Last week, at a huge and frightening retirement community in Florida known as The Villages, Donald Trump promised to protect seniors from two of the most menacing monsters lurking under their beds: Immigrants and socialism. You would think it might get boring, blaming everything on foreigners and commies, but its political utility is tried and true. Signing an executive order—which did not mention immigrants at all—before the assembled, Trump promised that he “will never allow these politicians to steal your health care and give it away to illegal aliens.” Democrats, he said, “want to raid Medicare to fund a thing called socialism.” Into this category he placed both single-payer health care alongside the “so-called public option.” Nevermind the fact that the latter policy bears as much relation to socialism as Trump does to a rose petal.
As hoary as the old-timey Red-baiting might seem, this executive order, and the rhetoric Trump deployed to promote it, is a distillation of his administration’s strategy to defeat the movement for single-payer. By pitting Americans against immigrants, and by telling seniors their Medicare would be under threat, Trump is banking on division and discord as a way to defeat a plan that would actually be beneficial for everyone except the very wealthiest. If Americans could realize the benefits of single-payer health care, and discover how different a life free from the worry of crippling health care debt could be, Republicans would not be able to persist in their promotion of the grim, race-to-the-bottom status quo. If this fight were fought on the merits and the facts, Trump would have no hope.
The executive order itself is a mish-mash of policy tweaks designed to further enhance the profitability of health care. Among the biggest winners are health insurers: The order instructs the Department of Health and Human Services to create rules promoting and expanding Medicare Advantage, the privatized part of Medicare under which insurers offer cheap plans that cover the benefits Medicare doesn’t. These ideas include encouraging “innovative [Medicare Advantage] benefit structures and plan designs”—“innovation” being the jollier term for privatization in the Trump era—and ensuring that the government doesn’t promote regular Medicare ahead of Medicare Advantage, which probably means directing the government to more fulsomely promote Medicare Advantage. The Trump administration already bumped up reimbursement for Medicare Advantage plans by 3.4 percent in 2018.
Hospitals and health care providers would also win big. The order directs HHS to study raising the prices paid by Medicare “to more closely reflect the prices paid for services in [Medicare Advantage] and the commercial insurance market,” which reimburses providers at a far higher rate than Medicare does. The goal is, according to the order, to “encourage more robust price competition, and otherwise to inject market pricing” into Medicare fees. It’s hardly worth noting the hypocrisy of a government that rails against the cost of socialized medicine proposing something that would cause government spending to skyrocket; this is the same bunch of crooks who pushed through a deficit-ballooning tax plan and claimed it would lower the deficit.
This particular proposal would be great for hospitals and other health care providers, who would stand to reap greater profits. It would be terrible for everyone else. Medicare premiums would have to rise to cover these costs. There is no sense to raising provider rates to reflect what private insurance pays, because those rates are stupidly inflated and, for that matter, deeply opaque: The public does not know what private insurance pays. (Last month, the Cleveland Clinic argued in a regulatory comment that it simply could not disclose all the prices it charges to insurers, because there are more than 210 million of them.) The market has not worked to constrain prices in the private market; it has sent them racing to unsustainable levels.
Currently, about a third of Medicare enrollees are on Medicare Advantage. Premiums are very low, or sometimes even nothing, and the plans cover things beyond Medicare’s purview, such as dental and vision care, along with fancier benefits like gym memberships. It’s appealing in part because of the rough state in which Medicare exists, with no cap on out-of-pocket costs and no coverage for certain important medical needs.
But Medicare Advantage is often only good until you have to use it: People who are sicker are more likely to leave Medicare Advantage plans than healthy people. The plans use networks to restrict which doctors patients can see: One Kaiser Family Foundation study found that on average, Medicare Advantage plans included just 51 percent of hospitals in their county, and a separate study found the networks included only 46 percent of doctors in a county. These plans also often have higher out-of-pocket costs. The average gross margin on Medicare Advantage plans is roughly double that of regular insurance, perhaps in part because the plans deny care that should be covered, and insurers overbill the government by billions each year.
Growing Medicare Advantage is terrible policy, but it would be a smart strategy in the effort to crush single-payer. It’s akin to the dynamic in the private market for younger Americans: People with nice insurance subsidized by their employer will naturally want to guard that privilege, misguided as they are about how good that privilege really is. By growing the population with these prized Medicare Advantage plans, it grows the number of people with a plan that would be ended by single-payer—thus growing the audience for attacks centered on scary socialists Taking Away Your Plan. And by repeatedly telling seniors, whether they have Medicare Advantage or not, that single-payer supporters want to destroy their health care, Trump aims to rally a reliable voting bloc against their own self-interest. It’s a cruel joke that seniors, one of the groups of people who would be most helped by Medicare for All, are already the least interested in the idea and seem to be a primary target for the lies of single-payer opponents.
