M4A is a good and just fight to have, but given the state of our democracy and the entrenchment of the current system, it'd be useful to sketch out a somewhat plausible long term plan of how to get from A to B beyond just yelling at a few politicians to hold doomed floor votes
Short term prospects for systematic health reform are looking extremely bad. Only marginal (though still impactful) changes seem likely to pass under the Biden admin. Obviously electing more left wing candidates, both at the top and down ticket, is key.
In the meantime M4A advocates should push policies that will make the eventual fight easier
• Build more publicly owned hospitals - private hospitals are a powerful and underrated lobbying forces against M4A, & expanding supply will also help address concerns around wait times
• Get more people on public insurance - status quo bias makes change hard, but the more people we get on public plans the easier the switch is. Medicare for Kids, Medicaid at 200% of the poverty line, federalizing Medicaid to close the Medicaid gap, strong public options...
On the latter point, it's important to remember that some public option proposals are really weak (like Biden's) but some can be quite strong. Taking the Americare approach of allowing employers to buy-in is a key difference, which could essentially nationalize employer insurance
• Take on big pharma - drug price negotiation is wildly popular and some moderate dems are blocking it. This is a winning wedge issue for the left, and would also make M4A easier by lowering headline cost.
• State level action - there are real challenges with doing things on the state level, but it's not impossible, that's how Canada's Medicare program started. Federal action on waivers is important, and states should be aggressive with gaming ACA subsidies
These policies will take big fights to pass, building up institutional muscle and countering cynicism that a better healthcare system isn't possible, all while reducing immediate material suffering and making full M4A more attainable

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More from @jdcmedlock

27 Jul
I think about this with regards to the ACA’s advance premium tax credit. It had a big welfare cliff at 400% of the poverty line, and if polling had been done on this it’s plausible it would have been more popular to exclude the richest despite it being sloppy policy
But I highly doubt that the exact phase out rate was an issue salient enough to move a singe vote. Most people were probably entirely unaware of the exact subsidy structure
On the other hand, it seems plausible to me that the implementation of this bad policy, where earning a tiny bit too much could result in having to pay back thousands at the end of the year, was enough to sour some people on the ACA. Very salient hassle for a concentrated group
Read 4 tweets
25 Jul
We’re reaching levels of online previously thought impossible
There’s a certain genre of nominally ‘leftist’ activist that has no constructive politics or vision for a better world, just all motivated by spite against whatever the establishment is at that moment, could have just as well been Ron Paul types if they saw a different YT video
I’m very much for a big tent left, but I do not think the jimmy dore types are actually interested in winning, in fact that would be counterproductive to their project
Read 4 tweets
16 Jul
What these takes always miss is that at what point people are financially stable enough to have kids is itself a policy variable that can be modified with things like the CTC
Rather than force the human lifecycle to conform to the way the market economy distributes income, we should conform the way we distribute income to the human lifecycle
Read 4 tweets
15 Jul
Pretty sure this is inaccurate, but I do wonder if the messaging should just be to talk about it as if it's permanent
The whole thing is so silly, because we don't actually save any money by pretending to only extend it through 2024, because we will just extend it later. "Too costly" doesn't make any sense, but I guess that's politics
Can you imagine if the original Medicare was a 4 year program that was just expected to be kept going via renewals every few years
Read 4 tweets
13 Jul
The idea here is that your labor market earnings are like a slab of butter slapped right at the center of your lifecycle (represented by the bread), but there are also times of your life you are a non-worker, like childhood, old age, and shocks like sickness, caregiving etc. 1/?
During those times, you earn no labor income, and so they’re represented by the dry parts of the bread. What the welfare state does is tax you with things like payroll taxes, which you pay most during peak earning years, and gives you that money back at times when you’re unable /
Read 9 tweets
12 Jul
If $3.5 trillion really is where they land, that is a big win, enough to not cut anything from the Families plan. A few weeks ago Manchin was talking about only doing $1-2 trillion
I have trouble seeing how they'll get above 2.5 trillion in pay-fors, so my guess is they'd go with a 15 year window or some sort of gimmick like that (which would be great)
Still think that Dems would be better off picking a few elements of the Families plan and doing them really well. The problem with the families plan was that most elements were underfunded to begin with
Read 4 tweets

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