Where the AHA is focusing its lobbying efforts in September

https://www.aha.org/news/perspective/2019-08-16-perspective-gearing-busy-september-capitol-hill

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Two weeks ago, I wrote about the important role AHA member hospitals and health system leaders play in advocating for the field. This week, I’ll tell you exactly what we’re advocating for when Congress returns in September … and how you can help.
 
Here’s where things stand: There will be three issues before Congress next month that could greatly affect our field: surprise medical billing, the planned Medicaid disproportionate share hospital cuts and prescription drug pricing.
 
The AHA and its members strongly support protecting patients from surprise medical bills. However, we have concerns about the proposals in the House Energy & Commerce Committee and the Senate Health, Education, Labor & Pensions Committee, which both contain a rate-setting approach for settling out-of-network claims.
 
We believe providers and insurers should continue to be permitted to negotiate payment rates for services provided … and we strongly oppose approaches that would impose arbitrary rates on providers. Hospitals and health systems work hard to align physician networks, but we cannot compromise independent physicians’ abilities to negotiate fair contract terms with payers. These approaches would add unnecessary complexity and burden to the system.
 
On Medicaid DSH, legislators need to act before Oct. 1 or $4 billion in automatic cuts to hospitals and health systems will go into effect. This will be followed by another $8 billion the following year. If these cuts proceed, they will threaten our ability to care for the most vulnerable members of society. The good news is that there’s strong support in the House for preventing these cuts from kicking in: The House Energy and Commerce Committee passed legislation last month that would eliminate the Medicaid DSH cuts for the next two fiscal years and reduce the cuts by half in the following year. So let’s make sure the Senate acts on this.
 
In addition, on drug pricing, legislators recognize that skyrocketing drug prices — as well as shortages for many critical medicines — are hurting patients and the hospitals and health systems that care for them each day. The Senate Finance Committee has taken an important step forward by advancing a drug pricing package to the full Senate. More work needs to be done, though … especially in the House.
 
Here’s where you come in: Your legislators need to hear from you. Urge them to protect patients while rejecting proposals such as rate-setting or setting a “reference” or “benchmark” price. Keep encouraging them to prevent the Medicaid DSH cuts from kicking in so we can make sure the most vulnerable can access care. And tell them how important it is to rein in the skyrocketing costs of prescription drugs.
 
You can read our latest Action Alert here, which includes key resources for talking with your legislators over the congressional recess.
 
On Sept. 10, we’re holding an advocacy day on Capitol Hill … so please make plans to join us if you can and add your voice to those of your colleagues.
 
At the same time, as we all know, the recent tragic events in El Paso, Dayton and Gilroy have increased the focus on addressing gun violence. Be certain: We will continue to give voice to the fact that violence is a serious health problem, as hospitals and health systems are on the front lines of taking care of the victims and serving their communities. Beyond supporting research and education and highlighting the innovative actions taken by our members to address all forms of community violence, we’ll also continue to closely monitor evolving efforts to develop bipartisan, consensus legislation in regard to more specific approaches to address this serious problem. 
 
You are leaders in your communities. You are the experts on health care. And when you speak up, your senators and representatives listen. Together, it’s time to engage with them so we can ensure every hospital and health system has the tools they need to always be there, ready to care.

 

I’ve lived the difference between US and UK health care. Here’s what I learned

https://www.cnn.com/2019/08/07/opinions/single-payer-healthcare-beers/index.html?utm_source=Sailthru&utm_medium=email&utm_campaign=Newsletter%20Weekly%20Roundup:%20Healthcare%20Dive%2008-10-2019&utm_term=Healthcare%20Dive%20Weekender

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Earlier this year, I shattered my elbow in a freak fall, requiring surgery, plates and screws. While I am a US citizen, several years ago I married an Englishman and became a UK resident, entitled to coverage on the British National Health Service. My NHS surgeon was able to schedule me in for the three-hour surgery less than two weeks after my fall, and my physical therapist saw me weekly after the bone was healed to work on my flexion and extension. Both surgery and rehab were free at the point of use, and the only paperwork I completed was my pre-operative release forms.

