Medicare-for-All Opponents Push Ads Around Democratic Debate

Image result for Partnership for America’s Health Care Future

An industry group opposed to Medicare for All will launch a slate of new television and digital ads around the Democratic presidential debate on Thursday as part of a seven-figure campaign aimed at eroding support for a federal health-care system.

Ads will also run on Facebook, Twitter, and Snapchat, according to the Partnership for America’s Health Care Future, whose membership includes drug makers, insurers, and others in the health-care industry. The organization said it will take over YouTube’s homepage following the debate.

The ad blitz show industry groups view Medicare for All as a serious threat in a 2020 election. Sens. Bernie Sanders of Vermont and Elizabeth Warren of Massachusetts, who are among the front-runners for the Democratic presidential nomination, back replacing the U.S. health system with a government program that would cover everyone.

The ads say Medicare for All, as well as options that let people buy into a program like Medicare, would lead to higher taxes, worse health care, and amount to government control.

Backers of Medicare for All say the proposal would lower overall U.S. health-care spending, expand coverage nationwide, and free people from costly premiums and deductibles. They say the current system lets insurers and others in the industry make unseemly profits.

The campaign, which is also opposed to buy-in options such as the proposal backed by former Vice President Joe Biden, also launched ads around the previous Democratic presidential debates.


How ‘Medicare for All’ Went Mainstream

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In the last presidential election, the idea of abolishing private health insurance was confined to the far left of American politics. Now it’s the central argument of the Democratic primary race.

On June 17, 2016, 15 prominent Democratic Party activists and elected officials gathered in a hotel conference room in downtown Phoenix. Their job was to formulate language for the party platform, which would be adopted at the following month’s national convention in Philadelphia. But the platform-drafting committee also had an unspoken mission: to defuse the lingering intraparty tension in the wake of Bernie Sanders’s spirited but unsuccessful primary battle against Hillary Clinton.

The Democrats hadn’t faced convention infighting since 1980, when Senator Edward M. Kennedy challenged the incumbent president, Jimmy Carter, and party leaders hoped to use the process of drafting the platform — the compendium of official positions on policies and issues that the party faithful formally approve at the convention — to head off a similar situation. Sanders, the Vermont senator, had been awarded five of the committee’s 15 seats in order to come up with platform language that would be as unifying and unoffensive as possible.

The fifth session was devoted to health care, and it began innocently enough. “The Democratic Party believes accessible, affordable and high-quality health care is part of the American promise,” the committee’s chairman, the Maryland congressman Elijah Cummings, intoned. Several minutes’ worth of earnest self-congratulation about the Affordable Care Act, the legislative centerpiece of Obama’s presidency, followed. The Republican presidential nominee, Donald Trump, had vowed to eliminate “the disaster known as Obamacare,” which mandated that private insurers offer health-insurance plans to those who otherwise didn’t have access to insurance, and mandated that most uncovered Americans enroll in them. The Democrats in the Phoenix conference room were unanimous in their desire to preserve the A.C.A. and to draft platform language assuring the American public that their nominee, Hillary Clinton, would do just that.

A half-hour into the session, Cummings directed the attendees’ attention to a guest on their computer screen. It was RoseAnn DeMoro, the executive director of National Nurses United, the labor group that for years had been the dominant advocate for a government-run national health care system, also known as “single payer” or “Medicare for All.” DeMoro was Skyping in from Chicago, where she was due to speak that evening at the People’s Summit, a gathering of thousands of Sanders supporters. Sanders had requested that DeMoro be given one of his five seats on the platform-drafting committee but had been overruled by Clinton’s loyalists, most likely because DeMoro’s union had loudly supported Sanders over Clinton.

DeMoro, now 70, tends to wear an intent expression that alternates between amusement and withering skepticism. She dispensed with the pleasantries. Obama’s health care program in many ways, she told the attendees, “has fallen short.” Costs were continuing to go up. Sick people continued to be denied coverage. The legislation’s biggest winners were the insurance and pharmaceutical industries. “We’re urging the Democratic Party to put patients before profits,” DeMoro said, “and to make health care for everyone basically a right.”

The Sanders delegates in the conference room applauded enthusiastically. Later the Clinton adviser Neera Tanden reminded DeMoro that the convention intended to feature stories of people whose lives had been saved by Obamacare. Representative Barbara Lee of California insisted that she and other House Democrats had “fought very hard” for single payer. Their goal now should be to “build upon the Affordable Care Act,” Lee argued.

DeMoro was not having it. Building upon a for-profit plan would only serve to entrench the profiteers, she insisted. For every Obamacare success story Tanden might wish to promote, she told the committee, the nurses could recite a multitude of tragedies. “You are not ever going to corner the nurses into saying it’s adequate,” DeMoro said. “I see the dynamic that’s happening here,” she added, her eyes narrowing. “You think that I’m criticizing the Democratic Party for not fighting hard enough for a single-payer health care system. And I think that’s probably accurate.”

Onstage that evening at the People’s Summit, DeMoro gleefully recounted the rancorous exchange. “They wanted me to say that the Democratic Party fought hard enough,” she told the audience. “But in reality, they didn’t.” Then, to thunderous applause, DeMoro said, “When I appeared by Skype before the committee, I could feel the Bernie movement’s power. I could feel the 58 percent of the American people who support single-payer health care.”

