Fighting About Modes of Delivery

Chris Bowers says I’m wrong and progressives will keep trying to expand the size and scope of the welfare state after all. But I think his discussion illustrates the point I was trying to make, a point that perhaps wasn’t made clearly enough. Here’s Bowers:

However, despite these gains, it is premature to declare progressive fights to expand the social safety net over. As just one glaring example, in most states, people aged 27-64, and with an income over 133% of the poverty level, are not eligible to for public health insurance. Without even mentioning ongoing disparities in other areas of the social safety net, such as education funding, the lack of access to public health insurance is a pretty big doughnut hole to fill. [...]

Taking the long view, the fights against shrinking the social safety net, and the fights to expand it by closing the doughnut holes in those nets, will closely coincide. In particular, allowing everyone to purchase Medicare can become a means of putting the program on solid financial foot over the long-term. As such, expect struggles over whether to expand, or reduce, the size of Medicare to become the main framework for the next decade of debates over the size of the social safety net.

I think this is right. But this isn’t really a debate about the size and scope of the welfare state, it’s a debate about the mode of delivery of health care services. To take an example, it’s now completely uncontroversial that the government should provide for K-12 education for all American kids. But we still have very contentious debates about how public schools should be organized and operated, about the scope for public charter schools, about the idea of privatizing public education and just giving people vouchers to take to private schools, etc. These are important debates. But they’re not debates about whether or not kids should be sent to school.

Similarly, on the health care front I expect we’ll continue to see proposals to give under-65 Americans access to Medicare and we’ll also continue to see proposals to turn Medicare into a more means-tested or more voucherized system. But those would be different kinds of debates than the decades-long argument about whether or not everyone should be guaranteed access to affordable health insurance. For example, you could imagine a lot of important purely generational tensions. We’re going to set up a system in which Americans of all ages are guaranteed access to insurance, but senior citizens are treated much more generously than non-seniors. Is it crazy to imagine that in the future the Democrats, with younger constituents, will want to transfer some resources from old to young whereas the GOP with its older base will resist those moves?

We’re not looking at the end of contentious political debates by any means. We’ll keep arguing about the way our social programs should work. And we’ll argue about immigration, about environmental regulations, trade, etc.