Death Panel Presents: Medicare for All Week 2021

M4AW2:06 – Nathan Tankus & Marshall Steinbaum on How to Pay for Medicare for All

Economists Nathan Tankus and Marshall Steinbaum join us to discuss the biggest red herring argument leveraged against the single payer movement: how are you going to pay for it? We discuss what this question distracts from, how the answer is actually quite simple, and the number of ways a single payer system would have profound macroeconomic benefits.

Nathan Tankus is Research Director at the Modern Money Network and the author of the publication Notes on the Crises.

Marshall Steinbaum is an Assistant Professor of Economics at the University of Utah and Senior Fellow at the Jain Family Institute.

This interview is part of Medicare for All Week 2021, our second annual limited series on building the movement for health justice. Every day from February 8-13 we'll be airing a new interview on single payer and the need for a national health system in America.

To support Death Panel and make series like Medicare for All Week possible, become a patron at patreon.com/deathpanelpod

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TRANSCRIPT: Nathan Tankus & Marshall Steinbaum on How to Pay for Medicare for All

(Medicare for All Week 2021) Air date: 13 February, 2021 — Transcript is slightly edited for clarity. [PDF — DOWNLOAD]

Beatrice Adler-Bolton  00:00

Welcome to Medicare for All Week. We're here today with two economists. Our first guest is Nathan Tankus. 

Nathan Tankus  00:05

Hi.

Beatrice Adler-Bolton  00:06

Nathan is the Research Director for the Modern Money Network and author of Notes on the Crises. And please welcome our second guest, Marshall Steinbaum.

Marshall Steinbaum  00:14

Hi, nice to be back.

Beatrice Adler-Bolton  00:15

Marshall is an Assistant Professor of Economics at the University of Utah and a Senior Fellow in higher education finance at the Jain Family Institute. Thank you both for coming today. We're really excited to have you both back on the show.

Marshall Steinbaum  00:26

Yeah, I got to thank Nathan actually, he's the one who told me about Death Panel in the first place.

Nathan Tankus  00:30

Yeah, it actually was when I told Marshall about Death Panel that I officially got granted my "economist" status, despite lack of credentials.

Philip Rocco  00:39

[Laughs] You got your wings?

Beatrice Adler-Bolton  00:41

Well, you know, we're all about mythmaking here on this show and, and building the grand illusion. 

Nathan Tankus  00:47

[Laughs].

Beatrice Adler-Bolton  00:47

But we've invited Nathan and Marshall here today to help us tackle part of the Medicare for All debate that has really taken on a life of its own to the point that I think we need to sit down today and set the record straight. And that's this, which is: what is the one thing that people always say about Medicare for All, what is the one question that people always have? It's "how do you pay for it?" 

Philip Rocco  00:48

[Laughs and sighs].

Beatrice Adler-Bolton  00:49

You hear this from all sides of the political spectrum, really: Medicare for All. Free health care? You know, it sounds awesome. It sounds like it would be really good. Maybe one day? You know, it just would be too damn expensive. And there are a lot of different answers to this question. Marshall, Nathan, how do you pay for it? 

Marshall Steinbaum  01:31

God, it sounds like we're back on stage in the Democratic Presidential Primary, bringing back traumatic memories. 

Nathan Tankus  01:31

[Laughs].

Beatrice Adler-Bolton  01:36

Right? Well, I mean, the real fact of the matter is, it's not actually a question that is really relevant. And that's kind of what we're gonna get into today. On one hand, people adamantly opposed to single payer have pay for arguments that they like to use, which they use as a reason to point to this policy as fiscally impossible. And Medicare for All advocates also have a set of arguments that they like to use, which we can get into. But ultimately, this isn't really representing a very accurate picture of what actually would be going on with Medicare for All.

Philip Rocco  02:07

So like, this debate is very fascinating to me. Because since I had become attentive to the issue of health care at all, the pay for debate has just been, like, around. And it's always striking to me because I teach policy analysis. And the stuff that I teach is always framed in terms of costs and benefits, right? And the really funny thing to me is the pay for debate just completely only talks about this policy—this really, really important policy that can save lives, in terms of a very narrow and like weird and baroque attempt to understand the cost accounting of this thing. Why is this pay for debate so—why is this the coin of the realm? Why do we have to worry about this so much?

Marshall Steinbaum  03:02

Well, it's because it's useful to the people who want to oppose Medicare for All. Like, so far, so far, they say the word "pay for" and the outcome of saying that word is the outcome that they want, which is that Medicare, for All does not happen. So they will continue to read from that script as long as it is successful at bringing about the outcome that they seek. And I think our job here is to at least make saying that, speaking from that script, not have the outcome that they want it to have.

Nathan Tankus  03:33

Yeah, exactly. The point of saying "how are you going to pay for it?" is saying "we shouldn't have that."  You know, when it's something that they want to happen, or that they're ambivalent to, but not actively hostile to, they're not going to bring up the how to pay for it question. This is, you know, the more basic point that if you propose a big increase in military spending no one's going to ask you how to pay for it. And there were some statistical work showing that actually, for the 2020 Democratic Primary, that that was the case. But more fundamentally, it's a question that is meant to end whatever policy you're talking about. And it's meant to be oppositional to big spending proposals. That's its purpose, its function is to invoke: you're going to pay more taxes, and you can't afford that, you're already, you know, living month to month, so they're going to upend your finances or make it so that you can't afford to go to the movies or whatever. 

Beatrice & Artie  03:40

[Both laugh]. Yeah.

Artie Vierkant  04:06

[Laughs].

Nathan Tankus  04:46

And that's the purpose of the conversation fundamentally, it's to kill any sort of proposal that you want to propose.

Marshall Steinbaum  04:57

Yeah. So one of the things that I think was a helpful addition to this somewhat tiresome debate that occurred in the Democratic Presidential Primary is the idea that our existing health insurance premiums are themselves private taxes that more or less everyone is required to pay. And the benefits that we get from paying those private taxes that affect to our employer for them to purchase a health insurance plan, supposedly, on our behalf. The benefits that we get are vastly unequally distributed. So if you think that everyone in the country, or most people in the country, are already forgoing a third of their paycheck to pay for health insurance, then the question of enacting Medicare for All is, in my view, a progressive restructuring of the American healthcare system, such that there's less of this, you know, "does my employer's plan, cover it, on what terms does my employer plan cover it?" But what doesn't get negotiated is the fact that a third of my paycheck is going to it. You know, that's a private tax. And so if we enact a Medicare for All program that's financed with a progressive tax where there's no question of eligibility or coverage, that just is a way of doing away with an exploitative private system and replacing it with a much more egalitarian public system.

Nathan Tankus  06:18

Yeah. And to jump off from there, I mean, what's remarkable to me, Marshall mentioned the interminable Democratic Primary for 2020. And what's remarkable is how many hours and hours and hours were devoted to that debate that didn't really get into the real issues at all in terms of the financing or the economic side. Because of course we had this long, long debate, and then we immediately increased healthcare spending by quite a lot without any quote unquote "pay fors," and immediately entered a depression where it would have been nice to reorganize our healthcare system on a much smarter basis, take the burden of those health care expenditures off of state and local governments—who would necessarily skimp on them, inadequately, causing death but also acting counterproductively in terms of what's best at the social level, even at the macro economic level. And at the same time as this argument was happening we have this monetary policy debate, this debate over interest rates. Mainstream commentators bemoaning how low interest rates were. And how if only we could get demand up in the economy, and thus have the space, quote unquote, to lower interest rates and stabilize the economy in the next recession. And so in this context, you have this huge program, Medicare for All, which isn't really about accelerating healthcare expenditures. It's about reallocating them. 

Philip Rocco  07:56

Right.

Nathan Tankus  07:56

And obviously we can get to this in terms of adequate health care justice spending, but even a lot of the most generous proposals, just by nature of how our healthcare expenditures have been growing, we're talking about not accelerating the rate of growth of healthcare expenditures, and even decelerating it over a longer term period. So really, all the action is on, as Marshall says, that private tax side.

