Last year, the politics of health insurance were all about repealing and replacing the ACA. Maybe it made sense from a political perspective for Republicans to go after the signature domestic achievement of the Obama administration. But in the bigger picture the antipathy is hard to figure. “Obamacare” was nothing if not incremental and so basically conservative of existing arrangements. Employer-based insurance and Medicare, which combined cover about two thirds of Americans, were left pretty much alone. The exchanges, the individual mandate, the ACA-mandated benefits, dozens of other provisions—they were remedial nudges to the individual market, long the problem child of American health insurance.
This year, the political swirl is spinning around Medicare. As Timothy Kelley, a senior contributing editor, reports, Democrats are flocking to Medicare for All, once a fringe proposition. Fueling the appeal is anger about high deductibles, coinsurance, surprise billing—and the shortcomings of the ACA, be they inherent or inflicted. Supporters believe “M4A” and single payer financing would rationalize American health care and make it more humane.
But Harold Pollack of the University of Chicago is right. The politics of Medicare for All will become very difficult (to put it mildly) if it seems (as it might) to threaten employer-based health insurance, that historical accident of a World II–era wage freeze and IRS tax ruling but an accident that now provides half of all Americans with health insurance.
The various plans to expand Medicare (or Medicaid) are more realistic. They don’t pose an existential threat to current coverage. Like the ACA, they would be incremental—in this case, a building out of public payer. And private insurers have nothing to worry about, not really. Look at how Medicare Advantage and Medicaid managed care are growing.