Understanding #Medicare4All & the Democratic Primaries

By | February 25, 2020


Since Saturday’s Nevada primaries, confusion seems to be reigning about how Bernie Sanders seems to be winning. Time (and not a lot more of it) will tell who actually ends up as the Democratic nominee. But the progressive side (Bernie + Warren) is doing much better than the moderate side (Biden/Butt-edge-edge/Klobuchar) expected, while we wait to see how the  Republican side of the Democratic primary (Bloomberg) does in an actual vote. The key here is the main policy differential between the two sides, Medicare For All.

Don’t get too hung up in the details of the individual plans, especially as revealing said details may have hurt Elizabeth Warren. But do remember that there is one big difference between Sanders/Warren and the moderates. It comes down to whether everyone is in the same state-run single payer system (a modified and expanded version of Medicare) or whether the private employer system is left as it is, with expanded access to something that looks like Medicare (the public option) for everyone else. Note that no Democrat wants to stand pat on Obamacare “as is”. Everyone is way to the left of what Obama ran on in 2008 (or at least what he settled for in early 2009).

Why has this changed? Well there’s been a decade of horror stories. I’m not talking about the BS anti-Obamacare stories from people forced to give up their junk insurance, I’m talking about people with insurance being bankrupted or put through horrendous experiences, like this mother who was put through the ringer by various insurers when her 1 year old son was killed and husband injured in a road accident. Or this health tech CEO, who was an MD & JD and had to put $ 62,000 on his American Express card to get surgery

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About 3 years ago as the dust was clearing from the Obamacare implementation, the impact of this started showing up in the polls. In 2017 for the Health 2.0 conference, Indu Subaiya & Hiliary Critchley ran a poll on health policy with Zogby. To me by far the most remarkable feature was that even though Obamacare was by then more popular than not among the public, the support for single payer had gone up dramatically since 2009–in the depths of the recession.

Zogby poll for Health 2.0, Fall 2017

In 2019 44% said they were utterly opposed to single payer (and 50% opposed overall). But by 2017 while the number strongly in favor had just edged up, 48% were in favor overall, with another 30% neutral or not sure. Now only 19% were strongly opposed.

Meanwhile, just a year later (October 2018) a lot of fuss was made about a poll from The Hill that had 70% of Americans supporting Medicare For All. This was the poll that had 52% of Republicans saying they were in favor of it. (Full data here). (Don’t forget that only about 30% of Americans identify as Democrats, while about 35% identify as Republicans and 40% say they’re independent). So if we are to believe that somewhere between 45% and 70% of Americans say they are in favor of single payer, almost all Democrats are. And in fact that is true. The Hill found 92% were and the Kaiser Family Foundation (KFF) shows 75%.

The issue of course is what “Medicare For All” means in reality. The KFF poll is very up to date and I can’t decide if it shows that the electorate is very confused or if the poll itself is a mess. (I highly recommend clicking though it). It basically says that Democrats want Medicare For All and want a public option while wanting to keep their own insurance (presumably many of them now have employer-based private insurance).

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But luckily there was another recent poll done by Bob Blendon at Harvard (who I worked within the 1990s), and (as I told the KFF folks and Topher Spiro on Twitter) this poll was not a mess. In fact it was crystal clear in herding its respondents into one of three camps and thus very instructive for the Democratic primaries. (Details here) The poll gave people a straight choice between single payer, or extending the ACA, or the Republican “alternative”.

Basically when you tell Americans that Medicare For All means “Medicare for You too” (i.e. All Americans would get insurance from Medicare), but offer them a choice of an ACA expansion, roughly a third choose either alternative.

Somewhat more remarkably this split is not just along party lines. Democrats in the poll were also evenly split between Plan A (Medicare for All) and Plan B (expanding Obamacare) although few of them wanted the Republican alternative and, if you include independents who lean Republican, a third of them want single payer or extended Obamacare!

Source: Commonwealth Fund/New York Times/Harvard T.H. Chan School of Public Health,
Americans’ Values and Beliefs about National Health Insurance Reform. July, 2019.

The inference is relatively clear. Almost all Democrats want Medicare (or something like it) “available” for All and about half of them (and about 1/3 of independents) are prepared to “mandate” Medicare For All.

How will that translate into the primaries? It’s relatively obvious that the most passionate and most progressive Democratic voters are a little more likely to vote in the primaries. I’ve cut some data from another poll from The Hill (Jan 15, 2020) that suggests that 58% of Democrats say they are certain to vote in the primary but 67% of liberals will, while only 50% of those who “lean liberal” will.

Question: How likely are you to vote in the Democratic primary election or caucus in your state to choose the Democratic nominee for the 2020 Presidential Election?

Which gets us back to the voting. Everything thus far is weird. Caucuses are stupid and unrepresentative, although they have elements of a good idea (2nd choice votes in multiple candidate fields). New Hampshire doesn’t look like America and neither does South Carolina. But with Sanders/Warren coming in at between 35% & 55% so far, and most more liberal and more activist Democratic primary voters favoring single payer, I suspect that we will see a majority of votes/delegates for Sanders/Warren by mid March assuming that health care stays the dominant and dividing issue.

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That likely means that even if all but one of the “BBBKS” moderates drop out, there wont be enough moderate delegates to stop the progressives at the convention. (Worth noting here that Warren has been saying “Medicare For All after we fix Obamacare” which gives her a little slack).

If that’s right and Sanders is the nominee, then the Democrats face an interesting problem. If like 2018, they can run on how evil Trump and the Republicans are on health care, but not say too much about their own plan, then they’ll likely win. If Trump succeeds in making it all about single payer socialism making people fear the devil they don’t know, it’s likely to be a losing issue.

Matthew Holt is the publisher of THCB and likes to remind people now and again that he has a Political Science degree and worked for a pollster once!

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