That power was not enough to sway the platform committee, which by a margin of one vote elected not to include any mention of a single-payer system in its 45-page official document. A little more than a month later at the Democratic convention, DeMoro remembers running into Lee. Lee, a liberal from DeMoro’s state, was still stung by her criticism. “Man, you went after me hard!” DeMoro recalls Lee saying. As a state senator in 1998, Lee reminded her, she had co-written a single-payer bill that died in committee. And Lee had, in fact, joined Sanders’s five drafting-committee members in voting to include single-payer language in the party platform.

DeMoro regarded Lee’s efforts as insufficient. The Sanders campaign’s success in making Medicare for All a defining progressive issue, she told me recently, “was a time in history when you knew change had come and the movement was moving past the standard-bearers of the left. It was one of those lead-or-get-out-of-the-way moments. And Barbara was playing an insider game and wasn’t willing to fight.”

Like many progressive activists, DeMoro — who retired from National Nurses United last year but remains an influential voice on the left — views her movement’s proximate adversary as the Democratic establishment rather than Trump’s Republicans. Of late, she has devoted much of her social-media energy to deriding Senator Kamala Harris, whom she has called “Chameleon Harris” on Twitter. A longtime resident of the Bay Area, DeMoro viewed Harris more or less favorably when she was California’s attorney general. But as Sanders’s presidential opponent, she had, to DeMoro’s thinking, revealed herself to be a transparently calculating triangulator: “There’s no there there.”

The day before the second round of Democratic presidential debates in Detroit, Harris’s campaign announced her new health care plan, which would guarantee universal coverage but also keep private insurers. Even though the plan was not a single-payer system, Harris had nonetheless felt compelled to call it Medicare for All. Three weeks later, however, she would tell her donors, “I’ve not been comfortable with Bernie’s plan, the Medicare for All plan.”

The contortions suggested how much the politics of health care among Democrats had changed — and how much Sanders and DeMoro had changed them. In a party that three short years ago kept single-payer advocates at Skyping distance, Medicare for All now sits at the head of the table, pulling the Democrats decisively leftward. Sanders’s Medicare for All bill in the Senate has 16 co-sponsors. In the House of Representatives, Pramila Jayapal, who is the co-chairwoman of the Progressive Caucus, has introduced a health care bill with 117 Democratic co-sponsors that is even more lavish in its benefits (and thus probably costlier) than the plan Sanders has put forward in the Senate; it, too, is called Medicare for All. In addition to Harris, two other presidential candidates have offered health care plans that pilfer from Sanders in name if not in substance: Pete Buttigieg, with Medicare for All Who Want It; and Beto O’Rourke, with Medicare for America — the latter borrowing from a proposal developed by Neera Tanden’s Center for American Progress, itself called Medicare Extra for All. The idea’s original advocates, like DeMoro and Sanders, after years of struggling to get into the mainstream Democratic policy debate, suddenly have an embarrassment of allies — or at least people who claim as much. “Medicare for All shouldn’t mean all things to all people,” Warren Gunnels, Sanders’s senior campaign adviser, told me. “It’s single payer. Everybody else’s program is Medicare for Some.”

Medicare for All, as envisioned by Sanders in a 2017 Senate bill, would expand coverage in phases over a four-year period. Drug co-payments would not exceed $200 a year. The overall cost of the plan would be roughly $30 trillion over a decade. According to an analysis by the University of Massachusetts Amherst’s Political Economy Research Institute, that amount would be largely offset through savings in areas such as administrative overhead, pharmaceutical costs and physician salaries. A combination of payroll, sales, capital gains and income taxes could pay for the remainder. The result would be a government-run health care system in which Americans of all ages are covered, are able to select whichever doctor they choose and incur almost no out-of-pocket expenses.

Not since the Great Society era has so ambitious a social program been so actively promoted by influential Democrats. Whether this is a good thing, both as a matter of policy and for a party longing to defeat Trump next year, is currently at issue. On the one hand, the predominance of health care as a voting concern typically favors Democrats; as Sanders’s pollster Ben Tulchin put it to me, “When the conversation is about health care, we’re already winning.”

Single-payer advocates achieved a victory of a sort in the July 30 Democratic presidential debate in Detroit, when the CNN moderator Jake Tapper said, “Let’s start the debate with the No. 1 issue for Democratic voters, health care — and Senator Sanders, let’s start with you.” The 10 candidates onstage discussed Medicare for All for the next 20 minutes — longer than any other issue.

It was an establishing shot that lingered even when the night’s camera frame panned over to immigration and climate change. A couple days after the debate, an ABC News/Ipsos poll showed that when Democratic voters watched both a video of Sanders explaining the virtues of Medicare for All and a video of the front-runner Joe Biden arguing for simply improving Obamacare, 31 percent found the Sanders plan “very convincing,” while only 18 percent said the same of Biden’s position.

