All federal programs are financed through a combination of taxes, fees and public debt. The details are worked out by relevant Congressional committees. With big legislative efforts, multiple committees in both chambers usually wrestle with the fine print. Multiple proposals are scored by the Congressional Budget Office, the House and Senate each settle on a bill, and then the two final bills are reconciled before a final vote.
Republicans tend to offer only hazy details–both about how their proposals would be financed and how they would impact the public. Tax cuts will always pay for themselves by unleashing a tide of private investment. They promised that repealing the Affordable Care Act and stripping coverage from millions of people would be offset by some unspecified future effort to replace it with something better. They get a bit of criticism for this at times, but it’s not the central focus of media coverage of their policy ideas.
The political press adopts a very different tone when it comes to progressive proposals. The lawmakers who offer them are relentlessly pressed to specify exactly how much they will cost and who will bear those costs. Those politicians are not running to be kings, but their proposals are parsed as if they would be enacted into law exactly as promised, without being altered in the legislative process.
It was in this environment that Sen. Elizabeth Warren chose to release a detailed proposal to pay for Medicare for All today. It’s the first comprehensive effort to detail precisely how such a program would be financed. As Ezra Klein argued, working out the specifics leaves her in a strong position to debate the issue with her more moderate rivals. But it also comes with a lot of risk. Releasing a proposal rather than laying out an aspirational “vision” sets off a new round of press coverage, and the central problem is that much of it shallow and some of it quite dishonest.
Some say it’s only fair to ask candidates how they’ll pay for big-ticket items on their agenda, and it would be if the mainstream coverage of these issues were thoughtful and balanced. It is not. The mainstream press have a status quo bias, and a bias toward perceived moderation. They tend to put more emphasis on the politics than the policy. Most of the people working in the industry would continue to be personally secure regardless of whether a big progressive idea lives or dies.
So the focus on costs always dwarfs any discussion of the benefits. The most prevalent point about Medicare for All in the mainstream discourse in 2019 has been whether private insurers will continue to have a role in the system, not what it means to achieve universal coverage or eliminate medical bankruptcies or be able to start a business or quit a crappy job or leave a bad relationship without worrying about losing insurance coverage. There’s almost no discussion about the potential stimulus effect of putting trillions of dollars back into the pockets of working people, who are more likely than the wealthy to spend it in our economy. It would be fair to ask candidates how they’ll pay for it if that led to a comprehensive discussion of the potential winners and losers, but that’s not something we were ever going to have.
Perhaps the most maddening piece of this is that the most-discussed aspect of Medicare for All by far is never going to happen. Democrats may win the White House and the Senate and hang onto the House. They may kill the filibuster. But if they end up with a Senate majority, it will include the likes of Joe Manchin, Jon Tester, Chris Coons, Krysten Sinema and other moderates. Other countries with national healthcare schemes maintain some role for private insurers–either offering supplemental plans or serving as heavily-regulated providers–and when the sausage is made, we almost certainly would as well.
Ultimately, Warren was damned if she did and damned if she didn’t. She could have remained vague, or played it like a Republican and promised that Medicare for All would pay for itself like high-end tax cuts–which has the virtue of being true when you consider overall spending on healthcare–but since it isn’t a conservative proposal, she would have continued to be dogged by the question of how the program would be financed for the duration of the race and subjected to fear-mongering with all sorts of dubious numbers.
She chose the other route, and in doing so she sparked another long round of coverage that’s stacked against big progressive ideas.
Disclosure: I personally support Warren’s candidacy.