Everyone is talking about the idea of Medicare for All (MFA) these days -- Democratic presidential candidates, the Congressional Progressive Caucus, and Republicans eager to scare people, since scaring people is pretty much their only strategy.
 
I have been an advocate of Medicare for All for more than 40 years, ever since I was in high school, when Teddy Kennedy and Jimmy Carter came to loggerheads over whether to push for it at the highest point of Democratic Party political power. Carter broke the party in half by refusing to work with Kennedy. Fast forward 30 years, after Kennedy’s death, and Nancy Pelosi narrowly salvaged the watered-down Obamacare bill, despite waffling Democratic support in the administration and Senate. The question in the coming years is whether the party can come together on health care and get something big passed if we sweep into power in the 2020 election.
 
I have a very up-close-and-personal view of the health care issue. In 1993, as a member of the Clinton White House, I was one of the first five staffers assigned to Hillary’s health care team. In 2008, I co-wrote the strategic plan for getting a health care reform bill passed for a new coalition called Health Care for America Now (HCAN), which played a central role in getting the Affordable Care Act passed. In 2017, I was part of the broad coalition working day to day for almost a year to stop the Republicans from repealing the ACA.
 
What I learned in all those battles is how difficult it is to enact big changes in health care policy in this country. Everyone takes the issue very personally; every single major interest group has a stake in the fight; and the health care industry itself is massive, complicated as hell, and enormously powerful. The ACA would never have passed, and repeal never would have failed in 2017, if Democrats had not succeeded at splitting the health care industry, getting parts of them to support our side and parts of them to agree to neutrality. That industry includes the American Medical Association (AMA) and various specialty doctor groups, the American Hospital Association (AHA) and various branches of the hospital industry, Big Pharma, chain drug stores, the insurance industry (including insurance agents, who are a surprisingly powerful constituency), and the medical device and equipment industry. The health care industry makes up almost 20% of the American economy, the biggest economic sector by far.
 
The problem with MFA is that it takes on almost the entire industry at the same time.  Not to mention, of course, the entire big money conservative apparatus: the Koch brothers network, the Chamber of Commerce, the National Restaurant Association, the National Federation of Independent Businesses, the Wall Street banks who have made heavy investments in insurance/pharma/for-profit hospitals, all the conservative think tanks and media outlets and grassroots operations. It would also likely be opposed even by some labor unions who have great health insurance plans that they have collectively bargained for over the years, and various big businesses that have their own plans they administer.
 
Some might argue that there are some doctors and  providers who are pro-MFA, and yes, there are at least a few. But the pro-MFA doctor groups are very small in comparison to the big institutional players, and have none of the DC clout that groups like the AMA, AHA, and Big Pharma do. Some will also argue that the popularity of MFA will carry the day. But when other side makes their arguments against it -- the big tax increase, the loss of your existing health plan, etc -- that popularity softens and erodes quickly. And yes, advocates can push back against those arguments, but when our side is being outspent more than 10-1, and the opposing message is being carried by credible spokespeople, it will be tough. No one should ever underestimate how tough.
 
That doesn’t mean that those of us who believe it is the most logical, humane, and cost effective health care system should give up advocating for it. Alexandria Ocasio-Cortez has already proven in her short time on the national stage that you can shift the debate on major issues like taxing the rich and a Green New Deal in a hurry. And progressive momentum continues to gather force in the Democratic Party and the country. But I also believe that those of us who advocate for MFA should be open to interim steps that would dramatically improve our current system and put much more pressure on the health care industry, such as a robust, well-subsidized public option, lowering the age eligibility of Medicare down to 50 years old, and aggressive cost controls on prescription drugs.
 
There’s one other really important point I want to make about about MFA:  just as it’s not easy to pass, it’s also not easy to define what it will look like when we do finally get it done. Think about just a few of the big decisions that will have to be made about the legislation: 

• how quickly it will be phased in
• what will be phased in first
• what combination of taxes will be raised to fund it
• do all businesses pay in at a proportional rate, or is small business subsidized
• what will be covered
• what and how tight will the cost controls be
• will Medicare Advantage still be allowed
• how do we make sure general practitioners are better rewarded, so that the specialty docs don’t make all the money
• will people with great plans they love be able to keep them, and if not, how long will it take them to be phased out
• will long-term care and special services for people with disabilities be included, and at what level
• will for-profit hospitals be eliminated
• will specialty hospitals like children’s hospitals get extra funding
• what special funding do we give for rural health care
• what happens to health research budgets
• do specialty health services like VA care and Indian Health Services get completely folded in or remain separate
• do people with bad health habits such as smoking have to pay more
• what happens to malpractice tort law under the new system?

 
Every single one of these individual policy decisions matters enormously to important constituencies. Like I said, health care is complicated. Just saying “pass Medicare For All” is not the end all, be all – there are still plenty of tough decisions that will have to be made.
 
Bottom line: I have no sympathy for the Michael Bloomberg and Howard Schultz types who just dismiss MFA as too expensive and who have no empathy for all the people being screwed by the insurance industry (that’s most Americans!). But there are lots of progressive politicians and organizations who have been working to improve our health care system for a long time who know how complicated both the policy and the politics of getting MFA passed are, and who don’t want to over promise, for good reason. There’s a wide range of views among genuinely progressive people about what the next steps are, and what policy decisions to make as we move toward a better health care system. Let’s work together to figure it out.