The Need for a Third-Way: Issues Surrounding Medicare-for-All

Runner-Up of The Politica's Research Essay Prize 2021

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INTRODUCTION

Contemporary progressivism in the United States can be briefly constituted via ardent support for a specific set of policy proposals. This “checklist” of issues not only conveys a progressive politician’s platform, but also serves as a litmus test for voters. If a politician is “off” on an issue or does not fully integrate his platform with the progressive standard, then voters will see that politician as unworthy of the progressive title, extraneous to the progressive movement, and most likely a center-left or moderate figure. As progressive commentator David Pakman noted,


“What was different, I think, [in the time of FDR, the New Deal, and progressive accomplishments] than the left now was that you didn’t have to be completely in line with a specific set of policies or ideas. And I worry that now there’s a little bit of the left maybe having this idea that if you’re not in line on all of these issues, whatever the checklist is, so to speak, you’re not really worthy of being a participant in what is clearly a leftward move.” [1]


However, these policies are simply one in infinite methods of reaching a specific standard or goal. A multitude of alternative policies exist to combat wealth inequality and poverty, yet every progressive in Congress must publicly support only a handful of the many existing policy options. Furthermore, it is difficult to see a viable path in Congress for the vast majority of left wing proposals (such as the Green New Deal, Medicare-for-all, and the fifteen-dollar federal minimum wage), as a variety of institutional veto points as well as path dependency have contributed to their present and future lack of success. In reality, these policy proposals are not the only way to achieve the outcomes progressives desire. What if progressives considered abandoning this checklist of policies in favor of “third way” alternatives – policies that achieve similar goals but via different political actors and methods? In this paper I look to convey the need for novel and robust discussion on alternative policy ideas. Moreover, while I am not able to construct an exhaustive list of every potential pivot legislators could make on every salient issue, I propose an alternative to the push for a Medicare-for-all: a Japanese style price control healthcare system.


WHY THE NEED FOR A THIRD WAY?

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A well-documented phenomenon critical to the foundation of this paper is the “double movement.” [2] Originally proposed by Karl Polanyi, the first double movement occurred during the industrial revolution. In response to a movement entailing the political and economic hegemony of marketization and industrialization, a subsequent movement rose in response to this widespread market commodification. This counter push laid the foundation for the modern welfare state, as a host of individuals demanded the state provide resources to counteract the ramifications of marketization. Mark Blyth further expanded on this double movement framework, arguing that the prior double movement was not a one-time occurrence, but, in fact, was a repeatable and identifiable part of an ever-changing ideological process. For example, Blyth points to the economic crises of the 1970s and the years following which “witnessed a counter double movement away from . . . embedded liberal ideas” [3] towards neoliberalism due not only to stagflation brought on by the economic crises, but also by the loss of confidence in Keynesian economic theory. While some criticize this punctuated equilibrium framework as potentially glorifying specific moments in time [4] while ignoring “the often cumulative consequences of incremental change between punctuating movements,” [5] Blyth’s model of institutional change is a widely accepted constructivist recounting of institutional evolution.


Blyth further expands upon his framework by emphasizing the foundational role new ideas have in underpinning institutional change. Like tools in a belt, ideas serve as the methods by which politicians can enact reform measures. Without a new set of ideas, politicians are forced to legislate via the same non-competing ideas as their political opposition. New ideas allow politicians to solve existing problems through novel methods and separate themselves from their political opposition. But new ideas themselves do not constitute a double movement, as it is the combination of new policy ideas and political opportunism in punctuated moments which creates a double movement and therefore, institutional change.