Philip Rocco  08:20

Well, I want to talk about this in the context of like the doorstep conversation, okay? Because there are a lot of moves that happen in this debate, like, of course we all realize that the pay for question is grounded in bad faith, all right? 

Beatrice Adler-Bolton  08:32

Mhm. 

Artie Vierkant  08:32

Yeah.

Philip Rocco  08:32

We all acknowledge that, right? But then the question is, how do you deal with that? Because we've been talking about spending right now in terms of global national health expenditure, right? But the way that the pay for canard gets used, and the way that "it's too expensive" gets used, is the figure that gets talked about as the primary thing is the additions to this technical device we've created called the federal deficit, this accounting fiction we've created called the deficit. And the trade off with that gets invoked when people talk about 'how do you pay for it?" it's not how does somebody else remotely pay for it. The implication is that you, you know, person at the doorstep, taxpayer, will be paying more for something, and presumably not really experiencing any benefit, or if anything, maybe even experiencing more headaches, this sort of Harry and Louise fiction of the 90s. Which I think at least that part of it has maybe become a little bit less relevant because of the increasing salience of the hell of private, privatized insurance, but I do think that the invocation of the pay for thing primes this sort of taxpayer identity in people's heads, and this zero sum kind of thinking and trade off. And I wonder how, you know, both of you are economists, but you also have—you know, we have two members of the "high priesthood" here today. 

Beatrice Adler-Bolton  08:59

[Laughs].

Philip Rocco  10:10

But I wonder how you talk about that, or you reframe that for a public audience? Because both of you also happen to engage with public audiences pretty well.

Marshall Steinbaum  10:19

Yeah. I mean, my quick answer to that is that a lot of people don't realize that they're already paying a third of their salary towards their shitty health insurance. So, you know, what's your salary now? What's a third of that salary? That's how much you're already paying. And you have deductibles. And you'll have copays. And a great deal of health [care] actually is just off limits, because it's out of your network. So that would all go away. And then I think secondarily to that you can overtly make the claim that if we enact Medicare for All then your salary will go up because you will get that extra 30% that's currently going to your health insurance. I mean, this was kind of a contentious issue back in the primary because this question of who exactly pays for health insurance, and who is the incidence on is a subtle one, and the sort of ideological valence of that question differs depending on what policy question you're talking about. But I think in this context, it's absolutely defensible to say, if we enact Medicare for All, then 1.3 times your current salary is what your salary will be. I think one aspect of this is that sort of past trauma that was relived by the 2020 primary experience. I remember exactly where I was sitting when I listened to Barack Obama's address to Congress introducing the Affordable Care Act, or sort of kicking off the congressional debate on that. I was sitting in my kitchen when I was in graduate school in Chicago, listening to this on the radio. And I think, literally, the second line of the speech, or the second paragraph of the speech begins with, you know, "for the vast majority of you who currently have private health insurance that you like, nothing is going to change." And that was clearly an attempt to head off the rhetoric of Harry and Louise, as you're talking about, that this is going to kick people off their private health insurance. And most people when polled on the question of "do you like your insurance?" say "yes," because they accurately perceive that many people in this economy don't have insurance at all. And so, the question as they read it is "do you want your insurance, or do you want your employer to just kick you off?" They don't think, okay, well, if they kick me off, I'm gonna get a 30% raise. So, Obama comes out of the gate with "nothing's gonna change for you if you have private insurance," that's the majority of, at least, working people. And then gives another 50 minutes worth of a speech about his revolutionary new proposal. And he just told you that you don't have anything to gain from his revolutionary new proposal. So the obvious implication is okay, well, someone's going to be paying for it. This revolutionary new proposal that you've just spent 50 minutes talking about how great it was, you just said I wasn't going to get any benefit from it. I can bet that you're hiding the fact that I'm going to have to pay for it, and somebody else is going to get the benefit. So to my mind, that encapsulates the sort of political perversity of all of the debate over pay fors and keeping your private insurance, radically overinterpreting the polling that says people like it, because they perceive that, you know, it's tied to their job, and their job is precarious. And I think there's a whole other language by which we can discuss Medicare for All that explicitly explicitly denounces those things. So it brings them forward and then says explicitly you've been lied to, the reality is the following: you get a 30% raise and you probably won't have to pay for it because we're gonna pay for it using progressive taxes, which you won't have to pay because you're probably not earning that much money.

Nathan Tankus  13:48

Yeah, I mean, I like focusing on precisely this income point. You know, this big program we're talking about has this many components. It has: shrinking to nothing this insurance industry, which, you know, reduces income. We're talking about taking the administrators and the claims adjusters and all of them and saying, you know, this isn't a socially useful activity anymore. 

Philip Rocco  14:18

[Laughs].

Nathan Tankus  14:19

And so, you know, that's one component. Then we have reallocating a lot of that spending towards actual healthcare delivery, delivery of actual health care. But the main other adjustment side is that we have this elimination of your private taxes, the health insurance, the copays, the deductibles, and so on. And reframing the question as "how much can society quote unquote 'afford' for your income to go up?" So what we're really debating is not, you know, how much you're gonna have to pay for all this good stuff. And you know, "this is gonna make your life worse off" and not improve your "access to healthcare" at all. What we're talking about is whether your disposable income is going to go up 30%, or can it "only" go up 15%? Because that's really what the debate—you know, the real macro[economic] debate, once you get rid of the network talking heads and such, when you push orthodox economists to really take the issue more seriously, and connect it up to these arguments about monetary policy that have been going on for over a decade. The real debate is just, in a lot of ways, really the debate that we're having over stimulus checks and Biden's $1.9 trillion proposal and Larry Summers and so on, and Olivier Blanchard, them arguing that we can't afford to spend all this money because we're gonna "overheat the economy." That's really the debate we're having. You know, or should be having, over Medicare for All is: how much can we "afford" your income to go up all at once. And if we can't afford your income to go up that much, you know, it's only going to go up, say 5%, or 10%, rather than 30%, because we're gonna replace some but not all these private taxes with public taxes, or whatever. But that's really what it's about, you know. Flip this idea that either you're gonna, as Marshall says about the Obamacare period, you're either gonna get nothing, or you're gonna have to pay higher taxes for the nothing you're getting. And make it about not only are we improving your health care delivery, but we're totally eliminating these private taxes. And you might have to pay some fraction of these of these public taxes, or you might not have to pay anything at all! And that's really something I tried to push in 2019 a little bit, pushing more now, and [what's] sort of becoming a conversation this week is this idea that spending a lot more than you need to get the economy back to full employment is exactly what orthodox economists should be pushing if they're really interested in, say, raising interest rates to get off the zero lower bound. To explain that a little more, we have this whole other side debate that we have the central bank, the Federal Reserve is the only one that's supposed to be responsible for generating full employment. But it can't because it can't lower interest rates anymore once interest rates are around zero. Well, the obvious solution to that which, you know, it's too obvious for anyone to say is, for fiscal policy, is for the government to spend enough money until the Federal Reserve actually has to start raising interest rates rather than lowering [them] because we're in a recession. But these conversations never connect up. And it's by keeping these conversations separate and preserving the cognitive dissonance that the conversation is kept impoverished. And then we have this fear that you're gonna have to actually pay more for this worse healthcare, rather than, we're actually talking about how much of a salary increase can you afford to get?

Marshall Steinbaum  18:13

Yeah, I mean I would say that when I try to enunciate the claim about current health insurance premiums being a private tax, and so enacting Medicare for All means that your income will go up by 30%, the reason to articulate that claim—aside from the fact that it's a true statement about a counterfactual in the economy—is that, that makes them saying the words "pay for" create an outcome that they don't want. Which is that: Medicare for All actually is good, not just because it is a good program, but also because talking about paying for it is talking about making people's incomes go up. [To] change the conversation is to un-poison the "pay for" claim to make it something that Medicare for All proponents would want to talk about as much as possible.

