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A few thoughts on Warren's M4A transition plan

First and foremost, you can't ban private health insurance using budget reconciliation. This means that, in order to do full single payer, you need to either a) get to 60 votes in the Senate that support M4A, or b) get 50 votes that support M4A AND support getting rid of the filibuster. Because of existing opposition to M4A and ending the filibuster among sitting Democratic senators, and because any seas we pick up in the Senate will be in purple or red states where the new senators are unlikely to support M4A or ending the filibuster, it's hard to envision a plausible way for us to ban private insurance after the 2020 elections.

This means that, under either a Warren or a Sanders administration, we would likely need to pick up additional seats before we can ban private insurance. The earliest opportunity to do that will be in 2022. The earliest that a Warren or Sanders administration could plausibly pass full M4A would be when those new senators are seated in 2023, i.e. the third year of their term.

So in practical terms, I don't see much of a difference in when they pass full M4A. The main difference between them is that Warren is proposing to lay the groundwork for M4A using budget reconciliation as soon as she takes office in 2021. That would lock in our gains and ensure that we make some progress. If we were to wait to pass something until after the 2022 midterms, we would run the risk of losing seats in the Senate rather than gaining them. That would put us right back where we started, with no Senate supermajority, no ability to pass single payer, and no healthcare reform at all.

That said, there are very real challenges implicit in Warren's plan. If we lay the groundwork for M4A in 2021 and then fail to gain a supermajority in 2022 (which is likely), then we would need to continue the M4A option for a long period of time. The public option would therefore be in competition with private sector plans, which it would need to outcompete. Auto-enrollment helps tremendously with this, but it's still a risky proposition. If the public option fails to compete with the private options on price, then the system could fall apart. This would still leave us with Medicare being expanded to everyone over age 50, but it's clearly not what we're hoping for. On the other hand, if the public option does outcompete the private ones, it would be the private ones that enter a death spiral, which would make banning them much easier politically.

Generally speaking, I would prefer to use a Medicare buy-in rather than a separate public option, because that would make it easier to keep the system stable during the transition. This is how Sanders envisions his transition period working, except that he would ban a steadily increasing percentage of the population from buying private insurance, which runs into the problems with the filibuster.

So overall, this doesn't change things as much as people think it does. The main difference between Warren and Sanders' plans is still that Sanders uses a sparsely detailed payroll tax and Medicare buy-in, and Warren uses a highly detailed employer fee for a new program. The main thing that's new is that Warren has a plan for passing it, whereas Sanders does not.

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