I make a living teaching students how to construct arguments and analyze arguments made by others. I wrote a book about logic. I love this stuff. So when I see a New York Times opinion piece titled “This Is the Strongest Argument Against Medicare for All,” my ears perk up.
The author, Reason magazine features editor Peter Suderman, tells the story of Vermont’s brief flirtation with the possibility of passing a state-level program similar in certain respects to Bernie Sanders’s federal Medicare for All proposal. According to Suderman, the effort failed, and this “failure” shows “why any similar project undertaken at a national scale is unlikely to succeed as well.”
There are two central problems with the claim that Vermont “tried” and “failed” to implement a “single-payer” health insurance plan. The first is that the proposal being considered in Vermont wasn’t a single-payer plan. The second is that it was never tried.
A single-payer system is one in which, even if private plans exist to provide supplemental health care, only one entity is paying for basic care. A system in which private plans compete with a public one to pay for such care is by definition multi-payer — and any version of the health reform being considered in Vermont would have fallen into the latter category.
Vermont probably couldn’t legally get away with trying to interfere with interstate commerce by banning private health insurance companies from doing business in the state, and in any case, their state legislature was never going to try. The bill they did pass to “investigate” the possibility of single payer also established (as required by the Affordable Care Act) an exchange for Vermonters to buy into private plans.
This isn’t semantic hairsplitting. Some crucial advantages of single-payer systems rely on the state having a monopoly on basic health insurance.
Take cost control. Many doctors currently refuse to take Medicaid because it pays out at a lower rate than private plans. If Vermont’s proposed public plan, Green Mountain Care, had come into existence, either it would have faced the same problem, or lawmakers would have had to continue to jack up the payout rates in a budget-busting attempt to compete with private plans.
If Bernie’s plan to abolish private plans (at least for basic insurance) were implemented, on the other hand, doctors and hospitals would have to either close their doors or make do with the rate that Medicare was willing to pay. The last several decades of Canadian history strongly suggest that most of them would learn to make do.
One of the logical fallacies I teach students in my critical thinking classes is the “fallacy of equivocation,” which is committed by arguments like this one:
Premise One: Only men are rational.
Premise Two: Women are not men.
Conclusion: Women are not rational.
On a syntactic level, this looks like a valid argument. The problem, of course, is that “men” is being used to mean “humans” in the first premise and “male humans” in the second premise. Similarly, Suderman’s argument seems to be something like this:
Premise One: Former governor Peter Shumlin tried and failed to implement single payer in Vermont.
Premise Two: ???
Conclusion: A President Bernie Sanders would fail if he tried to implement single payer on a national scale.
As we’ve seen, “single payer” means something different in the first premise and in the conclusion. In the premise, it means “a multi-payer system with a public option” — i.e. the sort of thing that candidates like Joe Biden, Julian Castro, and Pete Buttigieg have proposed.
More importantly, though, Suderman’s argument relies on a second equivocation. Governor Shumlin didn’t try and fail to get the legislature to sign off on the creation of Green Mountain Care. Nor was there some initial implementation of the program that ended in disaster. What happened was, quite simply, that Governor Shumlin got cold feet.
Suderman tells us that Shumlin decided not to go ahead with the plan for Green Mountain Care because it would have involved unacceptably high tax rates. Bernie Sanders, on the other hand, has always been comfortable telling voters and journalists that his Medicare for All plan would involve a tax increase for middle-income taxpayers. He’s emphasized, however, that the combination of this modest increase with the abolition of premiums, co-pays, and deductibles would mean considerable overall savings for those same taxpayers.
It’s hard to imagine Bernie Sanders simply deciding not to push for Medicare for All legislation after being elected president. If this isn’t what Suderman means to suggest, however, his central premise is irrelevant to his conclusion.
On the other hand, if he wants to suggest that single payer would “fail” in any other sense, all his work is still ahead of him. No one denies that a hypothetical President Sanders who used every available bit of political capital to push for single payer, instead of Shumlin-ing out, would face a steep uphill climb to make it happen. (No one is more aware of this problem than Sanders himself, who has been talking for years about the need for a grassroots “political revolution” to make his political agenda a reality.) Once such a program were in place, though, an abundance of evidence from several countries around the world strongly suggests that it would succeed in every sense.
Suderman describes the inference he tries to draw from Shumlin’s cold feet as “the strongest argument against Mr. Sanders’s single-player plan.” As a defender of Sanders’s plan, I hope he’s right. If this is the best argument the other side has to offer, they’ve lost the debate.