Compare that to another freak accident I had while living in Boston in my 20s. I spilled a large cup of hot tea on myself, suffered second degree scald burns, and had to be taken to the hospital in an ambulance. In the pain and chaos of the ER admission, I accidentally put my primary insurance down as my secondary and vice versa. It took me the better part of six months to sort out the ensuing paperwork and billing confusion, and even with two policies, I still paid several hundred dollars in out-of-pocket expenses.
With debate raging in the US among Democrats about whether to push for a government health care system such as Medicare for All, there is no doubt in my mind that the NHS single-payer health care system is superior to the American system of private insurance.
As someone who suffers from chronic illness, is incredibly clumsy and accident-prone, and has two young children, I spend an inordinate amount of time in doctors’ offices and hospitals. When my family is in our home in York, England, our health care is paid for principally through direct taxation, and we have zero out of pocket costs.
In contrast, when we are in the US, we are on my employer-based insurance plan. After years with one provider, rising costs pushed the premiums alone to above 10% of my gross salary for the family plan, and I recently opted to switch to a new provider, whose premiums are a more modest but still eye-watering 7% of my salary. I have had to switch our family doctor and specialists, with the attendant hassle of applying to have our medical records released and transferred to our new providers. In addition to my premiums, both plans include significant co-pays, although my new provider does not have a deductible.

In Britain, I am not entitled to the annual well patient and women’s health check-ups that Americans can now receive without a co-pay or deductible thanks to the Affordable Care Act. As an asthma sufferer, I do, however, have regular annual reviews of my condition. When one of my children becomes ill, I am usually able to receive same-day treatment in both countries, although in both cases this involves showing up early for the urgent care clinic.
The comparative ease and security of the NHS is why the system retains such high levels of support from the British public, despite frustrations with wait times and other aspects of service provision. A recent poll found that 77% of respondents felt that “the NHS is crucial to British society and we must do everything we can to maintain it,” and nearly 90% agreed that that the NHS should be free at the point of delivery, provide a comprehensive service available to everyone, and be primarily funded through taxation. Britons’ affection for their NHS was dramatically enacted in Danny Boyle’s 2012 Olympic opening ceremony extravaganza.
Yet, while I share my adopted countrymen’s support for the NHS, I can see almost no chance of America adopting a single-payer health care system of the kind described by Sens. Sanders and Warren any time soon. Sanders, Warren and other single-payer advocates not only face a strong and entrenched adversary in the American insurance industry, they also lack the broad public support for reform which characterized post-WWII Britain.
That broad public support for reform was crucial. Britain’s NHS system was very nearly defeated by opposing interests when it was introduced in the 1940s. It was initially opposed by the municipal and voluntary authorities, who controlled the 3,000 hospitals which Health Secretary Aneurin Bevan sought to bring under national administration, by the various Royal Colleges of surgeons and specialists, and by British Medical Association (BMA), the professional body representing the vast majority of the nation’s general practitioners, who stood to lose control of their private practices and become state employees.
At a meeting of doctors following the publication of Bevan’s proposals in January 1946, one physician claimed that “This Bill is strongly suggestive of the Hitlerite regime now being destroyed in Germany,” and another described the proposed nationalization of the hospitals as “the greatest seizure of property since Henry VIII confiscated the monasteries.” The BMA hostility persisted through rounds of negotiations lasting two years. Less than six months before the bill was set to come into effect on July 5, 1948, the BMA’s membership voted by a margin of 8 to 1 against the NHS, sparking serious fears within the government that GPs would refuse to come on board, effectively scuppering the NHS.
Bevan insisted that he would not cave but he did have to make several costly concessions to bring the doctors on board. First, he cleaved off the specialists (who were closely tied to the hospitals), by promising them that, if they signed on, they could continue to treat private patients in NHS-run hospitals in addition to their NHS patients, whom they would be paid to treat on a fee-for-service basis. Then, he offered the general practitioners a generous buyout to give up their stake in their private practices (effectively purchasing their patient lists), if they came on board. And finally, he promised them that the government would not be able to compel them to become fully salaried employees of the state without the passage of new legislation.
At the same time that Bevan offered the carrot of economic concessions, he also wielded the stick of public opinion against the doctors. Speaking in the House of Commons in February 1948, Bevan positioned single-payer healthcare as an issue of middle class survival, in language whose substance, if not its style, would not sound out of place in a 2020 Democratic primary debate: “Consider that social class which is called the “middle class.” Their entrance into the scheme, and their having a free doctor and a free hospital service, is emancipation for many of them. There is nothing that destroys the family budget of the professional worker more than heavy hospital bills and doctors’ bills.”
Bevan spoke for a public exceptionally united in support of an expanded state welfare policy as a result of the socially unifying experience of World War II. Fear of public backlash combined with economic incentives ultimately brought the medical establishment to heel.
Many were shocked when Bevan succeeded, but the BMA was arguably a less formidable threat to reform then than the American insurance industry is now. Insurance companies stand to be the biggest losers from a switch to single-payer health care, which seeks to achieve economies in large part through cutting out the profit-making middle man. As Elizabeth Warren noted in last Tuesday’s debate, US insurance companies reported $23 billion in profits last year. And the insurance lobby is determined to protect its position. That is why insurance companies are major donors in both state and federal election campaigns. The insurance industry has put massive resources into ensuring continued public and political opposition to the introduction of a single-payer system.
It’s possible that, if Americans were presented with an arguably cheaper and less bureaucratic health care system, they might decide that they liked it and were committed to doing everything they could to maintain it. But given the constellation of political forces in 21st century America, that just isn’t going to happen any time soon.

