M4A and the Michigan primary

A cross-post from the Remedy

This is a cross-post from my new newsletter, the Remedy. Subscribe below to get future issues.

The Michigan Senate race

Perhaps more than in any other race right now, Medicare for All has become an issue in the Democratic primary in Michigan. There are three main Democratic candidates running. One, Haley Stevens, is considered the moderate candidate. The two more progressive candidates, Mallory McMorrow and Abdul El-Sayed, have been trying to differentiate themselves by fighting over some very niche health policy details. (Polling suggests that the race is between Stevens and McMorrow, with El-Sayed generally in third.)

McMorrow argues in favor of a public option, meaning allowing people who don’t currently qualify for Medicare to opt in to a Medicare plan. El-Sayed — who previously wrote a book on Medicare for All — is in favor of M4A. These two policies don’t seem that different — they both expand the number of people who are on Medicare. But in a close primary, the two candidates (and by proxy, centrist Democrats and progressives) have been accusing each other of being incremental and unrealistic, respectively.

Then, in January, El-Sayed went on a podcast and mentioned that he had heard concerns from union leaders that his Medicare for All plan wouldn’t allow them to keep the union-won health coverage that they enjoyed. In response, he said that his plan would allow them to keep non-Medicare coverage if they wanted. This meant that the difference between El-Sayed and McMorrow’s approaches narrowed — El-Sayed’s plan is essentially that you can opt-out of being solely covered by Medicare (through maintaining private plans), while McMorrow’s is opt-in.

M4A and the 2020 campaign

Much of the Democratic infighting triggered by El-Sayed vs. McMorrow has mirrored the infighting of the 2020 presidential campaign. Several of the primary candidates — most notably Senators Bernie Sanders and Elizabeth Warren — proposed some version of Medicare for All during that contest. Sanders has been supporting M4A for decades and regularly re-files his Medicare for All bill. Warren has shown interest in M4A as a policy but clearly ranks other legislative priorities first (two books, Edward-Isaac Dovere’s Battle for the Soul and Joshua Green’s The Rebels, argue that Warren’s priorities have been a wealth tax and other financial reforms).

In 2020, though, healthcare was a major issue and Warren’s team felt forced to release a plan for how they would financially account for the costs of M4A. Although the plan was detailed and included acknowledgment that Medicare for All would in part cover itself because of the gains from administrative simplification (a key part of the cost accounting, in my opinion), it fell into the trap that Warren unfortunately has fallen into when she runs for national office: it was way too complicated.¹

Centrists and progressives

Reflecting on the 2020 campaign and the Michigan senate primary, Stefanie Feldman, the national policy director for Joe Biden’s 2020 campaign, wrote a post for Majority Democrats’ newsletter urging Democrats to take healthcare seriously by proposing more incremental reforms, referring to Medicare for All as a pipe dream:

Even more importantly, voters prefer candidates who will deliver real improvements to their health care instead of a pipe dream. A pipe dream doesn’t pay your hospital bill, but your Obamacare plan does.

It’s worth noting that the public option seemed like a pipe dream just a few years ago — not to relitigate 2009 (I was a freshman in high school), but centrists cut the public option out of the Affordable Care Act. From the hindsight of 2026, Obamacare plans might be covering bills but they’re not doing much to bring down the cost of healthcare, which seems to me like the major issue going into the 2026 and 2028 elections. And as I mentioned in the announcement post for the Remedy, it seems that Democrats (and Republicans, for that matter) are lacking a plan beyond fighting over subsidies for Obamacare plans. That does nothing to change costs, and nothing to move the ball forward. (And meanwhile, Medicare Advantage is marching along, costing far more than traditional Medicare.)

Affordability and M4A

For this first newsletter interview, I posed some of these questions to Alex Jacquez. He is the Chief of Policy and Advocacy at Groundwork Collaborative, and a former Special Assistant to the President for Economic Development and Industrial Strategy at the White House National Economic Council during the Biden years. He was also previously a Senior Policy Advisor for Senator Bernie Sanders, so he has deep familiarity with M4A on both the policy and political sides. Here is our discussion:

Olivia Kosloff: I’m interested in the Michigan Senate race and the way that they’re talking about Medicare for All. Because I think what is interesting is that it doesn’t seem like they are necessarily fighting over whether or not Medicare is a good program anymore, but whether or not how much Medicare to give people, or whether it’s opt-in or opt out.

Do you agree with that, and is that something that you have seen shift over time in your interactions with democratic candidates?

Alex Jacquez: I think things have certainly shifted since 2017 — or pre-2017 — and Bernie Sanders really popularizing both the slogan and the policy of Medicare for All.

The branding relies on the fact that Medicare is universally popular. People are overwhelmingly satisfied with it. It is a beloved institution. People want to protect it. And the argument that Bernie makes is that we have this great insurance program that’s run by the government, we should extend it out to more people.

And I think it’s something that certainly the establishment Democrats and middle and centrist Democrats have, post-ACA [Affordable Care Act], taken a lot more interest in — using Medicare or Medicaid or some of the public programs to explicitly call for public options. There’s definitely more appetite in covering more people, if we look at the pie of people and who they’re covered by.

There’s more appetite I think from Democrats now in covering more of that pie in public programs than there was before. And really moving not just to the the elderly and the low income, but being available and an opportunity for young families and middle income people as well.

It’s certainly something I credit Bernie with. I think even some of his other pushes to expand Medicare, to cover dental/hearing/vision, to lower the age threshold, these are now things that have been picked up elsewhere. Getting more people onto those public plans is a fairly standard talking point now for Democrats.

