Nevada’s caucuses are giving us all a health-care lesson – The Washington Post

February 17, 2020

Assisting the instruction are two ironies: First, the politics of health care in Nevada pit Sen. Bernie Sanders (I-Vt.), tribune of democratic socialism, against the unionized working class. Second, it is Sanders — not labor, or the Democratic rivals, desperate for union support, who are trashing him in the name of pragmatism — who’s closer to the right policy answer.

Whatever the details of other modern industrial nations’ health insurance systems may be, they all offer coverage on more or less equal terms, regardless of employment status. This is because having a job or not has nothing to do with one’s risk of injury or illness, or that of one’s family.

In the United States, however, some 58 percent of the non-elderly population received employer-paid health care in 2017, subsidized via $280 billion in federal tax breaks.

This accident of American historical development creates insurance-related “job lock,” incentives for overconsumption, a health-care system geared to the needs of households with income exceeding $100,000 per year — 84 percent of which are covered through their employers — and a large minority of uninsured.

And it creates a corrosive beggar-thy-neighbor dynamic. Case in point: the tension in Nevada between Sanders and the big dog in Nevada Democratic politics — a 60,000-member casino and hotel union, the Culinary Workers. The union’s excellent health plan, attained through collective bargaining, would be erased if Sanders-style single-payer became law.

It does Sanders no good to protest that his zero co-pay, free dental, free vision, free everything plan beats even the most generous union deal. Indeed, it’s the only conceivable version of health insurance guaranteed to beat every existing one. So what if it bears little resemblance to insurance systems abroad upon which Sanders supposedly modeled it?

Union members, well aware that Sanders’s program would be hard to get through Congress, quite rationally hesitate to give up, even in theory, what they already have.

Nor do union executives relish a world in which the rank and file would no longer need them to bargain for health care. This is especially relevant in right-to-work Nevada, where union dues are truly voluntary and might be harder to collect if union services no longer included health-care bargaining.

It’s tempting to say this serves Sanders right, since it proves that the working class — or the 10 percent of it that belongs to unions — is as much of an obstacle to single-payer as the greedy insurance companies. Unions were even ambivalent about Obamacare, because its coverage expansions for the poor were to be partly financed by a very modest tax on the value of their (usually) more-generous health plans. Years of union lobbying, in de facto cooperation with insurance, fossil fuel and drug companies, as well as congressional Republicans, got that tax repealed last year.

If anyone should grasp the collective-action problems facing single-payer, it’s a senator from progressive Vermont, which failed to launch a statewide plan six years ago. Among other issues, Vermont’s beloved family-owned roadside “creemee” stands, which sell maple-syrup-infused soft-serve ice cream in the summer, might have been bankrupted by a new payroll tax.

Sanders tried to placate organized labor last year by modifying Medicare-for-all to let unions convert its savings into higher contract wages or extra health-care benefits, though it’s hard to imagine what those benefits might be, given how sweeping Sanders’s plan already is. Perhaps cosmetic surgery coverage, which Sanders previously ruled out.

Also hard to imagine is the wider political appeal of “Medicare-for-all-except-a-little-more-for-unions.”

Sanders would have been better off sticking to his guns. Yes, his plan is an unaffordable pipe dream; the overwhelming opposition it would trigger could undo his administration within its first 100 days.

His basic insight, though — health insurance should be decoupled from employment — is sound. Alas, for reasons of both political necessity and ideology, he is incapable of incorporating it into a financially plausible proposal.

The alternative is right there in front of him. The Culinary Workers plan is indeed a good one, similar in broad outline to Western European plans. Beneficiaries pay no premium, but give up some wages (equivalent to extra taxes in single-payer or other universal plans). In return, they get medical, dental, vision and prescription drug coverage — with costs controlled through co-pays and other rules.

So how about “Culinary Workers-Care-for-All?” The union couldn’t object to that, could it?

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