Republicans ready to revive ACA repeal talks

https://www.beckershospitalreview.com/hospital-management-administration/republicans-ready-to-revive-aca-repeal-talks.html

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Sen. Lindsey Graham, R-S.C., promised to revive ACA repeal in Congress if Republicans can win back a majority in the House and reelect President Donald Trump in 2020, according to an interview on South Carolina radio show “The Morning Answer with Joey Hudson,” featured by The Hill

“This is what 2020 is about: If we can get the House back, and keep our majority in the Senate, and President Trump wins reelection, I can promise you, not only are we going to repeal Obamacare, we are going to do it in a smart way where South Carolina would be the biggest winner,” Mr. Graham said.

Mr. Graham, who failed to pass an ACA repeal plan in 2017, called “Medicare for All” and other Democratic presidential candidates’ healthcare plans “crazy.”  

“Medicare for All is $30 trillion, and it’s going to take private sector healthcare away from 180 million Americans,” he said. Instead, he proposed giving states the power to determine healthcare policy through block grants and other smaller reforms. This would allow states to test conservative healthcare policies against liberal ones, he said. 

“This election has got a common thing: Federalism versus socialism,” Mr. Graham said. “What I want to do is make sure the states get the chance to administer this money using conservative principles if you are in South Carolina, and if you want Medicare for All in California, knock yourself out.”

Conservatives buck Trump over worries of ‘socialist’ drug pricing

https://thehill.com/policy/healthcare/456457-conservatives-buck-trump-over-worries-of-socialist-drug-pricing?utm_source=&utm_medium=email&utm_campaign=24010

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Conservatives are growing increasingly uneasy with the Trump administration’s new drug pricing policy.

President Trump is desperately seeking an elusive political win in his efforts to lower prescription drug costs, but he faces a hard sell to conservative groups and GOP lawmakers as he touts ideas traditionally favored by Democrats and presidential candidate Sen. Bernie Sanders (I-Vt.).

In a rare break with Trump, conservatives are now pushing back against key administration policies and accusing the president of supporting what they call Sanders-style socialism.

The president has embraced importing drugs from Canada, as well as an international pricing policy that would bar Medicare from paying more than other countries for prescription drugs.

The moves are designed to co-opt Democratic talking points and position Trump as a populist champion of the free market.

Trump has made lowering drug prices a top priority of his presidency, but he has suffered some high-profile setbacks in recent weeks.

Drug importation and the international pricing caps proposal are the only remaining policies remaining that the White House can use to make a splash heading into 2020.

Trump has frequently railed against “global freeloading” and said he doesn’t think it’s fair that the U.S. subsidizes research and development in other countries.

Last year he went to the Department of Health and Human Services (HHS) and announced the plan to cap U.S. payments for expensive drugs, over the objections of some White House advisers.

Those objections later spread to include conservative groups.

Facebook ads this year from FreedomWorks, a conservative advocacy group, urged people to tell HHS Secretary Alex Azar to oppose “socialist-style price controls.”

Another ad warned the administration against “importing socialist European drug prices in America.”

Separately, a website sponsored by the American Conservative Union rails against the administration’s pricing index, calling it an experiment “directly out of the Bernie Sanders and Hillary Clinton government health care takeover playbook.”

In the GOP-controlled Senate, a bill backed by the administration is facing Republican opposition over a provision that would impose a limit on drug price increases in Medicare’s Part D prescription drug program.

The legislation would force drug companies to pay money back to the government if their prices rise faster than inflation.

The Senate Finance Committee approved the measure late last month in a 19-9 vote — all Democrats voted for it, and all nine “no” votes came from Republicans. Some GOP senators said they were concerned because they think the Medicare Part D provision violates traditional free-market principles.

