I wrote this new piece for the Health Affairs Blog published on Feb. 21 2020.
Medicare For All: What History Can Teach Us About Its Chances
Too much time has been spent in this presidential campaign season arguing about Medicare for All. It is not because it’s a bad idea. It is because, for the foreseeable future, Medicare for All has zero political chance to become law. To begin understanding why, consider the 70-year history of legislative efforts in the US to advance toward universal coverage. And then consider the realities in the current US political environment.
Let’s start with a capsule political history of serious federal efforts in the US to achieve or advance universal health coverage. Exhibit 1 synthesizes our history since 1950 of full-on attempts to enact national legislation to advance toward universality.
Exhibit 1: Significant efforts to achieve or advance universal health care in US Source: Author’s analysis.
Exhibit 1 details six health coverage expansion efforts by five US presidents, indicating the year of decision, plus party control of the White House, Senate, and House of Representatives. I characterize each effort as comprehensive, meaning an attempt to achieve full universality in one bill, or incremental meaning advances for discrete and previously disenfranchised subpopulations. The final column shows the outcome of the effort.
Some may see omissions. Presidents Ronald Reagan and George W. Bush achieved important expansions in Medicare via laws covering catastrophic costs (enacted in 1988, repealed in 1989) and outpatient prescription drugs (enacted in 2003), respectively. Both efforts involved benefit increments, not insurance coverage expansions. Others may resist describing President Lyndon B. Johnson’s (LBJ’s) historic 1965 law creating Medicare and Medicaid as incremental; yet President Harry S. Truman’s 1950 failure to win comprehensive universal coverage led health advocates in that era to lower ambitions, targeting only senior citizens (LBJ’s win), and hoping future laws would go further. I include the 1997 enactment of the Children’s Health Insurance Program (CHIP) as an incremental gain.
Insights leap from this table. First, over 70 years, serious, full-on presidential and congressional campaigns to enact full or near-universal health coverage—with the exceptions of President Richard Nixon in 1974 and President Bill Clinton in 1997—were during periods of unified Democratic control of the White House, Senate, and House of Representatives (aka: the Trifecta). Furthermore, landmark coverage advances in 1965 and 2010 came from US Senates with 68 and 60 Democratic members, respectively, while losses in 1950, 1974, and 1994 occurred with 54-, 56-, and 57-seat Democratic majorities, respectively. Based on this small sample, it is not just having a Trifecta that matters; it’s having a super-majority Trifecta.
Second, since 1950, windows of opportunity to advance universal coverage occur rarely, measuring 15 years between Truman’s and LBJ’s efforts, 9 between LBJ’s and Nixon’s, 20 between Nixon’s and Clinton’s, and 16 between Clinton’s 1994 effort and Barack Obama’s.
Third, among these six efforts (no hint at statistical significance although 70 years is a good run), three comprehensive bills lost and three incremental bills passed. Except for the limited—and subject-to-appropriation—CHIP program in 1997, a substantial Democratic Trifecta was a precondition for success.
In modern US history, say the 40-year era between 1981 and 2020, how many of those 40 years were characterized by Trifectas of either major party? Exhibit 2 shows results.
Exhibit 2: Partisan control of White House, Senate, and House: 1981–2020
Source: Author’s analysis. * In 2001, Republicans had Trifecta control until Vermont Senator James Jeffords switched to Democrat in late May of that year.
Four of the past 40 years saw Democratic Trifectas in two fleeting periods, the first two years each of the Clinton and Obama administrations, both characterized by contentious and ambitious drives to advance universal coverage, comprehensive and incremental respectively. Both drives were factors in Democrats losing their majorities in the House and Senate in 1994 and in the House in 2010. One clear conclusion: Since 1980, Trifecta control comes and goes, and goes more easily than comes.
Now, let’s examine the same results for the New Deal era: 1933–80 (exhibit 3).
What a difference a political era makes! In contrast to the New Deal era, our modern neoliberal era, kicked off by President Ronald Reagan, is characterized by a decided preference for divided government. Since moments of Democratic Trifecta control have been so fleeting, that demands responsibility to be mindful and strategic when those opportunities arise.
Exhibit 3: Partisan control of White House, Senate, and House: 1933–80
Source: Author’s analysis.
University of California, Los Angeles political scientist Mark Peterson notes: “To explain in brief the problematic politics of (health) reform in the U.S., just enunciate four simple words: the United States Senate. It is likely to remain the biggest stumbling block in the years ahead.” Based on the 1994 and 2010 experiences, plus lack of public support for Medicare for All by any incumbent Republican Senate or House member today, expecting any GOP support in 2021 would be foolhardy.
What are the prospects for Democratic majority control of the US Senate in 2021—and for a supermajority with at least 60 Democratic votes needed to avoid death by filibuster? According to the non-partisan Cook Political Report and the University of Virginia’s Center for Politics’ “Crystal Ball,” If Democrats beat the odds and win a Senate majority, they will at best have a 1–2 votes majority. While impeachment and economic uncertainty could upend that balance, hopes for a Democratic supermajority are close to zero, and hopes for a slender Democratic majority are 50–50 at best.
If Republicans hold majority control in the US Senate in 2021, prospects for any substantive health coverage expansion legislation drop precipitously. If Democrats have a tremendously successful night on November 3, 2020, they will be lucky to hold 51 Senate seats. One key fact: Of the 23 Republican-held Senate seats up in 2020, only two are in states that Hillary Clinton won against Donald Trump, Colorado and Maine.
Going for the gold ring of Medicare for All with a slender Democratic majority may guarantee repeating the 1950 and 1994 experiences, squandering another rare moment of Trifecta control. Meanwhile, groups such as the Urban Institute and the Commonwealth Fund have crafted sophisticated and smart reform proposals to achieve near-universality short of Medicare for All. Many of their proposals could be enacted by Congress using the budget reconciliation process that only requires 51 votes for Senate passage. Plausible pathways to universal coverage exist without the “burning down the house” risks of Medicare for All.
Just about anyone I know who supports the public purpose behind Medicare for All (I’m one of them) also supports action on other urgent, compelling matters affecting the nation’s health and well-being, including climate change, immigration reform, voting rights, campaign finance reform, tax reform, education policy, infrastructure, gun policy, and so much more.
If Democrats can further advance toward near-universal coverage without the life-or-death struggles of Medicare for All, they just might achieve meaningful and historic progress even as they preserve political capital to make progress on other compelling and urgent policy needs. They might even figure out how to hold Trifecta control in Washington for more than two years.