Obamacare Was Not Universal Health Insurance

When I wrote last week’s newsletter about Medicare for All, and seeking detente in the Democratic Party’s factional wars, I didn’t know the Searchlight Institute—a new, moderate-branded think tank—was about to release what authors David Bowen and Tré Easton describe as a “comprehensive plan to achieve universal health care.”

Searchlight proposes building on the foundation of the Affordable Care Act by fixing what Republicans have broken, then going further: more generous subsidies for private insurance; fewer obstacles to enrolling in Medicaid; then, over time, a public option that would bring Medicare Advantage plans (privately administered but federally powered) into marketplaces for people who don’t get affordable insurance through their employers.

Searchlight would also create a novel inducement to impel holdout states like Florida and Texas to expand their Medicaid programs: No augmented private-market subsidies for states that continue boycotting the expansion. But the way the provision is structured might actually limit the overall coverage expansion (why wouldn’t Republicans just say no to both?) and would be vulnerable to sabotage by an unreformed Supreme Court.

Even still, these reforms would bring coverage rates much higher than they’ll be at the end of Donald Trump’s term, possibly even higher than they were when the ACA was functioning at its best under Joe Biden. Their plan would improve public welfare significantly. Millions of Americans would be better off.

But would coverage be universal, as the authors describe it?

They use that phrasing, at least in part, to emphasize a conceptual distinction between multipayer systems that, in sum, cover every citizen, and plans that aim to pool all (or the overwhelming majority) of citizens into a single government-administered insurance program. Call the latter “Medicare for All.” The unspoken implication is that there’s a way to accomplish the goal of universality by sealing up all the cracks in the system that leave millions uninsured, without taking steps as radical as Medicare for All—which would either eliminate the private insurance industry, or shrink it dramatically.

This distinction is important to mainstream Democrats. If it is actionable in the real world, then the moral divide between the left and the center closes, and little is lost by embracing incremental reforms: We all support universal health care, we just have different ideas about how to achieve the goal.

The writer Jonathan Chait recently emphasized this point in an article called “You Don’t Need to Vote for Socialists to Get Universal Health Care.” In it, he asserts, “Nobody in the Democratic Party opposes universal coverage.”

Teeing off the same theme, Easton himself claimed that the plan I support—open up Medicare, and let it outcompete private health insurance—“isn't actually capitulating on Medicare for All. It's doubling down on a commitment to universal health care, which Democrats of every ideological stripe support.”

Are these claims true, though? Is there a way to make insurance coverage a basic, permanent fact of citizenship by incrementally reforming the current system rather than changing it radically? A lot hinges on the answer. If it’s “yes,” mainstream Democrats can protect the public from Republican sabotage without conceding much if anything to the left. We won’t, as I argued, “always be one election away from Republicans throwing 30 million people off their health plans.”

After covering national health care debates for about 20 years, though, I think the answer is no. Probably not on paper, and definitely not in our political reality, where all the different insurance systems comprise constituencies with different levels of political clout, and the right places bullseyes on the weakest.

The claim that Democrats of every stripe support universal health care is true abstractly but not programmatically. Many Democrats blanch at the steps that would be required to build o