Medicare for All, a middle-class tax cut for others. Photo: Elizabeth Frantz/Bloomberg via Getty Images

Kamala Harris’s position on Medicare for All has never made much sense.

From the dawn of her campaign, the California senator has made a $2 trillion middle-class tax cut her signature economic policy. At the first Democratic primary debate, Harris confirmed that passing this “middle-class and working families tax cut” would be her top legislative priority. And yet, the Democratic 2020 hopeful simultaneously insisted that she supported Bernie Sanders’s Medicare for All plan, a policy that would move virtually all health-care spending in the U.S. onto the federal government’s books, and finance the resulting $3.2 trillion increase in annual spending with broad-based tax increases.

Which is to say: If you took Harris at her word, her legislative plan for 2021 would be to first pass a law massively cutting middle-class taxes, and then pass a second law radically increasing them.

The fundamental incoherence of Harris’s agenda went largely ignored over the first seven months of her campaign. Instead, debate over the sincerity of the senator’s commitment to single-payer centered on her slippery position on the abolition of private insurance. At a CNN town hall in January, Harris suggested that she supported prohibiting private insurers from trying to compete with the new government plan. If insurers wished to cover services that the Medicare for All system would not, such as cosmetic plastic surgery, they would be free to do so. Otherwise, there would truly be a single (government) payer.

In which Jake asks Kamala Harris whether people would be able to keep their private insurance, if they prefer, under Medicare For All system — and she rejects that. "Let's eliminate all of that. Let's move on." pic.twitter.com/A1AY2TOT4g — Rebecca Buck (@RebeccaBuck) January 29, 2019

The next day, however, her campaign responded to backlash to this position by reminding the press that Harris (like Sanders) had co-sponsored many incremental health-care reforms that would preserve a major role for private insurers. That talking point led CNN to write the headline, “Kamala Harris is open to multiple paths to ‘Medicare-for-all.” And yet, in the body of that article, a Harris spokerson suggested that the candidate’s preferred path was identical to Bernie Sanders’s.

Harris’s position on private insurance only grew more muddled in recent weeks. At the first Democratic debate, Lester Holt asked, “Who here would abolish their private health insurance in favor of a government-run plan?” and Harris raised her hand. But the wording of Holt’s question was odd — what would it mean for candidates to abolish their private insurance? And the next day, Harris said that she thought Holt had asked whether she would personally be willing to give up private insurance to enroll in Medicare for All. Asked on MSNBC whether she wanted to outlaw private insurance, Harris said “No, no I do not,” — but then added, “I am a proponent of Medicare for All. Private insurance will exist for supplemental coverage.”

But no one in the Democratic field supports abolishing supplemental coverage (which is to say, private insurance that covers services the government’s plan does not). Bernie Sanders’s bill only prohibits duplicative insurance. So, Harris’s answer ostensibly meant that she did want to “abolish private insurance,” under Bernie Sanders’s definition of that phrase, (which was, implicitly, the definition that Holt was working from).

Harris threw one last shroud of confusion over her position on private insurance Wednesday. In an interview with CNN, the senator suggested that she supported the de facto elimination of private duplicative insurance, though did not explicitly say that she would legally mandate that outcome. “As it relates to private insurance, there will still be supplemental insurance, but yeah, transitioning into Medicare for All will at some point reduce the requirement for insurance because everyone will have access to health care,” Harris said. “Under … my vision of Medicare for All, people will have covered what they don’t now in terms of vision care, dental care, hearing aids.”

Question: "So people who have private insurance would eventually have to give that up under your plan?"



Sen. Kamala Harris: "They would eventually be covered under Medicare for all and they would still see their doctor. And that's what they want." pic.twitter.com/yUm9Nqx39U — The Hill (@thehill) July 17, 2019

But all of Harris’s fudging on the abolition of private insurance is sort of beside the point. If the senator supported all the other aspects of Sanders’s health plan, the question of whether she was onboard for banning duplicative coverage would be of little consequence (and not merely because this entire debate is almost certainly of little consequence due to dearth of support for any kind of single-payer bill in the U.S. Senate).