The bill faces long odds of making it to the Senate floor without substantial changes.

“I’m not comfortable with putting price controls on drugs,” Sen. Pat Toomey (R-Pa.), a member of the Finance Committee, told The Hill.

Toomey offered an amendment to strip out the provision, which failed on a tie vote of 14-14. All but two Republicans voted for his amendment.

Aside from capping drug payments, Trump has also softened his stance on importing drugs from Canada. The administration last week announced a proposal that would set the groundwork for states or wholesalers to launch pilot programs to safely import drugs.

Shipping in drugs from abroad has long been a goal of progressives like Sanders, but has also won the support of libertarian-leaning conservatives like GOP Sens. Rand Paul (Ky.), Ted Cruz (Texas) and Mike Lee (Utah).

But with Trump looking for a win on drug pricing, political analysts and health experts argue he doesn’t necessarily care about gaining the support of conservatives.

“This is the administration throwing down a wild card,” said health care consultant Alex Shekhdar, founder of Sycamore Creek Healthcare Advisors. “In order to win in 2020, they need to take into consideration independents and anyone else who thinks drug prices are an issue.”

Joe Antos, a health care expert at the conservative American Enterprise Institute, said it doesn’t matter if the policies Trump is embracing are traditionally Democratic ones.

“Just because Democrats endorsed it in the past, doesn’t mean Trump can’t take ownership and call it his idea. He might not call them Republican ideas, but he’ll call them Donald Trump ideas,” Antos said.

But some GOP senators cautioned against letting Democrats play too much of a role.

After the Finance Committee advanced the drug-pricing bill, Chairman Chuck Grassley (R-Iowa) told reporters that Republicans don’t want Trump negotiating with Speaker Nancy Pelosi (D-Calif.).

A competing bill from House Democrats is far more sweeping than the Senate’s, and includes direct Medicare negotiation on drug prices.

“It seems to me that the Grassley-Wyden approach is a very moderate approach to what could come out,” Grassley said, referring to the bill backed by him and Sen. Ron Wyden (Ore.), the ranking Democrat on the Finance Committee.

But a stalled bill could still work to Trump’s advantage, according to Antos, who said the president doesn’t necessarily need to lower drug prices, he just needs to convince the public he is trying. 

In that sense, Antos argued, Republicans haven’t offered anything better, and they will eventually support whatever the administration does.

“Republicans don’t have any alternative ideas,” Antos said. “Trump has full control of Republicans in Congress, so there’s just not going to be any response other than going along with what comes along.”

 

 

 

America’s mental health problem isn’t mass shootings

https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2013.0085

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The U.S. has a gun violence problem and a mental health problem. But conflating the two won’t solve either.

The big picture: The average person suffering from a mental illness is no more prone to violence than anyone without a mental illness, and mental-health advocates say exaggerating a link between mass shootings and mental illness can be stigmatizing and harmful.

Between the lines: “A very small proportion of people with a mental illness are at increased risk of violent behavior if they are not treated,” 2 former CEOs of Mental Health America wrote in Health Affairs in 2013.

  • These are the people with the most severe mental illnesses — often those characterized by paranoia and delusions, the authors added. These people also may have a substance abuse problem or a “history of victimization.”

Yes, but: Nearly two-thirds of gun deaths are suicides, and “mental illness is a very strong causal factor in suicide,” Duke University’s Jeffrey Swanson said.

Even if Congress did decide to further limit people with mental illness’ access to guns, they’ll quickly run up against the mental health system’s broader shortcomings.

  • A patient must interact with the system to receive a mental health diagnosis. And one of the system’s biggest problems is that many people with mental illness can’t get the treatment they need.
  • Only 25% of active shooters included in an analysis released by the FBI last year had ever been diagnosed with a mental illness, even though 62% had appeared to be struggling with some kind of mental health issue in the year before the attack.
  • “The act of somebody who goes out and massacres a bunch of strangers, that’s not the act of a healthy mind,” Swanson said. “But that doesn’t mean that person has a mental illness.”

 

 

 

 

Trump to Sign Medicare Order as Part of Attack on Democrats’ Health-Care Message

https://www.wsj.com/articles/trump-administration-proposal-would-allow-prescription-drug-imports-from-canada-11564580906?utm_source=Sailthru&utm_medium=email&utm_campaign=Newsletter%20Weekly%20Roundup:%20Healthcare%20Dive%2008-03-2019&utm_term=Healthcare%20Dive%20Weekender

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Administration moves ahead to bolster Medicare Advantage plans and authorize lower-cost drug imports from Canada, as it takes on Medicare for All.

