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Medicare for All Cometh

Senator Bernie Sanders of Vermont has introduced his much-touted Medicare-for-All bill with a good slate of cosponsors joining the effort. And it sets the opposition out to pick at the draft with calls of calamity.

There are those opposed on principle, but the most common criticism seems to have to do with cost, which is interesting in itself. Basically, if you aren’t opposed to the idea that everybody be covered, and be covered through a Medicare-style system, then all you have left is to say that we need to work out the details (or maintain, farcically, that no iteration can work).

Arguing that a Medicare system isn’t workable, period, doesn’t fly. Medicare itself is strong evidence that it is workable. Other countries have their own systems, too. Universal healthcare is entirely achievable.

Cost is the main target now. How to fund it, and are the benefits correct?

The benefits are possibly too generous, but not by a lot. They would be adjusted down in any serious negotiation to pass this bill. That would lower the costs, at least a little. But serious costs, the bulk, would remain.

To pay for this bill, or one like it, will require new revenues. Primarily, there will be new taxes imposed on some combination of employment and income. The tax increases will be offset by the reduction or elimination of individual and corporate costs for healthcare. There is a reasonable expectation that the tax burden will be less than the current burden of paying for healthcare, as there is widespread agreement that healthcare costs are artificially high.

People don’t want to pay taxes. That’s mostly a function of an anti-American narrative built by the right wing. ‘Taxation is theft,’ and other such nonsense. Taxation is debt. It is owed, not taken. Norquist doesn’t say to the restaurateur after his meal, ‘I want you to sign this pledge saying you’ll never adjust the cost of your food.’

More importantly, within the range of contemplatable taxes (i.e., up to the actual revenue needed to fund government), tax isn’t a problem. It’s a distortion in the minds of the wealthy that has led to such fear of taxes, even to the point where they are happy to overspend on a necessity like healthcare to avoid a lesser tax. That sort of distortion begs correction.

Given the inability of the Republican party to offer an alternative proposal that could even pretend to be universal, Medicare for All or some other system will happen. Taxes will be raised to pay for it. If the Republicans don’t like that, their only possible move is to formulate a state-level plan that ensures universal coverage. They will have to fight like hell, and with haste, to get it enacted in all 50 states before the Democrats have a chance to set up a national healthcare system. They will need to solve portability between states, too.

But they have run the clock out on not moving the nation to universal coverage.

Paths to Tax Reform

The Republicans have two basic options. They can go for expediency, raising the deficit in the short-term for tax cuts, avoid stepping on any toes, or they can go for real reform that involves dealing with blowback from special interests and being fiscally responsible.

It’s a hard choice. The early signal is they will go for the coward’s cut, since they are seeking to use reconciliation and not starting from a place of bipartisanship. It’s the route used under President George W. Bush, which is why his tax cuts expired.

But let’s say they want to go the responsible route, instead. How do you deal with the real estate lobby that will count the sitting president among its members? Or the carbon fuel lobbies that will want to keep their own favorite tax toys? Or pharma?

One way, maybe the easiest, is to reduce all of their loopholes equally. If they all get a haircut, it’s hard for any one of them to claim they were singled out. And the stock reply to their wailing becomes, “We did it across the board, fellas. Suck it up. Walk it off.”

Now, some of those groups may find pressure points to lean on, but if they are all pushing at once, it’s possible that they create a keystone arch of pressure, all pushing against each other, and leaving a pocket that allows the thing to pass. The weak point, they keystone, would be the president, who would probably cave on real estate treatment, and the arch would collapse.

Another option would be a sort of parametric tax code. Basically, you would formulate a point system based on size of business (gross revenue, number of employees, etc.) among other factors. Then the business can spread their points among various tax strategies as they see fit. Some might have more points in capital investment, while others might have more points in employee perquisites. But the overall deductible income would be minimized, and the tax code could be modified not only to strengthen or weaken the areas of deduction, but to increase or decrease the points available.


We really do need tax reform, and if the Republicans would take it seriously they could do a lot of good. Nobody expects them to set the rates high enough, but that’s the beauty of the tax code: the Democrats or future generations can always increase the rates to a responsible level. Right now, it’s more important to see the code simplified, even if it means the rates aren’t right.

Trade the Rich Their Taxes for Healthcare

Given the amount of control the wealthy have over the state and federal governments, this might be the best market-driven solution to healthcare. The basic outline is that the rich will pay less in taxes (limited to the portion paying for health-related services) as healthcare costs decrease and coverage levels increase. Since they care enough about taxes to make the Republican Party try to pass these bloodthirsty bills (AHCA and BCRA), we should let the rich take control over their own tax destiny.

Now, it’s a little more complicated than described, because there are more rich people in blue states that already make a bigger effort to increase coverage and decrease costs than many red states do. So the mechanism can’t be “if you live in a state that does better, you pay less tax.” That would also not work due to venue shopping, where the rich would just establish residency in states where they would pay less federal tax (some may already do this, if they can deduct state tax from federal and federal from state; but that depends on whether they can control which state their income comes from).

But the basic outline is there. And it could very well be bipartisan if the lever moves both ways. That is, if failure to diminish costs and increase coverage means they pay more tax, the Democrats might be able to deal with a bit of deregulation and help pass it.

Other sticking points would be that there would have to be a fairly rigid definition of coverage (something the Republicans seek to undo with their evil pair of bills), and there would have to be other broad strokes about existing conditions and bans on lifetime and annual maxima. But if the rich hate paying tax that much, they should be drooling at the chance.

Given we pay much more per capita and we don’t even have universal coverage, there should be a lot of cost savings available that the rich can tap to reduce their tax burden. They can buy all the hospitals and streamline them. They can focus on prevention and interventions for patients with high-cost conditions. They can buy the pharmaceutical companies and slash back the price hikes we’ve seen in recent years. Invest heavily in automation.

But one way or another, this country needs affordable care for everybody. If the rich want to get lower taxes in the bargain, I suggest that Congress lets them pull all of us up by their bootstraps.