Many of the most prominent of these opponents are Democrats. In July, Joe Biden claimed incoherently at an AARP forum that under Medicare for All, “Medicare goes away as you know it. All the Medicare you have is gone. It’s a new Medicare system.” A Joe Biden-linked polling firm was revealed last month to have tested messages opposing Medicare for All among Democrats, and found that one of the most effective attacks was claiming that it would lower the quality of care for senior citizens. And in February, Nancy Pelosi implied that Medicare under Medicare for All would be worse than the plans currently available under the Affordable Care Act, saying in a Rolling Stone interview:
When they say Medicare for All, people have to understand this: Medicare for All is not as good a benefit as the Affordable Care Act. It doesn’t have catastrophic [coverage] — you have to go buy it. It doesn’t have dental. It’s not as good as the plans that you can buy under the Affordable Care Act. So I say to them, come in with your ideas, but understand that we’re either gonna have to improve Medicare — for all, including seniors — or else people are not gonna get what they think they’re gonna get. And by the way, how’s it gonna be paid for?
Either Nancy Pelosi was desperately uninformed about what one of the most prominent bills her caucus had introduced actually contains, or she was cravenly lying. The same goes for Joe Biden. The fact is that Medicare for All would drastically improve Medicare for seniors, by eliminating almost all cost-sharing; by including free dental, hearing, and vision coverage; and by covering long-term care, which is currently only covered by Medicaid.
Whether these lies are told by Trump, the health care industry, or Democrats, the intent is the same: Lie to seniors about what will happen to their Medicare and pit their interests against the interests of everyone else. The absurd “keep your government hands off my Medicare” line that we’ve heard for at least 25 years takes on a new spin. It’s not just keeping the government’s hands off Medicare: It’s keeping your neighbors’ hands off it, too.
One of the groups that Trump believes the rest of America is most desperate to keep away from their Medicare are immigrants. Trump claimed that Democrats are proposing “draining your healthcare to finance the open borders,” and said Democrats “put foreign citizens who break our laws and endanger our country…way ahead of American citizens like you who obey our laws.” This is complete and utter dribble. How would raiding Medicare funding allow for open borders? Do open borders even cost anything? Wouldn’t it be cheaper, in fact, to disband the border patrol and open the border? But it’s a fool’s errand to try and ascertain meaning or assume any kind of linear, logical thinking from what Trump says. (Trump also suggested that the pharmaceutical companies might be behind the push to impeach him, in retaliation for his desire to lower drug prices.)
To be clear, immigrants pay far more into Medicare than they receive in benefits: A 2013 study published in Health Affairs found that immigrants “contributed $13.8 billion more to the [Hospital Insurance] Trust Fund than it paid out on their behalf,” largely because most of them are of working-age. The same is true for private health insurance, which is heavily subsidized by immigrant contributions. This discussion is all the more insane because undocumented immigrants are not even eligible for Medicare, Medicaid, or subsidies on the ACA marketplace. Even green card holders must live in the United States for five years before they are eligible for Medicare, regardless of age. (The law that put that last restriction in place was signed by Bill Clinton.)
As if to drive the point home, Trump followed up the Medicare order with another executive order on Friday night that will ban immigrants from obtaining visas unless they have health insurance or can prove they can afford care. It also effectively bans legal immigrants hoping to obtain visas from using the ACA subsidies that they otherwise qualify for, since those won’t count for the purposes of this rule. The order says the United States “admitting thousands of aliens who have not demonstrated any ability to pay for their healthcare costs,” contributes to the problem of uncompensated care. Immigrants already have to demonstrate that they won’t become a “public charge” while in the United States—meaning that they won’t use government funding for things like health care, a policy made even more onerous and cruel by the Stephen Miller-backed rule issued earlier this year. (When my husband sponsored my green card, he had to sign a form promising to pay the government back if I ever used a means-tested benefit, like Medicaid.)
This prospect of immigrants coming for your healthcare isn’t just one of the many whimsical notions lodged in Trump’s brain, like Graydon Carter’s relative standing in the New York media world. In fact, many Americans seem to believe that immigrants already get free care from the government. A Politifact article from earlier this year did the painstaking and futile work of debunking a Facebook post, shared over 14,000 times, that wondered why “seniors on Social Security have to pay for Medicare and a supplemental (insurance) and the illegals get it all for free?” Since most Democratic candidates indicated their plans would cover undocumented immigrants—who need and deserve free health care as much as anyone else—it’s plausible that this particular attack has taken on new significance, though it’s also true that Republicans have been saying this since long before that debate stage moment. Trump once said Democrats want to give every immigrant a car. At this point, it might not matter a lot what they’re actually proposing.
Trump’s intent is clear: Divide, blame, point fingers at any source of distress in the American health care system other than the profiteers who are actually at fault. In the most Trumpian way, it’s a combination of a sleazy sales pitch and the fundamental lies at the heart of American capitalism, telling people they must protect the jewels the market has given them when really all they have is Arby’s and an emptying strip mall. Medicare is not great, and Medicare Advantage is a scam, but they’re better than the nightmare landscape of the private market for people under 65, so threatening them with the false prospect of losing these treasures is effective. Throwing in some nativist harum-scarum adds the sleek veneer of “preserving the old way of life.”
“Divisive” is one of those words used so often in Washington that it has lost all meaning. But this is what opponents of Medicare for All, including both Trump and Biden, are doing: They are dividing Americans against each other to obscure our common interest in an equitable health care system. Despite the lies and fearmongering, almost every American would benefit immeasurably from Medicare for All. Their best bet for defeating it is in obscuring that fact. The cost is putting ordinary Americans at each others’ throats.