My family recently got some ominous news from the non-profit my wife works for. The organization will no longer be providing health insurance to its employees; instead, it’s moving to an Individual Coverage Health Reimbursement Arrangement (ICHRA, fittingly pronounced ick-ra), in which you’re responsible for choosing your own insurance from the Affordable Care Act exchange, and your employer gives you some nominal amount of money to pay for part of it. In our case, their contribution won’t even cover a quarter of our premiums.
You’ve probably never heard of ICHRAs; I hadn’t, and I write about health care policy all the time. They were quietly created by the Trump administration in his first term, and have recently begun to take off; among other things they have given rise to a whole new collection of middlemen sucking money out of the system. The online explainers about ICHRAs say that they “empower employees with choice” and are “rising in popularity,” which means not that actual people like them, but that employers are rushing to them as a new way to minimize their responsibility for their employees’ health care.
Here’s a prediction: In the next couple of years, millions of people will probably be shunted into ICHRAs, and they aren’t going to like it much. And that’s only part of what’s coming. By the time we get to the 2028 presidential primary season, so many Americans will be so pissed off about health care that it will once again be a central issue in a presidential race. And the Democratic candidates will be tempted to make the same mistake they made in 2020.
It’s not just this new way that so many people will have to pay more for skimpier insurance. Starting next year, Medicaid “work requirements” will begin; when Republicans wrote them into law, they made sure to delay implementation until after the midterm elections. I’ve written at length about how work requirements are actually paperwork requirements whose purpose is not to promote work (the vast majority of Medicaid recipients who can work are already working) but to take health coverage from as many people as possible by forcing them to navigate a bureaucratic obstacle course and then punishing them when they slip up. Which is exactly what will happen; the Center on Budget and Policy Priorities estimates that 10 to 15 million Americans could lose their coverage when the paperwork requirements kick in.
As Norm Ornstein reminds us, when you throw that many people off Medicaid, it isn’t just bad for them; the effects ripple out through the system, reducing revenues for hospitals and doctors and nursing homes, threatening access to care for millions more. The effects are going to be particularly devastating in rural areas, where care is already difficult to access. And that’s on top of the millions who have already lost coverage because the Republicans eliminated enhanced subsidies in the ACA marketplace, while premiums keep rising for those who do have coverage.
Put all these developments together, and we’ll arrive at a political moment in the run-up to the 2028 election in which Democrats will face a challenge and an opportunity. And they can’t screw it up like they did last time.
The mistake Democrats must avoid making
In 2020, Democrats running for president had a grand debate about what dramatic overhaul of the health care system they should pursue. They were divided into two groups: the more progressive candidates (including Bernie Sanders and Elizabeth Warren) who wanted Medicare for All, and the more moderate candidates (including Joe Biden and Pete Buttigieg) who proposed something that preserved much of the private insurance system while expanding coverage to everyone.
Each one of them published a plan for how to go about achieving their goals, and because they were Democrats who wanted to show everyone they were serious about policy, and they were advised by serious health care policy wonks, the plans were sensible and detailed. This was a mistake.
Do you remember Biden’s plan? It was actually pretty good, from a wonk’s perspective; it involved the creation of a new public option program and auto-enrolling uninsured people in Medicaid. But you don’t remember it, not only because it was lost amid all the competing plans of that primary, but because once he took office he promptly tossed it in a file drawer and never spoke of it again.
The Democrats running for president in 2028 need to avoid getting dragged down into an endless debate about details that not only won’t be decided until any reform plan goes through the legislative meat-grinder, but will allow them to be consumed by the “But how will you pay for it???” question that only Democrats have to answer.
So what should they do instead? Simplify, simplify, simplify.
I mean that in both how they campaign and what they advocate. My preference is still for a system that resembles what they have in countries like Canada, France, and Australia: a public program that covers everyone, combined with private supplemental insurance that would allow people to pay for fancier coverage if they want it. But to be honest, at this point I don’t really care if a Democratic politician shares my ultimate goal on this issue.
That’s because “What is the system we hope one day to arrive at?” and “What should we advocate and pursue next?” are different questions. Even if you believe that Medicare for All is the best idea (and there are excellent reasons to believe that), it’s kind of like standing at the eastern edge of the Rockies and saying you want to go to Hawaii. Hawaii is lovely, but you’d better have a plan to get over the mountains and across the sea if you want to get there.
Which is why I’ve concluded that the best next step should be a Medicare buy-in. We’ve talked about a public option for health care for a long time, and we almost got it in the ACA (Joe Lieberman, may his name live in infamy forever, killed it almost single-handedly for no reason other than spite at the liberals who beat him in a 2006 primary). As I said, Biden had a public option plan — but it was complex and created a new program, which was a mistake.
Paul Krugman recently laid out an extremely persuasive case for why a Medicare buy-in is a winner both politically and substantively, and one of the most important aspects of this idea is its simplicity. Here’s a comprehensive explanation of the idea: Allow people to buy their insurance from Medicare. That’s it. No new program, no new agency, no reconfiguring and reimagining and reorganizing. Just let anyone get their coverage from Medicare if they want to.
That won’t immediately solve every problem in our convoluted health care system, but it will go a long way to making things better, and will move us a significant way toward a universal system. The more people we get off of parasitical private insurance and into the public system, the better off we’ll be and the closer we’ll get to where we want to go.
Perhaps the biggest political benefit of a Medicare buy-in is that it requires almost no explaining, because everyone knows what Medicare is, and almost everyone loves it. Which is why it would be extraordinarily difficult for Republicans to argue against.
Unlike something like the Green New Deal, they can’t take a new idea and work to demonize it; not only is Medicare spectacularly popular, Republicans themselves have spent years pretending they want to protect it. They can’t now argue that Medicare is awful and we shouldn’t let anyone else be a part of it.
Yes, they’ll try to fool seniors into thinking that having more people in Medicare will destroy the program, but that is self-evidently bogus, and Democrats shouldn’t be afraid of that argument. They need to set the terms of debate, in the simplest way possible. Then the next time they take power, they might actually be able to achieve what they advocated for.
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Less hospital use saves $. Medicaid for ALL kids regardless of income will save $ cuz if kids are sick (VS adults) & don't have a MD, parents take 'm to ER. If all kids had Medicaid, schools could post team costs (PT,OT,SP) to it saving local $ & serve elders in school clinics.
Feds can add to Medicare or Gov's can use Medicaid waivers to give homecare to all in place of NH's. W 1,290,000 Americans in NHs it would save $160,000/ person/ yr over NH costs + $ for less meds & less hosp for infections & drug-ind illness or potentially $206 billion per yr.
https://thomastashjian.substack.com/p/healthcare-costs-are-treatment-induced?utm_source=share&utm_medium=android&r=6yutzs
Mr. Waldman, you wrote that "everyone knows what Medicare is, and almost everyone loves it. Which is why it would be extraordinarily difficult for Republicans to argue against." I would beg to differ. republican politicians HATE Medicare and are planning to destroy it, starting next year, if they somehow manage to cling to power in Washington after the mid-terms. Mike Johnson has already told us that they're coming after Social Security, Medicare, and Medicaid. They aren't even hiding it. It's why our first order of business is not to roll out a new healthcare option: it is to elect Democrats up and down the board in the mid-terms. That's the only way to protect what's left of Medicare. And frankly, it's the only way to protect what's left of American democracy. Trump and his republican flying monkeys are rapidly destroying everything good about this country. If we don't stop them in November, we can forget about healthcare plans or anything else. We won't have a constitutional republic left if we allow republicans to remain in control .