Beatrice Adler-Bolton  19:02

Well, I think there's this other component in play, too, which is that a lot of these framings, where we say that that Medicare for All is "too expensive" to be feasible, are also setting up this dichotomy between people who need health care and need resources allocated to them, and the people who consider themselves to be the sort of hegemonic taxpayer. Which is usually like a white, you know, full time employed homeowner of some kind. And I think this is part of this larger framing that we see often within the structures of a lot of different benefits systems, which is the sort of pitting of the needs of the quote unquote "workforce" against the needy and the vulnerable and those in need of care. And I think ultimately, the pay for argument is reflective of this resistance to renegotiating the value of health. Because ultimately, what Medicare for All does beyond just switching up the payers, Medicare for All also tries to reallocate resources according to need, not according to means. And I think a lot of the pay for argument actually boils down to this sort of weaponizing of the archetype of the "taxpayer" against the person on the dole.

Marshall Steinbaum  20:21

Well, I think there's definitely some of that at play. My own assessment of sort of the intellectual history of this is that that kind of dichotomy where the attempt of the rhetoric is essentially cream skim in the healthcare industry, or in the health insurance market, where you're trying to speak to the people who don't have many healthcare needs and saying, look, "under our proposal, you'll pay less and you won't have to support those, you know, downtrodden people who are very expensive, that's not your responsibility." My feeling is that the politics of that is not as potent as the people who want to have a shitty healthcare system want it to be because I think most people do, in fact, want very good health insurance that they just don't have to worry about, and the mechanisms of enacting a healthcare system that has a lot of cream skimming in it involves a lot of details that people don't want. So I think back to the politics of that RAND study from the 80s about how we should move to HMOs. You know, because people with overgenerous health insurance, or hypochondriacs or whatever, get too much care. Like that's really—

Philip Rocco  21:38

Those mythical hypochondriacs. [Laughs].

Marshall Steinbaum  21:41

Yeah. [Laughs]. You know, I mean, it's had a profound effect on the way health insurance works in this country. But I just think that it was really a profound misconception.  And I guess the way I hear what you're saying is like, you know, it's a problem to overcome the fact that some people just need a lot more care and a lot more expensive care than others. And we have to create a more solidaristic politics around that. I don't perceive that as being that big of a problem, to be totally honest with you. I mean yes, there's definitely asshole libertarians living in Silicon Valley who see the world that way. I don't think that that dichotomy of like, "the taxpayer versus the sponge" really is all that motivating in health care politics. You know, all of that foreordains the opposition to Medicare for All as coming from quote unquote "the people '' of one kind or another. And I just don't think that's the salient problem. What we're talking about is the rhetoric that elites use to try to prevent the political system from reflecting what it is that the people want, and what would be in their interest. 

Beatrice Adler-Bolton  21:52

Yeah. 

Philip Rocco  22:14

Yeah.

Artie Vierkant  22:46

Well, I can tell you exactly one place where it does exist. And that is in, and I think that this is in part because actually of the predominance with which the pay for question becomes a conversation not only as sort of an argument against Medicare for All, but it becomes part of the conversation in for instance even certain "progressive" circles. One of the reasons we're having this conversation in the first place, I think, is that one of the most frustrating quote unquote "progressive" or left counterarguments to the pay for question [is] "oh, well, actually it would be cheaper." Right? And there's study after study after study that look at the economic foundations of Medicare for All and they say, "oh well actually we calculated these line items, etc., and it's cheaper. And while that may be effective, in some sense, and that can certainly be a very good, quick, you know, cudgel, as as a rejoinder against someone bringing that invective to you, right? For one, one thing that we do know is that there is so much care that is not given or administered or sought in the United States that would be sought if people were able to actually go and see the fucking doctor. And that fundamental reallocation of resources and that redistribution of resources to the people who do need it, but who have their lives shortened by not getting it, often, as we've talked about in other things in this series, and on our show quite a lot. There's that that is not accounted for. And also sometimes, as in the recent CBO report that came out at the end of 2020 on how to finance five theoretical Medicare for All programs that the CBO decided to come up with, you can get the "oh it's actually cheaper" progressive headline or whatever on your lefty news site. But then, when you actually look at it, the cheaper option that the CBO put forward exclude things like long term care, which are things that especially people who are excluded from the workforce need. Right? The thing is that it was a huge victory for the fact that both the Jayapal and Sanders Medicare for All bills in 2019 included long term care. And part of that was because there was argument and derision among like inter-"progressive" factions, basically, as to whether long term care, which is a gigantic component of the healthcare system, should be included. You know, this is one of the reasons why I think it's so important to get past that pay for question, because even when we look at "how much is the national health expenditure" right now, when we think about how poorly resources are allocated in a situation where the administration of health care is run by market competition, essentially, even the picture that we have in the United States of what is present there is not accurate or adequate.

Marshall Steinbaum  25:56

Well, I agree with part of what you just said. I would disagree with the claim that the current administration of healthcare is run by market competition—

Artie Vierkant  26:03

You know I edit this podcast, right? [Laughs].

Marshall Steinbaum  26:05

[Laughs]. Well, but I think that gets to a larger issue that has tripped up the left, that I hope we can make at least some progress towards resolving here, which is that the existing American healthcare system is a complete fucking disaster. And that arises both because we spend too little in the sense that, you know, many people don't have access to health care that they actually need, and society would benefit and they would benefit from having access to, and also way too expensive, because any piece of healthcare that anyone does have access to is way, way overpriced. And, you know, a gazillion different people are skimming off the top. 

Beatrice Adler-Bolton  26:38

Nathan, I'd love to hear your take on this as well.

Nathan Tankus  26:42

Yeah. So obviously, from the point of view of someone coming from Modern Money Network, I think, like a lot of issues, I definitely do think that healthcare is infused with taxpayer money myth discussions. My experience of the health care debate, you know—obviously it was most present during the Obama era, because the Obama era was the biggest sort of [moment of] "moochers versus taxpayers" framing in that we weren't radically reforming the health care system as a whole, we were just patching it up. Our main thing was subsidies. So if you were above a certain income threshold, then nothing was changing for your health care needs. But if you didn't have access to your health care through your employer, and your income was low enough, you're going to get a big subsidy so that you can go on a private market exchange or a state market exchange to buy healthcare. Then that heightens the contradictions the most in terms of framing we have this "undeserving moocher" group, quote unquote, versus the "deserving taxpayer" who's going to have to shell out. But first of all, I think a lot of people are carrying that logic with them into the Medicare for All conversation.  If you're watching network television and you remember, even vaguely, the Obama era health care conversations, then it's very easy to just bring that same mindset that you had from that era. Which was the very heightened "taxpayer money" identity and taxpayer money debate into this conversation, which superficially can feel the same. It took a while to really get to the "health care premiums are private taxes, and we're talking about eliminating those" level and having Bernie, who finally sort of sharpened that way of explaining the private taxes point so that, in his framing, in his bill, you'll still be paying significant public taxes but there'll be lower than the private taxes that you were paying. So I agree with Marshall that when you use the private taxes framing that can be somewhat disruptive to how the pay for conversation goes, and you can peel off people who are otherwise turned into, you know, anti health care reform people by their quote unquote "pocketbook concerns." But at least my memory, my experience of that debate is then in the public conversation, in the network television and cable news television conversations, you know, it was many, many, many months of interminable Medicare for All debates before we got to that point in the primary. And by that point there were a lot of other things going on. So that I would put as one piece of it. The second piece of it is the pay for question. This question of, fundamentally a question of fiscal policy, is a question of macroeconomics. But macroeconomics was never really a part of these conversations. Even the private taxes point only slowly starts to get us a little bit to macroeconomics. And you know, we have these conversations, which are just about these nice, as Phil said, cost accounting. Where we've got: we want to make this book balanced, and we've got, you know, some taxes over here, we've got some public expenditures over here, and we're gonna make everything balanced. And it doesn't really have much to do with how we manage the macroeconomy or what the macroeconomy needs. And so, from my point of view—for myself and my colleagues at the Modern Money Network—part of where we feel it's powerful to shift the conversation about Medicare for All is making it a macroeconomic conversation. Is asking questions about, okay, we're talking about eliminating these private taxes and spending the same amount, or similar amounts of money? What is that going to do to the economy? And are some of these outcomes desirable? Are some of these outcomes undesirable? What do we have to do to avoid these undesirable outcomes? And once you get into that conversation, then the pay for conversation shifts. It doesn't become this baroque, well, we've got one $1 expenditure, we need $1 of tax revenue. It becomes a question about balancing the economy of how close we are to full employment, of what actual social resources in the sense of labor, land, machinery, and so on we need to move around to produce what we want to produce. And so it becomes this conversation about macroeconomics. And then when you have that conversation, we're in a very different world. And of course for the last year or so we've been in the pandemic depression. And, you know, employment has collapsed. So now we're in a very different conversation macroeconomically. But the Medicare for All pay for debate stays the same. Because it's just this, you know, "dollar of tax revenue versus dollar of spending," rather than what we want to do to the economy. And when you look at it from what we want to do the economy, things look very, very different. 

