Dear Mayor “Extremely Vague” and Senator “Pipe Dream”: Put Up or Shut Up

Posted in: Politics

It turns out that the attacks on Senator Elizabeth Warren for not yet having explained in detail the financial underpinnings of Medicare-for-All were pretextual and dishonest. Now that she has responded to those criticisms, we are learning that she will supposedly harm rural hospitals, or that she used a bad assumption about tax enforcement, or something.

Should anyone be truly surprised? This was never about whether Warren needed to “come clean” that her plan would include some things labeled taxes—as if any family who is worried about medical expenses gives a hoot about whether they pay a fee, a coinsurance payment, a payroll deduction, a co-pay, or a tax, or for that matter, a “health-related cost defraying remittance.” (Surely, some insurance company somewhere must have used an even more absurdly Orwellian term to describe what is simply a cost by another name.)

Again, Senator Warren continues to be completely right that a Medicare-for-All plan (or other single-payer plan) could reduce costs overall even if the part of our costs that are called “taxes” go up. Indeed, that outcome is all but guaranteed when we change from a system as grossly wasteful as ours, which pours time and money into needless marketing onslaughts and systematic efforts to deny medical care to people (and to refuse to reimburse those who do receive care). The administrative costs alone in our system are a scandal.

But if this latest political drama was not about Warren “just admitting that taxes will go up,” what was it about? It was those who (consciously or not) defend health insurers’ profits engaging in a collective primal scream about the growing possibility that a very popular presidential candidate might stop the health care gravy train. At least implicitly, those politicians are defending the most wasteful, expensive health care system in the world (by far), one that delivers mediocre health outcomes and leaves tens of millions of Americans uninsured and at risk of financial ruin if they become ill.

To be extremely clear, I am not sure who I want the Democrats to nominate for President. I suppose that I should disclose here that I have exchanged emails with someone in Senator Warren’s campaign about my thoughts on her wealth tax proposal and its revenue-raising potential, but that was driven by an overlap of interests on a particular policy question on which I have some expertise. I might yet write more about that issue, but if I do, it will not be as an affiliate of Warren’s campaign (or anyone else’s). The Senator impresses me in many ways, but so do some other candidates, all of whom would be better by a mile than Donald Trump as president. I am simply not sure at this point about my preferred outcome in the Democratic contest for the presidential nomination.

I should also be clear that I do not agree with Warren (and others) that the path forward is to immediately adopt Medicare-for-All. Although I am not a politician, it has long seemed to me—even before the dishonest hounding of Warren began in earnest among her competitors—that the country is simply not politically ready for a direct leap to Medicare-for-All. Warren might end up proposing a transition path that makes sense, but as of now, I actually think that a politically savvier path would involve first adopting the so-called public option and only then setting the country on the path to some kind of single-payer system like the Medicare-for-All plan that Warren has now announced.

Again, however, I am not a political consultant (and would never want to be one), and it is possible that a Go Big strategy is the right one for health care. In fact, perhaps the only way to break through decades of gridlock in the current (wasteful and cruel) system is to be truly disruptive. I simply do not know, and I should add that most of the people who write columns like this also do not know, but they certainly think that they do.

What I do find amazing is that it is only Elizabeth Warren who is being treated in this way. Somehow, Mayor Pete Buttigieg was not deemed a complete jerk after the last presidential debate, during which he made snarky remarks about Warren’s supposedly “extremely evasive” answers. Indeed, he has surged into the top tier of candidates.

Senator Amy Klobuchar has not seen a reward that is quite so large for attacking Warren, but she has certainly not been criticized for attacking Warren in a hypocritical fashion. Indeed, calling Warren’s plans “pipe dreams” garnered a lot of positive notices for Klobuchar, who is now apparently thought to be the big truth-teller in the race.

So, in a slightly longer version of the title of this column, it is now time for Mayor Pete “She’s Being Extremely Evasive” Buttigieg and Senator Amy “Don’t Sell the People Pipe Dreams” Klobuchar to step up and say what they are for rather than what they are against. Buttigieg (who, perhaps coincidentally, but perhaps not, is now the largest recipient of Wall Street donations among the Democratic candidates) and Klobuchar apparently do not like Medicare-for-All—or maybe they like it but are willing to savage it because they think doing so exploits people’s dislike of taxes and thus enhances their personal political standing.

Buttigieg, after all, has claimed that he is all about “freedom” in allowing people to opt into a public health insurance plan, and he lectures Warren with condescending arguments that if she is right about Medicare-for-All’s many positives, she should be brave enough to think that Americans will see its virtues and not need to be forced to leave a private plan. (No matter that people are forced off private plans all the time. Buttigieg and others have no time for such inconvenient facts.) He has not, in other words, argued against Medicare-for-All on the merits, choosing instead to say that it might actually be great, but he simply lacks the nerve to back it.

What next? New York Times columnist Elisabeth Rosenthal, put it this way:

[N]ow all the candidates need to tell us more of those details about their health care strategies. It’s time for the candidates to stop talking slogans and start talking sense—or dollars and cents—so that voters can know what they mean and choose among them.