President Trump is preparing to sign an executive order next week on Medicare and moving ahead with allowing some drug imports from Canada, part of the administration’s effort to engineer a response to Democratic proposals that candidates say would expand health coverage to all Americans.

The executive order would aim to strengthen Medicare for 44 million Americans and portray the president as defending it against Democrats who want to expand it nationwide under their Medicare for All strategy, a White House official said Wednesday.

The administration on Wednesday also said it would allow the imports of some drugs from Canada, backing an idea most Democratic candidates have also said they support. More executive orders, including one on drug prices, are possible, according to a person familiar with the plans.

Mr. Trump is taking a two-pronged approach to his 2020 campaign message on health care, attacking Medicare for All as socialism and rolling out a blitz of health-care initiatives intended to position him as the person who can drive down costs and protect health care.

The president is expected to contrast the Democrats’ plans with his in a speech set for Aug. 6. “He’s going to indict and impugn the idea of Medicare for All,” a White House official said of the speech. Senior White House aides and agency officials are holding meetings several times a week on health care plans, the official said.

Democratic challengers say Mr. Trump has endangered coverage by backing cuts to Medicare and a lawsuit that could dismantle the Affordable Care Act.

“We are not about trying to take away health care from anyone,” Massachusetts Democratic Sen. Elizabeth Warren said during the candidates’ debate Tuesday. “That’s what the Republicans are trying to do.”

This week, the administration proposed a rule that would compel hospitals to disclose discounted rates with insurers. The president signed an executive order to overhaul kidney-disease care, and the White House relaxed restrictions on pretax health savings accounts so the money can be used on treatment to prevent disease.

Mr. Trump is expected to sign the Medicare executive order next week at The Villages, a Florida retirement community with 120,000 residents that is majority Republican.

Mr. Trump may call for agency action to bolster Medicare Advantage plans, which private insurers offer under contract with Medicare and cover about 22 million people, according to two people familiar with the executive order. The president is likely to focus on curbing waste and abuse in Medicare that can add to the program’s cost. In addition, the order may aim to let Medicare Advantage plans offer a wider array of supplemental benefits. The administration has already taken steps in this direction by letting home health-care providers become partners in the Medicare Advantage contracts.

Mr. Trump also is expected to push for changes that could lower the price of patient visits to hospital outpatient clinics, two of the people said. Those visits can cost more than visits to clinics operated by doctors. “This is part of the president’s broader vision to put American patients first,” one person familiar with the executive order said.

A White House spokesman declined to confirm the details or comment on the executive order.

House Republicans and Health and Human Services Secretary Alex Azar have criticized the plans from Democrats, saying they would end Medicare Advantage and imperil the Medicare program, which covers 44 million Americans.

“Our administration wants to strengthen the program, protect the program, make sure it’s sustainable over the long term,” Seema Verma, administrator at the Centers for Medicare and Medicaid Services, said Wednesday at a press event. “We need to work toward that instead of forcing so many more people onto the program.”

 

 

 

Democratic Debate Turns Ferocious Over Health Care

Candidates in the first night of this week’s Democratic presidential debates sparred over health care coverage.

It took only one question — the very first — in Tuesday night’s Democratic presidential primary debate to make it clear that the issue that united the party in last year’s congressional elections in many ways now divides it.

When Jake Tapper of CNN asked Senator Bernie Sanders whether his Medicare for All health care plan was “bad policy” and “political suicide,” it set off a half-hour brawl that drew in almost every one of the 10 candidates on the stage. Suddenly, members of the party that had been all about protecting and expanding health care coverage were leveling accusations before a national audience at some of their own — in particular, that they wanted to take it away.

“It used to be Republicans that wanted to repeal and replace,” Gov. Steve Bullock of Montana said in one of the more jolting statements on the subject. “Now many Democrats do as well.”

Those disagreements set a combative tone that continued for the next 90 minutes. The health care arguments underscored the powerful shift the Democratic Party is undergoing, and that was illustrated in a substantive debate that also included trade, race, reparations, border security and the war in Afghanistan.

In the end, it was a battle between aspiration and pragmatism, a crystallization of the struggle between the party’s left and moderate factions.

It is likely to repeat itself during Wednesday night’s debate, whose lineup includes former Vice President Joseph R. Biden Jr. and Senator Kamala Harris of California. He supports building on the Affordable Care Act by adding an option to buy into a public health plan. She released a proposal this week that would go further, eventually having everyone choose either Medicare or private plans that she said would be tightly regulated by the government.

