Early in his administration, an astute Trump friend was quietly urging him to support a single-payer insurance system, like Medicare for All, to replace Obamacare. It is too bad that he didn't take up his friend's proposal.
In 2017 I wrote a column suggesting that Trump could score politically by backing such a program. Conservatives in Taiwan in the 1990s had reversed their hostility to single-payer and profited politically, stealing a major issue from the liberals' platform. The same thing could have happened here.
Republican politicians had long opposed single-payer insurance. But they repudiated their previous support for free trade and opposition to tariffs under Trump's leadership.
The case for Medicare for All is a strong one, but it is complicated. It would take true leadership to convince voters it is a good idea. Whatever one may think of Trump, he was a marketing genius who could have sold the idea to the country.
Trump had promised to replace Obamacare with a much better system that would cover everybody. Medicare for All would do exactly that, but establishment Democrats had painted themselves into a corner by promising not to raises taxes on most Americans, which Medicare for All would require. Most Republicans had painted themselves into a similar cul-de-sac by taking the "Norquist Pledge" never to raise taxes.
But most people are just interested in the bottom line. Nearly everybody's higher taxes would be more than offset by their increased wages once employers were no longer providing their insurance. Trump could have insisted that Congress require that every dollar no longer subtracted to pay for a worker's insurance be added to his or her pay.
Trump, who excelled at getting national attention, could have pointed out how vested interests exploit two important facts to confuse voters about where their interests lie:
Fact 1: Workers insured through their jobs think it is paid for by employers. But the money employers pay for insurance is just part of their costs of labor, subtracted from the pot from which cash salaries are paid.
The workers are therefore paying, indirectly, for that insurance themselves. But this large amount of money is invisible to them because the dollars they are paying never pass through their hands.
Fact 2: The tax increase required by Medicare for All would be totally visible to workers, even though it would be less than they were previously paying because of Medicare's administrative efficiency.
To workers unaware of how much they are currently paying, albeit indirectly, Medicare for All therefore looks like a terrible deal.
Medicare for All would serve three important conservative values:
Efficiency and saving money: It now costs $80,000 to $100,000 annually for every doctor to bill multiple insurance companies with complicated policies, an administrative expense which is reimbursed by the insurance and drives up its cost. But under Medicare, providers' administrative costs are much lower because they only have to bill one insurer.
Simplicity: Obamacare is terribly complex and people whose incomes fluctuate often "churn" between different insurance programs. Any medical policy short of single-payer reinforces governmental complexity and imposes impossible choices on individuals because it forces them to decide what insurance policy to buy without having the information needed to decide intelligently.
Competition: Single-payer insurance would not create a governmental monopoly on providing medical services. There would still be competition among providers, especially if they are forced to stop keeping their prices secret. (How can comparison shopping work if people can't find out what something will cost?)