Beatrice & Artie  28:09

[Both] Yeah. 

Beatrice Adler-Bolton  32:19

Right. I mean, one of the things that I like to push back when people say that it's about 'controlling costs" and that Medicare for All is really an argument about making things more efficient—and usually that's coupled with very correct points about, well, people can't see their PCP, we've got bad spending because people are forced to overly rely on emergency care, etc. It's really not—Medicare for All is really not about that, actually, Medicare for All is about changing systems of value and systems of resource allocation for the reproduction of health. 

Philip Rocco  32:56

Yeah.

Beatrice Adler-Bolton  32:56

Because as it stands right now, in the United States, health is pretty uniquely coupled with employment in a way that is very different from a lot of other countries. And I think what you see in all these other ways that health interacts with our systems of employment and our systems of allocating resources, it's all about this "certification for work." Disability certification is a good example. When you're being certified as disabled, it is in one part a medical certification, but more so it's actually a certification as to whether or not you can be retrained for work. And so we basically gatekeep access to care through participation in the workforce. And what I think the argument really needs to shift to is not necessarily how much it's going to cost total. But how much do we need to spend to allocate care to everyone who needs it? Because what we are ultimately doing is changing the way we choose to allocate access to health. 

Marshall Steinbaum  34:00

Yeah, I mean, I profoundly agree with that. And I think that's an important way of framing the discussion here. Because, you know, we have basically made the political economy choice to link access to the health care system to either supply market labor or running through the hoops. 

Beatrice Adler-Bolton  34:15

Totally.

Marshall Steinbaum  34:15

I mean, I suppose what you're referring to is the idea of getting certified as disabled, meaning that you don't have to supply market labor in order to get care. But that's a very high bar to clear in our fucked up system and—

Artie Vierkant  34:30

Well and, just really quickly, to interject. And to get on SSDI Medicare, as opposed to SSI disability, you have to have previously logged a certain amount of work hours. 

Beatrice Adler-Bolton  34:42

Mhm. 

Marshall Steinbaum  34:43

Okay, so it's like social security in the sense of like, you accrue credit that enables you to then become an "official" disabled person—

Beatrice Adler-Bolton  34:49

Exactly.

Marshall Steinbaum  34:49

—and that gives you access to Medicare, as opposed to getting to the age of 65 and having accrued credit to become a person who's "deserving" of Medicare. Yeah, I mean, I completely agree with that. So I think you can make a fully straightforward case that says, look, this is a stupid system that lets your boss decide whether you and your family are healthy or not. And, you know, who here wants their boss deciding whether they and their family are healthy or not? No? Okay, here's our alternative to that. Medicare for All. How are you going to pay for it? Well, actually we're gonna pay for it by increasing your income by 30%. And insofar as there's something that still needs to be paid for, you know, rich people will have higher taxes. That would be basically my way of boiling down this debate.

Beatrice Adler-Bolton  35:33

I worry, though, that tying it to, like, we're gonna tax the rich in order to pay for your care can be an austerity trap. Because that means that there is this finite pool that we have to work with. And I think my concern just from my study of how disability policy has been implemented in the United States over the past 100 years, the original systems of support for disabled people and for the "needy poor" in the United States were private charity organizations where you have wealthy people taking from their stores of money in order to take care of people who were in need of help. And that has shifted, right, but the conversation has remained very much on the left this sort of like, we've got to implement wealth taxes "in order to" care for those in need. And my concern is that sometimes the Medicare for All debate gets caught up in this feedback loop where we're all just reinforcing these sort of charity models, which are things that I think ultimately as a movement we all want to get away from. And so one thing I'd be interested to talk about is how do we take the narrative and move it as far away from this charity model of, you know, needing to—not that we're gonna let the rich off the hook!—but "needing to" tax the rich in order to fund supporting people?

Marshall Steinbaum  37:02

I think that those things absolutely don't have to be linked. I mean, there's a fundamental difference between extracting money through the coercive power of the state from rich people in the form of progressive taxes than a charity would be, but nonetheless they bear some similarities such that they could be denounced in the same terms. Just like your and your family's health status should not be dependent on whether your boss likes you or not, it also shouldn't be dependent on whether some benevolent rich person likes you or not, or whether you comport with their definition of a "deserving" recipient of care. So yes, I do think we need to depart from that. I think there's a whole—I'm, as you are, reluctant to discuss progressive taxation as a "pay for" for Medicare for All, because I think progressive taxation is entirely independent of the money that it raises being used for anything, just as the case for Medicare for All is entirely independent of the answer to the question of "how are you going to pay for it?" 

Beatrice Adler-Bolton  38:00

Totally.

Philip Rocco  38:01

You made a good point earlier, Marshall, which I think we should talk about, which is that whatever one thinks about polling data, or the depth of public sentiment or mood for something like Medicare for All—I tend to be an optimist on this, right? I tend to think that, you know, when you boil it down to the sort of the bare bones of the policy that this is a thing that has a huge latent base of support. The issue is the elite discussion around this, which has a way of transcending, you know, through cable, through NPR, into this mass consciousness a little bit, is this elite conversation about the accounting, which why I made the joke about having like two "high priests" on from the high priesthood. And I think that the thing that we're sort of dancing around, but I think that this conversation about disability brings it up quite nicely, is that these questions about valuation and accounting have actually displaced conversations about what we value. The things that matter. And actually displace and prohibit a broader conversation about what our values are. It almost makes me long for the days where they would just have to say that Medicare was communism.  Or that social security was communism? I mean, of course people still do say that, but the argument has now become—because I guess they realize that middle class, like, white people have grown like a little bit more sophisticated or at least communism canard has fallen off the radar. So they now have to frame the opposition, in terms of policy sophistication, right? Like, I've definitely been on doors where the patina of "sophistication" was their thing they brought it back to. But I do wonder how in the broader conversation we shift from talking about these sort of accounting maneuvers to what exactly it is that we value and how we how we place a value on that.

Beatrice & Artie  39:31

[Both laugh].

Marshall Steinbaum  40:23

Yeah, I mean, the reason why they constantly go back to the pay for debate is, exactly as you're saying, because they don't want to have the conversation about what we value or what kind of society we want to live in, because they know they'll lose that. And I guess part of my skepticism here is that, yes, I do think that we need to sharpen our knives in order to do better when Mara Liasson next asks "how are you going to pay for it?" But she's not—she's going to ask something else. She's not going to have the debate that we want her to have if we have a good answer that, you know, makes her look bad when she asks the question "how are you going to pay for it?" If we have that answer, she's just not going to ask that question again, she'll ask another annoying question that also seeks to deploy the apparatus of policy sophistication against a liberatory policy agenda.

