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Paul Krugman
Biden’s Hidden Health Care Triumph
Opinion Columnist
A Republican member of Congress said something epically stupid the other day.
No, I’m not talking about Marjorie Taylor Greene’s warning about Nancy Pelosi’s “gazpacho police.” If you ask me, Greene was performing a public service; we all need some good laughs, especially given the demise of the borscht belt.
I’m talking, instead, about Representative Thomas Massie of Kentucky, who tweeted out a novel argument against universal health care: “Over 70% of Americans who died with Covid, died on Medicare, and some people want #MedicareForAll?”
To belabor a point that should be obvious, Medicare recipients have been especially vulnerable to Covid because they generally suffer from a serious pre-existing condition: advanced age.
Maybe Massie should have looked instead at Canada, which has single-payer health insurance for everyone — it’s even called Canadian Medicare. Canada, as it happens, has had only about a third as many Covid deaths per capita as we have. More generally, Canadians can expect, on average, to live almost four and a half years longer than Americans, even though health care spending per person is only about half as high as in the U.S.
In any case, whatever its intellectual merits, as a practical political matter Medicare for All isn’t coming to America any time soon. What’s actually at stake in the political arena are more incremental policy changes. Yet such changes can still have a huge effect on health care. And the partisan divide on health policy is as wide as ever.
Massie’s statistical gaffe was a reminder that Republicans still hate government programs that help Americans pay for health care. I wonder how many voters remember how close the Trump administration came to repealing the Affordable Care Act, a move that the Congressional Budget Office estimated would cause 32 million Americans to lose health insurance. That effort failed only because three Republican senators had the courage to stand up to Donald Trump.
Does anyone imagine that we’ll see a similar display of courage if a party that considers a violent attack on the Capitol “legitimate political discourse” regains control of Congress and the White House?
More immediately, if the G.O.P. regains control of either house of Congress this November, we’ll almost surely see some reversal of the major health care gains that have been taking place under President Biden.
Oh, you haven’t heard about those gains? I’m not surprised. Health care is one of the huge but hidden successes of Biden’s first year.
The story so far: Obamacare, which was enacted in 2010 but didn’t go fully into effect until 2014, was and is a bit of a Rube Goldberg device. Instead of simply paying Americans’ medical bills, it expanded Medicaid while using regulations and subsidies to encourage an expansion of private insurance. It fell far short of universally guaranteed coverage, but it nonetheless led to a large decline in the percentage of nonelderly Americans without health coverage.
Trump, as I said, tried but failed to undo this achievement. He did, however, preside over a gradual erosion of health coverage, probably reflecting a lower-profile strategy of sabotage on multiple fronts.
Despite this erosion, the core of the Affordable Care Act remained intact; in 2020 the AC.A. really proved its worth, helping (with an assist from emergency federal programs) to sustain health coverage despite huge job losses.
And the Biden administration has moved to strengthen the program. It increased outreach to potential enrollees, which Trump’s officials had drastically scaled back, while the American Rescue Plan substantially expanded subsidies for Americans buying insurance on health care exchanges. According to the National Health Insurance Survey, the percentage of nonelderly Americans without health insurance fell significantly between the fourth quarter of 2020 and the third quarter of 2021, bringing it almost back to its pre-Trump low.
The months ahead look set to be better still. Enrollment in the A.C.A.’s exchanges is limited to a few months a year, to deter people from waiting until they get sick to buy insurance. The enrollment season for 2022 coverage is just winding down now, and we’re seeing blockbuster numbers: More Americans are signing up for coverage than ever before.
We still won’t have the kind of universal health care guarantee that every other advanced nation has managed to provide its citizens, but we are getting closer.
Unfortunately, this progress faces huge political risks. The rescue plan provided only two years of enhanced subsidies; unless Democrats either pass an extension quickly or hold both houses of Congress, the subsidies will soon be gone. And if Republicans get unified control in 2024, they’ll surely send us back to the era when health insurance was available only to people who had either jobs providing good benefits or impeccable medical histories that made them attractive to private insurers.
So I hope people will remember what we almost lost in 2017 and understand that even if Republicans aren’t currently talking about it very much, health care is still very much on the ballot.
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