Throughout this campaign, Joe Biden has not proved himself to have a particularly nuanced or accurate understanding of American healthcare. Earlier this year, he criticized Medicare for All by saying it would let employers “off the hook,” since they’re currently spending a lot of money on their employees’ health plans. “What happens then to this whole thing about profit?” he added, an incomprehensible question.
Yesterday, Biden demonstrated once again that he does not understand the left criticism of American healthcare. In an interview with CNN, the former vice president criticized Medicare for All proponents for wanting to “dismantle” the Affordable Care Act, saying: “The idea that you’re going to come along and take the most significant thing that happened — that any president has tried to do and that got done — and dismantle it makes no sense to me.” He also said that “starting over would be, I think, a sin.”
This is an asinine and entirely wrong interpretation of what Medicare for All is—and it’s a dogshit lie that’s pushed by the healthcare industry and other opponents of Medicare for All to try and scare voters away from single-payer.
To start, Biden said he is “opposed to any Republican who wants to dismantle it or any Democrat who wants to dismantle it.” This is an absurd false equivalence. Republicans want to dismantle the Affordable Care Act and replace it with nothing; Democrats who support Medicare for All want to replace the ACA with a much more comprehensive and equitable system.
Sanders’ Medicare for All bill, for example, has a four-year transition period, in which time certain people would be immediately covered, but no one loses their insurance. Things get immediately better, and continue getting better until the new system is fully in place. There would be no period in which neither the ACA nor Medicare for All would be in place, and the old, bad, Wild West of pre-ACA insurance, where insurers could deny you care based on preexisting conditions and sell you plans that didn’t cover essential services, would be revived.
So, the implication of saying Medicare for All supporters want to “dismantle” the ACA is that there would be some period of nothingness in between. Biden implies this because what voters who currently have access to healthcare fear more than anything is losing that access, which is why the Republican attempt to repeal the ACA failed, and why Republicans have had to work so hard to lie about their desire to get rid of protections for preexisting conditions. Biden implies this because he wants to scare people away from Medicare for All.
People were desperate to preserve the ACA not because it’s a wonderful system that works for everyone—it absolutely does not—but because it offered a few basic protections that didn’t exist before. It’s not that Medicare for All would destroy those protections; it would simply render them irrelevant. There would be no insurance companies to refuse to cover essential health benefits, or discriminate on the basis of preexisting conditions.
This strategy also underpins one popular political argument against Medicare for All and, often, in favor of a public option instead—the idea that voters who currently like their employer-sponsored insurance will be too afraid of losing that insurance to support Medicare for All. The anti-Medicare for All crowd loves to point to polling showing that people don’t support Medicare for All so much if it means they have to give up their private plan, but they don’t understand why that is. They don’t understand what, exactly, people fear so much about losing their insurance, which is losing access to care. This is why poll respondents do support Medicare for All if they’re told it would mean they could keep their doctor, which it would.
(They also don’t understand, or don’t admit, that the respondents in these polls are not healthcare wonks who are intimately familiar with what Medicare for All is, and are used to a system in which losing your insurance is literally life-threatening. If you ask a person who has only ever lived under a system where insurance determines your ability to access healthcare “Would you support this plan that would mean you’d lose your insurance,” yeah, they might say no—maybe because they simply can’t imagine a system where losing your insurance is no longer a possibility. Combatting this lack of information—and often outright misinformation—is the only way to win an equitable healthcare system.)
So, as Biden has apparently discovered, it’s very politically savvy to act like dismantling the ACA would happen first, separately, before Medicare for All was passed. Being honest about it would not be good politics.
It’s important to note that what Biden said yesterday is almost exactly what the healthcare industry is pushing, too. (I wonder why?) One of the key messages pushed by the Partnership for America’s Health Care Future, a coalition of insurers, drug companies, and hospitals, is that Democrats should commit to “build on what is working.” (Again, the current system is not working.) In March, the group noted the ninth anniversary of the ACA, and the millions who gained coverage since its passage, by saying:
That progress – and the opportunity to cover millions more by using the tools available to us under our current system – stands as a strong rebuke to those who advocate eliminating our entire health care system and starting from scratch with a one-size-fits-all government-run program, such as Medicare for All-style proposals that include so-called “buy-in” or a public option as stepping stones to a single-payer system.
Eliminating our healthcare system! Starting from scratch! Very very frightening! It’s notable that PAHCF even rejects Biden’s preferred option, a public option, as an unacceptable slippery slope to Medicare for All. A group representing insurers and hospitals, who make more money off privately-insured patients than government-insured patients, has no interest in expanding government coverage. But that little policy difference doesn’t mean Biden can’t pick up the industry’s messages for his presidential campaign.
In order to fight charges that Medicare for All is fixing something that isn’t broken, however, it’s also important to explain why the ACA is worth replacing wholesale. Biden, and PACHF, act as if the Affordable Care Act is the apotheosis of healthcare policies, one that can be tweaked and improved but couldn’t possibly be replaced with something better. But the ACA is built on a fundamentally rotten system; the fact that Medicare for All would replace this system is actually what makes it good.
The fundamental pillars of the ACA were regulating insurance, expanding Medicaid, and establishing the insurance exchanges and subsidies. The insurance regulations, like mandating coverage of preexisting conditions and essential health benefits, were good and vital, if you’re going to keep insurance. Expanding Medicaid was good, if limited, and would have been even better had it not been hobbled by the Supreme Court.
In his CNN interview, Biden responded to criticisms that non-single-payer plans are half-measures by saying, “I notice the measures in the Affordable Care Act work pretty well.” He noted that millions of people gained insurance after the ACA, which is true. It is certainly better that people have insurance, if we’re going to have insurance at all.
But as the People’s Policy Project has pointed out, those numbers don’t tell the whole story: 50 million people each year have a period without insurance. The ACA has done nothing to stop skyrocketing premiums, or deductibles that make insurance useless. And the insurance exchanges, the most innovative part of the ACA, are an extremely mixed bag; as we heard from readers last year, millions of people pay hundreds of dollars in premiums each month for plans with high deductibles that mean they can never use them.
Even the supposedly beloved employer-sponsored insurance is getting worse, with high-deductible plans on the rise. There’s nothing in the ACA that can stop this. And a public option wouldn’t necessarily lower premiums by much; in Washington state, the new public option will have premiums that are just five to ten percent lower. Do you think the healthcare system is so close to good that insurance just needs to get five to ten percent more affordable for everything to be fine?
This is all to say nothing of the fundamental problem with the healthcare system: That in America, access to healthcare is metered by how much money you have. That 30 million people still don’t have insurance at all. That people still die because they can’t afford the drugs they need.
Any system that is based on the preservation of private insurance will never be equitable. A system that maintains the basic structure of our healthcare system, even with a public option, keeps the horrific injustice of premiums and deductibles; it keeps fighting with an unaccountable private insurance company for coverage while you’re sick or dying, or your family member is sick or dying; it keeps the complicated, cruel system of income-based subsidies and means-testing.
There would be problems with single-payer, and the fight to ensure that the system becomes equitable and just would not end with the passage of the Medicare for All Act. But the idea that only a system built upon the rickety, cracked foundation of the ACA can bring us towards health justice is not just wrong, it is a lie. Joe Biden is lying to you. Don’t be fooled.