Nathan Tankus  41:09

Yeah. So I wanted to hop a little bit on the taxing the rich conversation, because, you know. Obviously Bea, you're speaking my language. I definitely agree that the tax the rich conversation is an improvement over the charity model in the sense that it's not something that the wealthy can quote unquote "make choices" about in the same way that they can in a charity structure. But I do think that we have difficulty, especially in what you're talking about, in terms of what we value and what we're trying to value as a society and what we're trying to reproduce and what we're not trying to reproduce. The tax the rich, or the progressive tax answer, attached to the eliminating private taxes answer, can have the trouble that you're talking about in the sense that we have to get what we need to deliver people health care from people up the income chain, or the wealthy, and/or the wealthy, to deliver these needs, rather than we need to reallocate our resources, our collective resources in the sense that the labor time, the land, the machinery, you know, our collective resources to producing outcomes, healthy and healthier people that we want in the world. And so for me, focusing on [changing] this from this dry cost accounting conversation to a macroeconomic conversation, to a question about: we have this collective pool of resources that we can devote to what we want to devote things to. And we have these tools—the money power, taxation, you know, this whole fiscal infrastructure that can be mobilized to proceed these activities—to me, I think can be a useful reframing in terms of where we want to go and fully break us from this conversation and this reliance on the rich. Although there still [are] difficulties in terms of workerism of, you know, once you're moving it to resources, well there still is the question, aren't there these quote unquote "productive" workers who are helping these other people who have needs, and conceiving of this sort of, like, break off of "unproductive" people? So I don't want to say that any framing that we pursue, from whatever point of view, is able to fully break from the deeply held ableist visions that are embedded in our society, but I do think that kind of framing can break us some. Which isn't also to say that, you know, the progressive tax answer can't be useful in certain circumstances, because the biggest problem, of course, is just concision. We have so little time getting our message out to specific people, and the other side has, you know, hundreds of hours of propaganda that they pump out all the time, to everyone.  So, you know, regardless of what your answer is, the biggest problem is just the inequity of the time you get to explicate your answer.

Artie Vierkant  44:34

[Laughs].

Beatrice Adler-Bolton  44:34

Yeah.  Right, which is why I think so often here on Death Panel, we say, you know, it doesn't matter what Medicare for All costs. What matters is actually thinking about how we can use economic policy to change people's lives. And I think that's something that you two both think about really well which is, it's a losing game to engage with justifying certain things on this cost basis. Because we know, as we've been saying over and over, this is a bad faith, false framing, because it tries to take something which is about sort of dealing with and addressing structural inequity. And it tries to reframe it as something that can be somehow negotiated through the process of cost-benefit analysis. And ultimately speaking, what I think is important is to try and, as a group of people who are all advocating for a better life for everyone, to be actively sort of refusing to engage in these reductive, repetitive conversations and saying, you know, what? What is important instead is talking about how can we use economic policy to change people's lives? How can we move away from these framings that we know are inherently embedded in eugenicist frameworks, right? And how do we try and preemptively not just respond in a defensive way, but move forward and away from this idea that economic policy has to somehow be justified by the, you know, holy blessing of the CBO?

Philip Rocco  46:17

Yeah, I mean, I think the thing that's fascinating here is like—and listeners will detect—there are different views about the way the economy works, in the way that public institutions relate to the economy in this conversation. Which is great. 

Beatrice Adler-Bolton  46:30

Right.

Philip Rocco  46:30

I think the thing that's fascinating to me, is that neither of these perspectives is really represented at all in the institutions we now allow to be gatekeepers of economic policy, right? If you think about the things that like—just the basic transaction costs, like what it takes to get a bill over in one chamber of Congress. I mean, we have given, not just the economists who died long ago, but living economists who pray to those people, a huge way of defining and delimiting the pieces of legislation that we consider. And you know, I wonder how either of you think about the way that we get out from under that rock? Because I think one thing that just hasn't been, I think, talked about a lot is, there are other changes that we need to be pushing for that aren't just about Medicare for All, but also about the institutions within government that make it so damn hard to consider this policy on its own terms, and in the terms that really makes sense to the way that most people think about how it would benefit their lives.

Marshall Steinbaum  47:49

Yeah, I mean, that's completely right. The CBO, as just one specific example of that, is constructed on a false pretense that a policy alternative can be evaluated in terms of its effect on the budget and nothing else. I mean, in this case, some institutional history of the CBO is in order, given its sort of outsized role in gatekeeping public debates about things that we care about. [The CBO] was enacted by Congress in response to Richard Nixon's attempt to basically thwart the budget that Congress had actually passed. Congress realized that they needed their own capability of evaluating budget policy independent of the President's Office of Management and Budget. And so they created the CBO. And they happen to have created it at sort of the height of—I don't know if I would say the height of neoliberalism, but certainly while neoliberalism was on the ascendant, while the influence of neoclassical economics on public policy was in the ascent—and so the way that, as all public agencies or policies bear, to some degree, the imprint of the political circumstances of their birth, like the big bang's radiation can be felt throughout the universe forever, given its circumstances, that austerian ideology has infected that organization throughout its history. So we're now in a place where they write a whole thing about evaluating different alternatives for Medicare for All as though informing Congress on that matter. And it's all through the lens of what is the effect on the federal budget when that's the least relevant policy question that Congress should consider when debating whether to enact Medicare for All. I mean, I also deal with them, in fact I've done work for them to some degree on student debt-related matters, and income driven repayment, and they're just as capable, in some ways, they're better at evaluating policy alternatives than many of the think tanks that are in that business, in part because they have both access to data that is generally not available on the outside, and also because they actually do have pretty decent policy wonks on staff. Like they can do that. But then they contort it into, like, "okay, well, what's the effect of the income driven repayment program on the federal budget situation?" Like, I don't want to get sidetracked into student debt. But there's basically no way of robustly analyzing that question. And yet, the only way that the CBO can really deliver a verdict about these things to Congress is in that form. So fundamentally, it's just not going to serve the end that we care about. And, you know, this whole conversation is about pay fors for Medicare for All. So long as the CBO is a gatekeeper to congressional action on Medicare for All, it's only ever going to be talking about pay fors, because that's the thing that the agency exists to do.

Philip Rocco  50:46

Yeah, I sort of wonder, both of you are in this world where you're interacting with people who are members of a profession who do have, let's admit it, a really outsized role. I mean think about it, compared—just compared to other professions. Public health, right? In a pandemic, it very much seems like I have heard more economists and health economists and public health people who are basically hangers on in the economics field—you know, not not to malign your field by any means—but like, than I have heard from people who understand the business end of public health logistics and infrastructure—

Marshall Steinbaum  51:33

You know, that's a profoundly unjust—it's a correct assessment of the state of public debate, and it's a profoundly unjust one. But like, the reason why it is is because the people who you're hearing say the things that people in power want to hear, and public health people, by and large, don't. And so they get silenced. Like, that's, I don't know how to interpret what's going on in anything other than those terms. I mean, just I one thing I wanted to bring up in this conversation, because I think it's quite telling is that there's recently a paper about basically pass through of Medicare reimbursements to physician salaries, written by some economists, one guy at the census. And some outside, in fact, there may be more than one at the census, but know the one who's at the census, and some other economists on the outside. And what they find in that paper is basically, you increase the reimbursement rate for something by $1 and the most senior highest paid specialist who's involved in providing that medical treatment gets a raise of 50 or more cents. So, you know, that's more than 50% of marginal spending on health care treatments that the federal government undertakes passes through to the salaries of the highest paid doctors. Okay, that's a very interesting finding. They could only have done that with, you know, tax return data from extremely highly paid, identifiable specialists. That's very granular in the sense of going medical specialty by medical specialty and looking at the effects on salaries of people in those highly specialized fields. They spend an inordinate amount of time in that data, as well as the public framing of that paper, basically saying, "but this does not mean that Medicare for All would reduce spending." And they have a bunch of ways of trying to prove that, which I don't think are successful at proving that but like, you can tell that what's going on there is perfectly reasonable data analysis, using data no one else has access to, to answer a very important policy question of much public import, but because it's being done by economists, the gloss on it is: okay, let's do all this other totally unnecessary stuff that has nothing to do with the actual finding of the paper to rule out the obvious implication that the real paper rules in. So that is the result of a field that is fundamentally a handmaiden of power.

