state governments, so filling up the program with Federal support eases pressure on everything else state and local governments have to do.

The U.S. Left tends to be focused on national changes, either incremental, accomplished in Congress, or very big, accomplished who knows how. My long-standing pet peeve is that we neglect the fundamental nature of the U.S. public sector: federalism. We have over 90,000 local governments. It’s the states and their local governments that deliver most services. The Feds mostly mail checks (to retirees, health care providers, and military contractors).

The Left chooses to operate under a national constraint — everything, everywhere, all at once. But the decentralized nature of the public sector provides opportunities for more modest gains. The radical rejection of incremental reform tends to be illogical. A negative reform is met with derision, which is fine, but that implies the lack of such a reversal would be good. Or that a positive change would be even better. The one-sided complaints about regress are asymmetrical. If cutting food stamps is bad, not cutting is less bad, and expanding is even better.

It is said that reforms quench social demands for bigger change, but that’s just like, your opinion, man. I could just as easily say that victories generate optimism and demands for further progress. It’s hard to drum up morale for unlikely objectives.