Medicare for All, Medicare for All Who Want It, a public option, improving the Affordable Care Act—those are 30,000-foot concepts that, depending on the details, could work (or not) and be popular (or not). …

Joe Biden, Kamala Harris, Pete Buttigieg, et al.: Does your public option—a government insurance policy that anyone may buy—resemble Mr. Sanders’s enhanced Medicare, or current Medicare or Medicaid, which is far more bare bones?

Voters need to know.

Yes, they do. But before they even get there, it is depressing to note that Vice President Joe Biden’s campaign has decided to adopt a full-on Republican attack strategy in going after Warren. His increasingly harsh criticisms (which will be all but impossible to reel back, if Warren ends up being the nominee) include having his campaign staff say things like this: “The mathematical gymnastics in this plan are all geared towards hiding a simple truth from voters: It’s impossible to pay for Medicare for all without middle-class tax increases.” (Biden’s people are wrong about that.)

This means that Biden has not even moved past the “but if it’s called a tax then it’s bad” school of political sophistry. But it is actually worse, because he has also attacked Warren on the basis that her now-released plan’s partial reliance on business taxes is actually a tax on workers, which is ridiculous for two reasons.

First, and most directly, Warren’s “tax on business” is not an increase in business costs but simply a redirecting of what businesses currently pay for their employees’ health care expenses. That is, if any employer pays $20,000 per year to provide health insurance for each of one thousand employees—and we should remember that those employees will nonetheless be paying plenty in addition to the employers’ share, to cover their part of all of the not-called-a-tax costs on which Warren has rightly focused—then under Warren’s plan that employer would spend the same twenty million dollars annually on a Medicare-for-All contribution.

There is thus no increased cost for the employer to pass along to her employees in the form of decreased wages. Biden, then, is actually saying that it is somehow worse for workers if their employer pays each of them $20,000 less per year because of something called a tax than if they receive $20,000 less per year because of bloated health insurance costs that do not even cover the full cost of medical care. Something that, under Biden’s own logic, would result in no change at all in actual wages and salaries is somehow a unique burden on workers.

Second, it is worth recalling that Biden offered a snarky comment in an earlier debate that contradicts his own reasoning (if one can call it that) in attacking Warren. The Guardian described it this way: “The former vice-president also challenged Sanders’ proposal to force employers to effectively pay out union members for any savings from a shift to a single-payer health system. ‘For a socialist, you’ve got a lot more confidence in corporate America than I do,’ he said.”

What was that about? The starting point, which is true, is that unions have done a very good job of getting better-than-average health insurance for their members. (That is one of the reasons that unions are so important to the future of workers’ wellbeing.) But Biden then says that somehow it is harmful to union members for the whole country to have comprehensive health care, because the unions “fought for” their great coverage, so why take it away from them?

One answer: Because they will not need it anymore when all Americans have what should be a basic human right, not as an accident of whether one is working in one of the few remaining unionized industries in the country. But the second answer, which is what Biden was mocking, is that businesses actually would face lower costs per worker under a single-payer plan, and they could then use those savings to reward their workers with higher pay.

To be clear, Biden is not necessarily wrong to argue that employers will try to keep their savings rather than sharing it with their workers. Indeed, this is what tax scholars refer to as the “incidence question.” When the government makes it unnecessary for an employer to continue to pay $20,000 (for health care or anything else), the question is who will benefit—workers, the employer, or both—just as we face the opposite question when we add a cost of any kind.

But the point is that Biden is absolutely sure that businesses will never give back the money they currently spend on unions’ negotiated health plans even as he is just as sure that those companies have shifted their health care costs onto workers. That is possible under extreme assumptions, I suppose, but such assumptions cannot possibly be consistent with a unionized industry in which workers and their union possess enough negotiating power actually to have won what they have won in the real world. If a union is powerful enough to get what are sometimes called Cadillac plans, why would it not be powerful enough to get at least a big chunk of that money in salary increases for its members when those plans become unnecessary?

The answer, again, is that Biden and the other so-called centrists are not engaging in good-faith arguments. He, Buttigieg, Klobuchar, and others could—as I argued recently on Dorf on Law—say something like this:

Republicans will—quite unfairly—use [the “but it’s taxes!” line] to attack [Warren] if she is the nominee, and sadly it might work. That’s why I think we should go with my plan instead, because I think we run the risk of scaring voters unnecessarily. But let’s stop with this “Will taxes go up or down?” nonsense right now. It is beneath us, and rather than acting like Republicans, we should be united in calling them on their dishonesty when they do it.

Now that Warren has actually released a plan that does not, in fact, raise taxes on the middle class, it is especially incumbent on other Democrats to forgo their own short-term political advantage and remember what they supposedly stand for.

At the very least, however, Biden and the two “winners” of the most recent presidential debate’s Snide Remark Contest need to be as clear and honest about what they are proposing as Elizabeth Warren has been. She is surely not right about everything, but her detractors have been very, very dishonest in the debate about how we should fix our broken health care system.

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