ISSUES WITH MODERN PROGRESSIVISM

Gage Skidmore


To understand the linkage between the double movement framework and progressivism, we must first examine the Democratic Party. Diverse in its ideological composition, the modern Democratic Party can be characterized as a group of elected officials with little to no cohesive policy preferences. Rather, elected Democrats traverse wide ideological bounds [6], with social democrats sharing the same tent as laissez faire conservatives. This is no surprise, however, as a wide array of beliefs in a two-party system created via a single-member district electoral system is quite commonplace. While this may be a relatively common occurrence, this party design essentially handicaps left wing policy proposals. The large ideological gap among elected Democrats, in comparison to Republicans, [7] leads directly to inefficacy in the legislative process. Dissention among party elites in adopting policy ideas [8] has, from a historical perspective, yielded little to no policy actualization. In fact, an example demonstrating the ramifications of ideological dissention has already been mentioned in this paper. Lack of cohesion among left-wing elected officials in the 1970s inadvertently contributed to the preeminence of supply-side economic theory. While Democrats were unable to unify around a cohesive industrial policy apparatus [8], Republicans, swayed by figures such as Arthur Laffer, had already adopted supply side economic theory and, subsequently, had synthesized legislation incorporating these new ideas. This does not mean that simple programmatic proposals, ideas that “specify cause-and-effect relationships and prescribe a precise course of policy action,” [8] are inherently superior to complex proposals. What it does, however, demonstrate is the potential political power of a unified party ready to collectively actualize new ideas.


I do not mean to suggest that progressives should abandon their core ideological beliefs in exchange for diluted or reduced reforms. Instead, I propose that progressives replace their policy proposals with alternative ideas that have the potential to prompt party unification. It is difficult to predict which exact policies will prompt this unification but taking into account the welfare state regime-type (Esping-Anderson 1990), the welfare production regime (Estevez Abez), and a host of other factors, it appears that the most efficacious approach would entail replacing the idea of Medicare-for-all with a more market-centric Japanese system.


ISSUES WITH MEDICARE-FOR-ALL

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To briefly summarize, the United States epitomizes a standard liberal model of welfare expenditure, with a particular emphasis on means-tested programs, work requirements, and a variety of caveats linked to an individual’s performance in the job market. Due to high levels of both stratification and commodification in comparison with other OECD countries [9], it is uncontroversial to describe the US as the most marketized OECD nation. As such, advances towards socialized medicine are repeatedly hindered by a variety of business interests. Furthermore, although many of these interests oppose programs such as Medicare-for-all in a self-preservative nature (fearing profit reduction), their overall concern may actually be valid. Only expanding social programs and hoping that they improve living standards, reduce wealth inequality, and aid marginalized groups without taking into account the broader economic implications is reductionist, and at worst, naïve. The social protection and skill profile [10], while not directly related to the type of healthcare system a country has, neatly maps OECD countries into groups based on two factors: 1) employment protection and 2) unemployment protection. From this graph, we can see a stark contrast between the United States and the Nordic countries (whom the model for Medicare-for-all is derived from). The U.S. and the Nordic countries sit on opposite ends of the model, clustered into their distinctive skill profiles: the skills which laborers develop due to the interplay between their country’s welfare apparatus and their economic system. While I will not go into excessive detail on the differences between each skill profile, the general point is that these economies operate in completely different economic spheres. The high levels of commodification and stratification in the U.S. contribute to a system where workers are incentivized to pursue general skills, while low levels of commodification and stratification in the Nordic countries to pursue a mix of industry-specific and firm-specific skills.

[10]


Advocates for Medicare-for-all ignore the deep roots of neoliberal economic policy in the U.S. Thus, the introduction of a Nordic-style healthcare program may not be conducive to the existing economic apparatus. There are also a host of issues with the program itself. In 2016, 81% of Medicare recipients had some version of supplemental insurance [11], so the solution to achieving adequate coverage is not simply expanding this program to cover the whole nation. Furthermore, although the Sanders plan does set provisions to help workers in the private health insurance industry who are dislocated by Medicare-for-all, these provisions expire after 5 years [12], potentially leaving more than 2 million Americans without immediate job prospects. [12]