Nathan Tankus  53:51

Yeah, I mean, precisely on that point, I think a big under-discussed element of that is simply that we need a ton more public funding for these kinds of activities. I mean, you know, Congress doesn't actually fund itself very much. And when Congress doesn't fund itself very much, and when there aren't an array of institutions that purely subsist on public funding in doing their research and being anointed to do specific policy analysis, what you get is Congress relying on a bevy of think tanks. you know, And even just straight up lobbyist work, because they don't have anything else. You know, I remember, many years ago I visited Congress on an unrelated trip, when I was involved in Occupy the SEC. And one of the things I attended was this staffer event that Maxine Waters was putting on in the context of Dodd Frank, in the implementation of Dodd Frank. And the event was just a kind of basic, like 101, "what are derivatives?" And they had someone from CATO, they had Simon Johnson. And I think they had a couple other people. But they were holding this event—super basic, you know, "what is derivatives?"—for staffers. In other words, the people who do the bread and butter work on these issues. And that's the kind of thing that happens all the time. Because those are the only people who have any sort of expertise at all. You know, Occupy the SEC notably did actually have a significant amount of influence in its day, precisely because it was just, you know, half a dozen people got together to write comment letters and to make themselves dot the I's cross the T's experts on the very granular details in those areas. But it's really—that's very hard work to do sort of bootstrapping on your own. And it's a ton of work to put yourself in the administrative agency conversation by continuously writing comment letters and such. And it's just something that needs to be massively resourced. There won't be any sort of real transformation of these institutions until we have, say, like $20 billion devoted to that kind of research funding, where some portion of it goes to independent left wing research that is completely independent of the current nexus of think tanks and such. 

Philip Rocco  56:30

Yeah, I mean, I think the big public point of this is that people are telling you that we can't afford this, or that this is, you know, they're asking the question "how are you gonna pay for it," but they have a sort of, I don't want to use the term monopoly, but like—who are they? I mean, one question at present is like: "who are these people? Do you trust them?"

Beatrice & Artie  56:53

[Both laugh].

Philip Rocco  56:53

"What are their interests?" Right? I remember going to an event at the National Press Club. And there were these models of the cost of long term care, like in the future. And they were like, "we've been very transparent about our assumptions." And like, you go in and look at their assumption, it's like, yeah, I'm glad you've been transparent, because the keys are all insane! But like—  —but like, somebody said to me at that event. "You know, the problem with this is there are only three or four people working on this particular version of this, this like modeling. And they're using a computer program that was written in the 60s. 

Beatrice & Artie  57:15

[Both laugh] [Both laugh]

Philip Rocco  57:30

There's only so many people who can really review these papers that come out. And it's just like, as a layperson, sitting here thinking about this, why should I trust the people who are telling me that this is unaffordable? It's bizarre to me.

Beatrice Adler-Bolton  57:45

Right. And I think so often in the conversation around how do we allocate such a precious resource like health care, the way that expertise is used can be super harmful, because as we've seen throughout the pandemic, but also throughout the multi decade long fight for single payer, you know, early on in the movement you have expertise organizations, like the AMA, pushing to undermine the fight for single payer. You have them hiring really expensive Washington PR people to put together astroturf grassroots campaigns, you have doctors putting up signs in their offices, writing letters to patients. There has for a long time been gatekeeping around health care, where we constantly tell people, you know, your experience of healthcare is—it doesn't matter. Your own expertise, your own lived experience, navigating the system or being cut out by the system, or maybe not worrying about the system that that doesn't matter. What matters is what people who are ordained experts have to say about how it works. And I think there's this constant sort of paternalistic push from the media portrayal of how healthcare works in the US, where we tried to sort of break up constituencies and disempower people from speaking about their own experiences and disrupt movements, like ACT UP, you know, who are trying to call public attention to the defunding of public health infrastructure, for example. And it's all sort of part of what I think is important to try and actually mimic and replicate but from our own perspectives.

Marshall Steinbaum  59:31

Well, I think there's an optimistic interpretation of what you're just describing, which is that all of that effort has not been successful at convincing the public that their interest is not in seeing comprehensive health care. You know, it has been successful at making it the case that we don't have those things in the United States. But I think that one optimistic takeaway is just that, you know, they've tried throwing the book for decades of policy motivated policy analysis and nonsense economics at it and they have not succeeded. They want to bury this forever and that it's not going to [work], in fact, it's getting more and more widespread and with greater support. So I think the issue is really just at the elite level, I guess I don't have the sense that the public is, you know, radically misinformed and, you know, we need to come up with a way of informing them.

Beatrice Adler-Bolton  1:00:17

I don't think it's that the public's misinformed, I think it's more that there are very complex systems and structures of power in this country where people feel like—you know, I don't think it's an indictment of anyone needing to be educated or that anyone's against us, I think it's important for people to develop more complex theories of power and more complex understandings of what their own expertise actually brings to the table and what we can demand. Because what we have the right to demand, and what is literally and economically feasible to do in this country, in terms of refiguring, how we're going to allocate resources, I think is about trying to push people to expand their political imagination and push the will to act into a completely different realm than what we've been working with for the past 40 years.

Nathan Tankus  1:01:04

Yeah, I don't think it's about people being "against us," per se, I don't think the point of the pay for debate is really to turn—I mean, obviously to a certain extent to turn people against us, in the sense that like, if you had a Medicare for All bill and there was going to be a vote that day, they would call their Congressman, to tell them not to vote for it. It's more making them feel like it's irrelevant, because it's not going to happen. 

Beatrice Adler-Bolton  1:01:32

Yeah. 

Marshall Steinbaum  1:01:32

Yes. Yes, exactly. 

Nathan Tankus  1:01:33

—and that it's unrealistic. So for example, I mean, I think this is where the kind of, like, people support Medicare for All polling gets a little tripped up, because I think, you know, if you look at the Democratic Primary, you'll have majorities of people who support Medicare for All, maybe a job guarantee, maybe other things. But those people still voting for Biden in that primary, or one of the other candidates, and not Bernie and, you know, obviously, there's an element of that of just, there is just actually that base level of "this is unrealistic." So you shouldn't, "you shouldn't even dare think about this, because it is unrealistic." 

Artie Vierkant  1:01:33

Yeah.

Philip Rocco  1:02:19

Yeah, it's one way of bleeding off the moral intensity of the demand.

Artie Vierkant  1:02:24

Well, that's one of the reasons that we wanted to have this conversation in the first place, because we're not talking about other people, we're talking about that public sentiment, which even we hear a lot: love that you guys are so idealistic, etc, whatever, whatever, sort of, you know, condescending platitude, they want to try it out at any given moment—  —but then I think for a lot of people, you'll talk to them, and they'll be like, you know, love the idea in theory, of course—and I think this is, you know, this is part of the way that the majority of the Democratic Party really operates in terms of being able to frame its 80s Republican policies, or whatever, as some sort of shield, defender of freedom and democracy bullshit, or whatever. But they say, you know, love it, agree with you in theory. However, I know the thing that you don't, which is: it's so expensive. Or one example, one really high level example which is I think the inverse of the thing that you guys referenced, the inverse of the "maybe your paycheck would go up because the employer won't be spending money on health care," the inverse of that argument from a lot of those people will be, [because] the only public understanding of how you would pay for it is either this progressive tax or by putting this, like this god awful employer tax proposal that Warren put out in [2019], like that would actually depress the labor market somehow, by making it prohibitively expensive to hire new employees or whatever.

Beatrice Adler-Bolton  1:02:44

[Laughs]. Well I think actually the role that pessimism and this sort of nihilistic doom of like, "nothing will fundamentally change"—

Philip Rocco  1:04:25

Yeah, that's nihilism. 

Beatrice Adler-Bolton  1:04:27

Yeah, I understand why it's easy to feel that way because it absolutely sucks to experience using healthcare in this country. You are made to feel worthless, even if you have fantastic insurance. And it just reminds me so much of a very early interview we actually had on the show, which was with scholar Jamila Michener. Jamila's work looks at Medicaid and the disparities from state to state in Medicaid, and one of her books is fantastic because it just really talks about how the experience of government, how generous you perceive your survival aid to be, really influences how people feel about being part of society or a community or, you know, a "sovereignty," right? And the more that people are made to feel like shit when trying to seek access to their care, the more we create room for stuff like predatory wellness industry, and Gwyneth Paltrow goop vaginal eggs, and all these sort of leech products, these markets that are oriented around dealing with the alienation you experience from accessing care! Right? And I just feel like so often, I think about your Jamila's work, and I think about this process that she describes of when you interact with things that are dysfunctional, it makes you feel disenfranchised. It makes you feel worthless, unwanted, and it makes you feel like your opinion isn't considered. And I think part of what is really important is to be, you know, empowering people to be like, yeah, what you think about Medicare for All matters. More than what a poll says.