If the government offers comprehensive insurance coverage that is free at the point of service — and which all health-care providers are required to accept — the private insurance industry will be decimated, whether or not it’s formally outlawed. The point of banning duplicative insurance is ostensibly to avoid the development of a two-tiered system, in which more affluent Americans can purchase shorter wait times and fancier accommodations by buying into private coverage. But, as Jon Walker notes in The American Prospect, Sanders’s plan would not actually stop the wealthy from purchasing superior care:

Section 303 of both Medicare for All bills allows individuals to privately pay doctors for treatments that Medicare for All covers. You can’t buy private insurance that pays for faster appointments, more time with doctors, and/or shorter wait times. But you can directly pay health-care providers for these same perks. The current proposals very explicitly create a way that CEOs or other rich people can pay for better health-care access, using exactly the kind of mechanism one would expect people making $500,000 a year to take advantage of … If the question was better understood as “Should we allow some upper-middle-class people to get faster access because they buy private duplicate insurance, or allow a slightly smaller group of well-off people to get faster access by buying annual membership fees to private clinics?” it would be unlikely to generate the same headlines. This is why health-care policy experts often find the focus on it perplexing.

Some single-payer advocates dispute aspects of Walker’s analysis. But one fact that is beyond dispute: There are countries that have established single-payer without banning duplicative insurance; but none that have done so without raising taxes on non-rich people.

And in her interview with CNN Tuesday, Harris confirmed that she is, in fact, committed to doing the latter. “My vision of Medicare will not be about a middle-class tax hike,” the senator said. “So, I’m not prepared to do that at all. And in that way, perhaps my position is different from some of the folks who are on the debate stage, but that is not what is going to happen.”

Rather, Harris suggested she would finance a program with a projected price tag of $32 trillion per decade with a tax on financial services.

The senator’s position might be coherent if she officially endorsed the view that Medicare for All would actually be deflationary (e.g., “pay for itself), a proposition championed by some economists in the Modern Monetary Theory movement. But she doesn’t. And if you do believe that the government must offset most of its spending with revenues, then it isn’t credible to suggest that some kind of financial-transaction tax could cover the cost of universal, premium, and deductible-free public health care.

But the substantive absurdity of Harris’s health-care position is less puzzling than its political incoherence. It would be one thing for Harris to cynically embrace the popular aspects of Medicare for All, while disavowing the unpopular provisions that make those goodies possible. She wouldn’t be the first presidential candidate to campaign on a beautiful lie. But that isn’t what she’s doing. Rather, she is effectively taking ownership of an unpopular, peripheral feature of Sanders’s plan (the elimination of duplicative private insurance), while disavowing an unpopular provision that is fundamental to his vision for single-payer (broad-based tax increases to replace private-insurance premiums).

There is no political logic to occupying this patch of middle ground. The only electoral incentive for a Democratic candidate to support the elimination of private insurance is to curry favor with Bernie Sanders’s most ideological supporters, and the broader Medicare for All movement. But Harris’s opposition to raising middle-class taxes sends such voters an unambiguous signal that she does not actually support Sanders’s bill. And if Harris isn’t courting that constituency, then she might as well follow the lead of almost every other Democratic candidate and either pretend that Medicare for All would have no significant impact on the availability of private insurance, or forthrightly endorse a Medicare buy-in (which currently polls better than single payer).

The most plausible explanation for how Harris ended up with her current, bizarre version of a “third way” plan is that she initially believed there was some advantage in emulating Sanders on health care — then decided that this was a mistake — and is now trying to pivot without acknowledging that her stance has changed. Since she already publicly owned the abolition of duplicative coverage, she’s uncomfortable fully walking that back. She sees no benefit, however, in embracing middle-class tax hikes for the sake of appealing to committed Berniecrats.

But it is already impossible for “clarity and consistency on Medicare for All” to be one of Harris’s strengths as a candidate. At this point, her best bet on health-care policy might be to stop worrying about “flip-flops” — and start telling voters whatever her consultants say they want to hear.