And do you think of a public option as a viable halfway step, or do you think that people who are calling for a public option are treating it as like a terminal option — and under that framework, you’re against it?

I think it really matters what the details look like. And the reason why is something that was discussed in that 2017 to 2020 period, but I really feel like fell off — President Biden campaigned on a public option. And then we never heard about it again. It never got proposed. We never really had a debate about it. And so we really haven’t had this discussion about what the Democratic plan for healthcare would be.

And I think the important part to understand about a public option is that it could suffer from this unstable equilibrium problem where if you design it too weak, you just draw sick patients and people out of the risk pool who private insurers are, actually, more than happy to get rid of. It becomes a spiraling doom loop and the plan never gets the critical capacity and the diversity to be able to sustain itself on its own. So it either dies or you have to pump a ton of subsidies into it.

The other side: if you make the public option too good, then it draws people out of private insurance and creates those doom loops on the private insurance side too. So you have to design it almost perfectly to get the risk pools and the networks and everything to match up to make it almost perfectly comparable to private insurance.

But the promise of a public option is that you can cut out all that administrative bloat and deliver things for lower costs than the private insurance. So if it spurs competition amongst private insurers to get them to adopt administrative efficiencies and the rest, I think that would be a good outcome.

But I think the position that some people have taken, just saying, oh, well, we’ll have a strong public option, misses many of the details that would actually make it palatable. I mean, you could imagine a scenario where you have a very strong public option in which insurers are not able to compete, and you see the exit of private insurers, you see the constricting of networks, you see plans canceled, you see states, people pulling out of coverage areas, and generating much of the same kind of chaos in the private market that, a Medicare for All system would — essentially ending private insurance by being too good.

I think you’re the first person I’ve ever heard that from, because I would see that as a good thing [competing favorably with private insurers]. But the way that you’re framing it is almost like we would have to bail out UnitedHealth because the alternative — you are assuming, probably correctly, that the public option going really well wouldn’t necessarily mean the implementation of Medicare for All. It wouldn’t mean that we’re all hitting the button on Medicare for All because this public option experiment went really well.

It could, right? I think that the interesting thing is about framing. Critics of Medicare for All don’t want to move people off of their private insurance that they generally like to a public plan, which they might like more, but it’s still a forced choice. People really don’t like things being taken away from them. And the public option is presented as a choice — but if your insurer pulls out because it’s no longer competitive, then you’re not really faced with a choice, right? You are losing something and going onto the public option. I could see a scenario in which that kind of chaos happens and everybody really loves the public plan, and then it perpetuates until it eats up more and more of the pie. But I don’t think that’s what proponents are really envisioning when they talk about it like this.

Yeah, it’s a very interesting point.

Groundwork recently put out a report about the annoyance economy, and you gave an interview to Fortune and you called it a vibes-based analysis, which I really appreciate. So I’m asking you for a vibes-based analysis here. What do you think Democrats that are running in 2026 and 2028 should be thinking about when they’re thinking about what to do with Medicare?

My personal policy preference — look, it’s no surprise. I worked for Bernie Sanders, I believe deeply in Medicare for All. I think that, of course, he’s very right about the interests that are aligned against it. There is a lot of money out there to be made in the private insurance and private healthcare world. And there’s also a lot of public opinion that that can be weaponized against it around existing insurance and doctors and things like that.

This is maybe a cop out of your question, but I think we need to tackle the insurance question. First of all, there’s going to be millions of people thrown off their insurance because of the One Big Beautiful Bill. We need to figure out a system that works for them.

I don’t think the answer can be — 15 million people are kicked off Medicaid, when Democrats come in, we’re gonna put 15 million people back on Medicaid. I think we need to be thinking about a bigger system.

If I were giving ‘26, ‘28 candidates advice on what to do with Medicare and the system specifically, I would go less at expansion of insurance and more at reduction of cost. And so in the Medicare program, specifically Medicare Advantage, Democrats need to take a stand on Medicare Advantage. The fraud, the corruption, the administrative bloat, and the price increases that are affecting that program. [They need to] really take a stand against the corporatization of Medicare. I think that’s a really dangerous direction that Medicare is going in. Prescription drugs, certainly, both in the Medicare population and outside.

And I think we need to think about supply. I gave this talk at Democracy Journal. Groundwork will be putting out a paper on what we’re calling an American Health Service, where we massively scale up both the scope and number of community health centers.

We introduce a new hospital building program and massively increase our supply of physicians and nurses with a focus on primary care, in particular where we’re going to see massive shortages. And with the ability for those public sector entities to bring down costs in the system.

We’re going to hopefully not have the same kind of 2020 discussions about Medicare for All versus public option, and then end up doing neither of them when Democrats win. Hopefully we will have some discussion about insurance and what the right pathway is there.

But I’m hoping that we get some really focused attention on costs for people within the system right now. We’re seeing it creep up again and again. It’s a top three issue for people, how much their premiums are going up, how much their prescriptive drug prices are going up, how much their out of pocket costs and deductibles are going up.

And so I think taking those head on while we figure out the broader system is gonna be critical.

1. There’s a lot more to discuss here that I’m eliding for now — HHS is not currently structured to administer a comprehensive Medicare plan, voters lack confidence in government programs, and the polling is so complex as to be basically untrustworthy (voters love Medicare, they like Medicare for All, many like their current insurance and don’t want to lose it — although some polling suggests voters still love Medicare for All even when told that they might lose their current coverage — and they’re greatly worried about cost). All of these might be fruitful areas for future newsletters but too much for this one.