Democrats know all too well that the issue of choice in health care is a potent one. When President Barack Obama’s promise that people who liked their health plans could keep them under the Affordable Care Act proved to be untrue, Republicans seized on the fallout so effectively that it then propelled them to majorities in both the House and Senate.

On Tuesday night, Representative Tim Ryan of Ohio evoked those Republican attacks of years ago on the Affordable Care Act, saying the Sanders plan “will tell the union members that give away wages in order to get good health care that they will lose their health care because Washington is going to come in and tell them they have a better plan.”

Republicans watching the debate may well have been smiling; the infighting about taking away people’s ability to choose their health care plan and spending too much on a pipe-dream plan played into some of President Trump’s favorite talking points. Mr. Trump is focusing on health proposals that do not involve coverage — lowering drug prices, for example — as his administration sides with the plaintiffs in a court case seeking to invalidate the entire Affordable Care Act, putting millions of people’s coverage at risk.

It was easy to imagine House Democrats who campaigned on health care, helping their party retake control of the chamber, being aghast at the fact that not a single candidate mentioned the case.

Mr. Sanders’s plan would eliminate private health care coverage and set up a universal government-run health system that would provide free coverage for everyone, financed by taxes, including on the middle class. John Delaney, the former congressman from Maryland, repeatedly took swings at the Sanders plan, suggesting that it was reckless and too radical for the majority of voters and could deliver a second term to Mr. Trump.

Mr. Sanders held firm, looking ready to boil over at time — “I wrote the damn bill,” he fumed after Mr. Ryan questioned whether benefits in his plan would prove as comprehensive as he was promising. Senator Elizabeth Warren of Massachusetts, the only other candidate in favor of a complete overhaul of the health insurance system that would include getting rid of private coverage, chimed in to back him up.

At one point she seemed to almost plead. “We are not about trying to take away health care from anyone,” she interjected. “That’s what the Republicans are trying to do.”

Mr. Delaney has been making a signature issue of his opposition to Medicare for all, instead holding up his own plan, which would automatically enroll every American under 65 in a new public health care plan or let them choose to receive a credit to buy private insurance instead. He repeatedly disparaged what he called “impossible promises.”

He was one of a number of candidates — including Beto O’Rourke, the former congressman from Texas; Senator Amy Klobuchar of Minnesota and Mayor Pete Buttigieg of South Bend, Ind. — who sought to stake out a middle ground by portraying themselves as defenders of free choice with plans that would allow, but not force, people to join Medicare or a new government health plan, or public option. (Some candidates would require people to pay into those plans, while others would not.)

The debate moderators also pressed Mr. Sanders and Ms. Warren on whether the middle class would have to help pay for a Sanders-style plan, which would provide a generous set of benefits — beyond what Medicare covers — to every American without charging them premiums or deductibles. One of the revenue options Mr. Sanders has suggested is a 4 percent tax on the income of families earning more than $29,000.

In defending his plan, Mr. Sanders repeatedly pointed out how many Americans are uninsured or underinsured, unable to pay high deductibles and other out-of-pocket costs and thus unable to seek care.

Analysts often point out that the focus on raising taxes to pay for universal health care leaves out the fact that in exchange, personal health care costs would drop or disappear.

“A health reform plan might involve tax increases, but it’s important to quantify the savings in out-of-pocket health costs as well,” Larry Levitt, executive vice president for health policy at the nonpartisan Kaiser Family Foundation, tweeted during the debate. “Political attacks don’t play by the same rules.”

A Kaiser poll released Tuesday found that two-thirds of the public supports a public option, though most Republicans oppose it. The poll also found about half the public supports a Medicare for all plan, down from 56 percent in April. The vast majority of respondents with employer coverage — which more than 150 million Americans have — rated it as excellent or good.

In truth, Mr. Delaney’s own universal health care plan could also face political obstacles, not least because it, too, would cost a lot. He has proposed paying for it by, among other steps, letting the government negotiate drug prices with pharmaceutical companies and requiring wealthy Americans to cover part of the cost of their health care.

Had Mr. Sanders not responded so forcefully to the attacks, it would have felt like piling on, though some who criticized his goals sounded more earnest than harsh.

“I think how we win an election is to bring everyone with us,” Ms. Klobuchar said, adding later in the debate that a public option would be “the easiest way to move forward quickly, and I want to get things done.”