Nathan Tankus  1:06:20

Totally agree. I know you're beating your head up against that, at this very moment. I mean, and this is why I think the taxpayer myths, I think, is an important angle to really hit because it's not so much that like, I think any given policy proposal, someone is going to oppose on that basis. But I do think it builds in this feeling of insecurity on the part of people who feel like they are barely getting by themselves, that, you know, proposals to use our fiscal infrastructure, use fiscal policy to benefit people are a threat to them. It's not so much that people are necessarily going to oppose any individual proposal, but it creates this broader sense of insecurity that big changes are something that's very scary, and something to be very careful about. It's that, you know, general sense of insecurity, of fear, of paranoia, that makes generating movement around changing things in big ways so difficult. And it's something I worry about with the pandemic is that that feeling has only been hardened, that on one hand, the pandemic is this huge example of how Medicare for All would obviously improve things on a number of different axes. But yet, at the same exact time, change is now even, you know, more dangerous, you feel more precarious than ever. Your life, your home life, your childcare situation has all been so radically upended, that all you're looking for at the end of this pandemic is for actually things to get completely "back to normal." And pursuing another set of changes is almost like going back to the bad times.  And I think it's possible this can just totally sweep things, get people to think about things the other way, think about how much more effective this system would have worked with a Medicare for All system. But I think that an inertia, a direction that is in flux right now. And we could really go either one of those two ways over the next like months or a year. To be—to put a touch of optimism in I will say, as much as I think that the weight of the economics profession is now being redeployed in these quasi-empiricist ways, I do think that now relative to times past it's easier to blunt the influence of these kinds of things, because these arguments get deconstructed in real time and get pushed back upon— 

Beatrice & Artie  1:08:36

[Both laugh].

Philip Rocco  1:09:41

Yeah. 

Nathan Tankus  1:09:42

—much more rapidly now. And the economists can put out whatever they want, but it's really just staffers. And then of course, you know, some upper level economic advisors for, say, the Biden administration, who are arguing these things out. And arguments that we make deconstructing, showing how bad X or Y paper is in the argument they're making, do I think end up in these economic policy conversations, within Congress at least, if not the White House. And do have the ability to blunt the influence of these toxic studies in a way that they wouldn't have in say, 2008 or 2006.

Philip Rocco  1:10:26

But I want to notate something that both of you, I think, are getting at, which I think is important, because, you know, I'm not an economist, like in this realm, I'm a lay person. And when I hear economics, it can feel like something that just exists to dominate me in some way. Just one other thing. Just one—  —other form of expertise. But I think this is something that's so important for people to understand, because all forms of expertise work like this at one point or another. They are they're tools, they're created as tools, experts are deployed as tools, right? And sometimes the tasks to which we delegate these to experts have to return because of a great moral need to society, because we no longer accept the valuations that the experts we've delegated to come up with. We now have a moral need to displace these forms of authority. And that's, I think, the realm that we're in. So like, this is not me being an optimist necessarily, right? And it's not me also saying, pessimistically, like—I'm quite aware that it's very, very difficult to displace the sort court and the courtliness of some of these "courtly philosophers." But at the same time, that illustrates to me that part of the project here is not merely getting, the public kind of riled up behind one particular policy idea. But getting people into the habit of saying, "No, it doesn't matter what you've said, you know, Emily Oster. I don't actually feel comfortable. And I think it is unsafe, because of my knowledge of my craft, to be in a classroom. I don't care what knowledge you've come up with in the episteme. Like, this is not the case. You do not value the things that I value in the same way. And my will trumps yours." That is the—I don't see another way out of this. 

Artie Vierkant  1:10:44

[Both laugh]. 

Marshall Steinbaum  1:10:45

That's correct, yeah. Yeah. I mean, you're just saying that, you know, these people can't be allowed to dominate and influence and control the public debate and as much as they currently do, and I completely agree with that. But that's a matter of contesting political power— 

Philip Rocco  1:12:46

Yeah, I think that's right. That's exactly right. 

Marshall Steinbaum  1:12:48

There's obviously a sort of information ecosystem propaganda element to that. But that's fundamentally what we're talking about. 

Philip Rocco  1:12:55

No, I mean, but I think that one of the themes in this Medicare for All Week is going beyond the sort of narrow confines of this debate to think about the broader social structures that absolutely have to change and the forms of contestation that have to happen. And I think you're right, Marshall, which is that like, we cannot be naive, necessarily about how these things work. And both of you know this because of the worlds that you've been situated in, but it also helps to highlight what forms of contestation have to go on alongside the specific movement for Medicare for All, such as it is. 

Beatrice Adler-Bolton  1:13:39

Well, yeah, I think breaking Medicare for All out of its more reductive, simple framings, as we've been talking about this whole time, you know, the financing side of Medicare for All is so much more than just eliminating copays and out of pocket costs. It's also about financially redistributing resources to hospitals, changing the priorities that hospitals have by changing their funding, and I think that there are ways to create policies where there are fundamental changes to institutions. And I think conversations like the ones that we're having in Medicare for All Week are important because it does help empower people to understand and discern for themselves, you know, is this policy just reformism? Or is this policy facing so much opposition because it is fundamentally challenging systems of power? And I think ultimately, what you see both in COVID and in the debate over health justice is the weaponization of the sort of professions that describe and account for value in our society against any policy that could potentially be disruptive to existing institutions of power.

Marshall Steinbaum  1:15:00

Yeah, that's right. That's why the economists aren't going to be going anywhere anytime soon because they continue to hold that function. They continue to usefully re-weaponize or recast whatever is the prevailing empirical or any methodology in the field. And in terms of serving that end that's how we all have—or not all of us, but you know—why we have so many people with such high prestige, comfortable positions is because they're doing what powerful people want them to do. And they've, you know, continued to do that and figured out how to do it in different environments and in response to changing circumstances,

Philip Rocco  1:15:33

Nationalize the American Economic Association. [Laughs].

Nathan Tankus  1:15:38

I mean. Foreclose on it. 

Philip Rocco  1:15:39

Foreclosed on—[Laughs]. 

Nathan Tankus  1:15:39

Or abolish. 

Philip Rocco  1:15:39

[Laughs] Abolish! 

Artie Vierkant  1:15:39

Yeah, abolish, hell yeah. 

Beatrice Adler-Bolton  1:15:39

Abolish, yeah. [Laughs]
Marshall Steinbaum  1:15:46

Unfortunately, abolishing the association isn't gonna do that much.  I mean, hopefully, it'll get rid of the fact that they're pretending to operate a sexual assault and discrimination policy and a professional code of conduct that they're not actually enforcing and actually worsening the professional climate in the field by virtue of espousing a policy of not enforcing, but, you know, the association began life as an organ of progressivism within the economics profession, and was very quickly corralled into the role of releasing the parameters of what's ideologically acceptable to espouse as a professional economist. So like, I don't know, there's no one institution that is the source of—

Philip Rocco  1:15:50

[Laughs] No, I was joking [laughs].

Marshall Steinbaum  1:16:27

—all the grievances that we feel 

Nathan Tankus  1:16:30

Well, I mean, I think we can easily develop a RICO case, which ties the American—

Philip Rocco  1:16:35

[Laughs].

Nathan Tankus  1:16:36

—all the top Economics departments and, you know, create a sort of single entity theory.

Beatrice Adler-Bolton  1:16:47

[Laughs] I like this.