CONCLUSION


As I mentioned earlier, a double movement is not just the creation of new ideas. Thousands of new policy proposals are generated from think tanks and organizations every day; yet, we rarely hear of bombshell new ideas which completely alter the political landscape. A broader movement must accompany these novel proposals. Rather than stick with a policy proposal which will mostly likely never come to fruition, it is necessary for progressives in the Democratic party to take the lead and embrace new, albeit uncomfortable, ideas. I see promise in replicating a health care program similar to the Japanese healthcare system, which incorporates a fee schedule, an individual mandate, and a public option. This program balances the robust capitalist model of production by servicing healthcare via either an employer or a government program while also providing assurances to access of high-quality services. It is a matter of another paper to fully analyze this framework in the context of the U.S. economic and political landscape, yet our current predicament is clear. Without drastic change in the Democratic party, we will unfortunately continue to witness stagnation in achieving progressive goals.

[1] Pakman, David. “David Pakman Explains the Problem with Medicare for All | Joe Rogan.” YouTube. YouTube, June 5, 2019.

https://www.youtube.com/watch?v=50WcUC0iO5w&t=66s.

[2] Polanyi, Karl. 2001. The great transformation: the political and economic origins of our time. Boston, MA: Beacon Press.


[3] Blyth, Mark. 2003. Great transformations: economic ideas and institutional change in the twentieth century. New York: Cambridge University Press.


[4] Kerr, Peter. “Saved from Extinction: Evolutionary Theorising, Politics and the State.” The British Journal of Politics and International Relations 4, no. 2 (June 2002): 330– 58. https://doi.org/10.1111/1467-856X.t01-1-00008.

[5] Hay, Colin. "Ideas, Interests and Institutions in the Comparative Political Economy of Great Transformations." Review of International Political Economy 11, no. 1 (2004): 204-26. Accessed March 26, 2021. http://www.jstor.org/stable/4177494.

[6] Bonica, Adam. "Mapping the Ideological Marketplace." American Journal of Political Science 58, no. 2 (2014): 367-86. Accessed March 26, 2021. http://www.jstor.org/stable/24363491.

[7] Grofman, Bernard, Samuel Merrill, Thomas L. Brunell, and William Koetzle. “The Potential

Electoral Disadvantages of a Catch-All Party: Ideological Variance among Republicans and Democrats in the 50 US States.” Party Politics 5, no. 2 (April 1999): 199– 210. https://doi.org/10.1177/1354068899005002004.


[8] Campbell, John L. "Institutional Analysis and the Role of Ideas in Political Economy." Theory and Society 27, no. 3 (1998): 377-409. Accessed March 26, 2021.

http://www.jstor.org/stable/657900.

[9] Esping-Andersen, Gosta. 1989. The Three Worlds of Welfare Capitalism. Oxford, England: Polity Press.


[10] Estevez‐Abe, Margarita, Torben Iversen, and David Soskice. “Social Protection and the Formation of Skills: A Reinterpretation of the Welfare State.” Varieties of Capitalism, 2001, 145–83. https://doi.org/10.1093/0199247757.003.0004.

[11] Damico, Anthony, Juliette Cubanski, Tricia Neuman, and Gretchen Jacobson. “Sources of Supplemental Coverage Among Medicare Beneficiaries in 2016.” KFF, December 5, 2018. https://www.kff.org/medicare/issue-brief/sources-of-supplemental-coverage-among medicare-beneficiaries-in-2016/.

[12] Neuman, Tricia, and Karen Pollitz. “What's The Role of Private Health Insurance Today and Under Medicare-for-All and Other Public Option Proposals?” KFF, July 29, 2019. https://www.kff.org/health-reform/issue-brief/whats-the-role-of-private-health-insurance-today-and-under-medicare-for-all-and-other-public-option-proposals/.


[13] “Facts + Statistics: Industry Overview.” III. Accessed March 26, 2021. https://www.iii.org/fact-statistic/facts-statistics-industry-overview.