Artie Vierkant  1:16:48

So, we've had fun here today, maybe something that we could end on is, especially because I know we have, you know, speaking of CBO reports, we have at some point in the near future, we have been promised from the CBO a study that I'm sure that the Death Panel will be discussing at length that will discuss the sort of macroeconomic effects of a Medicare for All proposal. And while, for all the reasons that we've discussed before, I have no reason to think that that will necessarily, you know, be a particularly insightful addition to the debate, as it were, it does make me think that before the CBO has a chance to weigh in, I am curious, if you, perhaps both of you, could give us just sort of as as a parting take, your best take on what the impact of switching to a single payer system—where we have, you know, no private health financing actors, where we've removed the role of the private insurer, which is a financial institution that we venerate and hold up and have all sorts of policies around in the United States—what the effects of that would be, economically?

Nathan Tankus  1:18:05

Sure. I mean, one thing I didn't mention in this conversation but was one of the first things I wrote about last year, is that Medicare for All is a great policy for changing how our budget responds to recessions. What economists call countercyclical, you know, the idea that when there's a boom spending is up in the private sector, and when there's a bust spending is down. We want government spending to move the opposite way. The problem is that we have, because of our private health care system, when people lose their jobs, they lose access to their health insurance, if their job had employer-provided health insurance. Losing access to their health care also means expenditures on their health care go away. And also all sorts of federal tax subsidies for that healthcare go away. And at the same time, you have all sorts of state local financing of healthcare in certain ways that lead to impacts on state and local budgets, which they may respond with just budget cuts, or changing their—reducing their Medicaid spending, as Cuomo was proposing to do right as the pandemic recession was getting going. And so, in this structure, one of the things that happens when you go to a fully federally financed system is that you're removing all these sort of procyclical omits from our public financing system of health care, meaning spending is gonna go up more in recessions and less in booms. So, you know, Medicare for All makes our budget more countercyclical. And at the same time, it gets rid of the copays, the deductibles, the premiums, which, as Marshall was talking about, are these kind of private taxes that get imposed. And so Medicare for All gets rid of those private taxes. Until then, the question from there is just, can the economy absorb all that additional purchasing power that will be unleashed by eliminating those private taxes? And if— —and if it can't: implement public taxes that take back some portion of that huge boost in income. But the big picture being that we have this budget that is more countercyclical, that responds to the needs of the economy more, and at the same time, we have these capricious private taxes that get eliminated, and the question just becomes, how much does our fiscal infrastructure need to reabsorb to keep the economy balanced in that initial transitional period? But, of course, you know, this is just a transitional period. It's a period from one period where people's disposable income is at one level, and then it jumps up suddenly. But that only happens once. You only have that jump up level once. And then we have this new fiscal infrastructure that is much more responsive to your health needs, and also much more responsive to the state of the economy.

Artie Vierkant  1:20:35

[Laughs].

Marshall Steinbaum  1:21:39

All right, well, Nathan gave his answer about macroeconomics, which is what he does, I'm gonna give my answer about labor economics, and specifically the border of labor and competition, which is what I do. So I think the effect of Medicare for All would be to radically increase people's earnings and wages. And that's a great thing to do after 40 years of wage stagnation. So, you know, Nathan mentioned the copays and deductibles that are eliminated by Medicare for All, I think the more salient aspect of Medicare for All is not just that, but also the health insurance premiums that employers are paying. We had the discussion about, you know, that's 30% of most people's salaries. So you could just imagine your salary going up by 30%, I would say even more fundamentally than that enormous raise is the shift in bargaining power in the labor market towards workers as a result of making them not depend on their employer for access to the entire healthcare system. And I think that shift in bargaining power would mean not only that we can believe that there would be that pass-through of existing premiums to workers' salaries, when under existing power relations in the labor market, if you, say, reduce the taxes that employers have to pay on their workers, you wouldn't necessarily trust that workers would get a raise as a result, because employers would just pocket the difference. I think one of the fundamental reasons why our labor market is so imbalanced as to who has power is exactly because workers are so dependent on their bosses, so make them less dependent. So there would be more worker-friendly labor market dynamics that would not just mean that the 30% of salaries that's currently going to premiums would instead go to workers themselves, but also that more generally, workers would be in a position to claim the difference between the value of what they produce and what they actually get paid.

Beatrice Adler-Bolton  1:23:34

Yeah. And I think I'll add also from the perspective, and to the perspective, of someone who is "surplus labor," I think it's important to also underline that the severing of employment and health coverage is fundamentally transformative because it removes a lot of the barriers which are currently locking a bunch of people into programs where they are policed, surveilled, and forced to live in abject poverty, like when you're forced to do a "Medicaid spend down" to keep your assets under $2,000 just to qualify for long term care. Taking long term care and making it accessible to everyone, taking health care and making it accessible to everyone. This is a huge step towards taking down some of these infrastructures of valuation that we've been talking about where the disabled person with health care needs exists as this, you know, "warning" to workers as to what to avoid, right? Which is, you've got to keep your job, otherwise you'll be out of luck, disabled and dependent on the state. Disrupting that that binary is, I think, fundamentally important.

Artie Vierkant  1:24:54

Yeah. And I think to add to that, to that point about the the surplus population, as regards the labor force, you eliminate the situation that a lot of people have experienced, and Bea has gone through this, and I know that a lot of people who listen to this show have too where the social welfare programs the American state currently runs, you're not satisfactory of the conditions to qualify for them. Simultaneously, you perhaps have to work a job to continue to get health insurance through your employer, to continue to get your medication or treatment, whatever kind of treatment that is. And then in the process of doing that, even if you're pretty much just working that full time job in order to keep that health insurance, either making yourself sicker or making it so that you have to ration the amount of times that you can like get checked up or checked out. You know, some people have to go to the doctor much more frequently than, let's say, an employer allows for paid sick days.

Beatrice Adler-Bolton  1:26:25

Yeah, I like to call this the "sick person so sick they must work for the healthcare, despite the fact they are too sick to work" paradox.

Marshall Steinbaum  1:26:33

Yeah. 

Artie Vierkant  1:26:33

[Laughs] A mouthful. 

Beatrice Adler-Bolton  1:26:34

We need to solve for that. Phil, any final comments or anyone have any final? 

Philip Rocco  1:26:40

No, I'm good, this is great. 

Beatrice Adler-Bolton  1:26:41

Thank you both so much for coming today. Where can people find you if they want to follow your work? Maybe we'll do a Nathan first.

Nathan Tankus  1:26:49

I write a newsletter called notes on the crises. Just finally got back on the horse writing again. You can subscribe at nathantankus.substack.com/subscribe. 50% off for the month of February, so say hi or subscribe, or read the free pieces, whatever you want, but you can find me there and of course on twitter at @nathantankus.

Marshall Steinbaum  1:27:16

Yes, Nathan is one of the few people who got to substack for not being thrown out of whatever mainstream publication they were writing for because they were too racist.  He's actually a part of good substack. I am at @Econ_Marshall on Twitter, I have a website called marshallsteinbaum.org that has my academic work on it in case anybody happens to be interested in that. And I teach in the Economics department at the University of Utah, so in the event that you've been moved to study Economics as a result of this somewhat disheartening conversation, you're always welcome to apply and enroll in my department and get a degree in the subject that is the source of all of our problems. 

Philip Rocco  1:27:25

Yes. [Laughs].

Death Panel  1:27:25

[All laugh].

Nathan Tankus  1:27:41

University of Utah Economics department is, very famously, a department [whose] modern, or close to modern, incarnation began when a bunch of Mormons looked around and the only people that they could get to move to Utah to teach Economics were people who are blacklisted because of McCarthy. 

Beatrice Adler-Bolton  1:28:25

Oh my god. [Laughs].

Nathan Tankus  1:28:27

So for many years was a haven for Marxist and alternative heterodox Economics on that basis, and Marshall is currently on the last bastion of defending the department. 

Marshall Steinbaum  1:28:42

[Laughs].

Beatrice Adler-Bolton  1:28:46

Love it. Listeners, thank you so much for joining us for another episode of Medicare for All Week. As always, Medicare for All Now. Solidarity forever. Stay alive another week.