A few days later, however, a Monmouth University poll of likely Democratic caucusgoers in Iowa found that 56 percent preferred the option to receive Medicare, as opposed to a mere 21 percent favoring a government-run plan that abolished private insurance. It underscored the fears of Democrats on the center-left that the issue will boomerang on them in 2020 — that campaigning on an entirely government-run health care system, the creation of which would remove about 156 million Americans from their employer-based plans, according to a Kaiser Family Foundation analysis, will invite an electoral backlash. “It’s been the case of health care policy for decades,” Tanden told me. “If a health care plan is perceived to be about protecting something, it’s usually good. If it’s about losing something, it’s usually toxic.”

Eighteen percent of the United States economy, or $3.5 trillion, is tied to health care, up from 5 percent in 1960. The United States spends at least double per capita what other industrialized nations spend on health care. The health sector is among America’s most profitable industries. And despite the vast profits and expenditures, the United States has comparatively worse health outcomes than other advanced nations that spend far less on health care: higher overall mortality rates, higher premature deaths and higher preventable deaths — all on top of the fact that two-thirds of all bankruptcies and nearly half of all foreclosures in America today are related to medical costs.

In spite of these dismal returns, the health care system has proved extraordinarily resistant to disruption — no doubt in part because of the uniquely palpable stakes. “Health care is unlike any other issue,” Tanden says. “People feel an expertise about it, because they’ve lived it. It’s very personal to them: They think of the care of their child, of their aging parents, of their own vulnerability.”

Though highly attuned to the health care system’s deficiencies, the public has also been fretful that their political leaders will only succeed in making a flawed system worse. For a quarter century, Gallup polls have found that almost without exception, 65 to 73 percent of Americans believe the health care system to be in a state of crisis or having major problems. The same polls observed Republicans feeling especially dire starting in 2010, while conservatives were condemning Obamacare; and Democratic fears spiked in 2018, after Obamacare narrowly escaped repeal by congressional Republicans.

Those sentiments might suggest that Americans would prefer the government to leave well enough alone. But at a moment when a reconsideration of the party’s staid politics is already brewing, they might just as easily be interpreted as a call to arms: a rationale for burning down the system and starting anew.

“I’m not an incrementalist,” DeMoro told me one afternoon at a pizza restaurant in Napa, where she now lives in retirement. “I firmly believe that change happens through rupturing. Trump’s a prime example of that. And the Democrats have used Trump as an excuse not to have a platform of their own. Well, Bernie’s running for systemic change.”

DeMoro became the executive director of the California Nurses Association in 1993. The daughter of the owners of a pizza parlor and a beauty salon in St. Louis, she had never worked in the medical profession. She was fluent in political theory as well as in blue-collar issues and had become close with two of the most tenacious grass-roots activists in postwar American history: the labor organizer Tony Mazzocchi, who successfully agitated for passage of the Occupational Safety and Health Act of 1970; and Ralph Nader, who prodded Congress to pass the Consumer Product Safety Act into law in 1972. “She was steeped in the history of the labor movement, had a critical mind and locked horns with everybody,” Nader recalls. “She would trash the A.F.L.-C.I.O. for lacking substance and courage. But she also really understood the issues. I thought she was the greatest labor leader out there.”

DeMoro took her post shortly after Bill Clinton was elected president, at a moment when rupture seemed imminent in the American health care system. The number of uninsured Americans under 65 had risen steadily from 33.4 million in 1989 to 37.1 million in 1992. (It would be 41.6 million in 2004.) This troubled a Washington State congressman and former child psychiatrist named Jim McDermott. As a medical-school student in the early 1960s, McDermott watched with interest as Canada built its single-payer system while, he recalled, “the American Medical Association leadership predicted that this was the end of the profession, socialized medicine, blah blah blah. Then they said the same about Medicare, until it became a goddamned cash cow for doctors.”

By 1993, McDermott was single payer’s leading champion in Congress. That same year, he put forward a single-payer bill in the House. (Among its 90 co-sponsors was an obscure Vermont freshman named Bernie Sanders.) “Then Clinton came into office,” McDermott told me recently. “Mrs. Clinton needed my 90 votes for their health care plan. She didn’t want to have anything that looked like socialism. She said, ‘Jim, you want to take out the insurance industry, but it’s deeply embedded in our society.’ ”

McDermott gamely offered his support. But Hillary Clinton’s determination to preserve the private insurance system was not enough to assuage Republicans or health care industry lobbyists. The 1,342-page Clinton plan known as “Hillarycare,” which required employers to either provide insurance or pay a penalty that would finance insurance exchanges, was demonized by the health-insurance industry’s “Harry and Louise” TV ads as a wallet-busting bureaucracy that would eliminate Americans’ right to choose their doctors.

The Democrats abandoned their efforts six weeks before the 1994 midterm elections so as to minimize the political damage. In the years that followed, health care costs rose and coverage rates fell. In 1999, medical expenses consumed 14 percent, on average, of American’s take-home pay. By 2017, that figure would more than double, to 31 percent.

These costs ballooned despite the health care industry’s efforts to maximize efficiency through a “managed care” approach, restructuring hospitals and clinics as health maintenance organizations, or H.M.O.s. Under the H.M.O. model, nurses found themselves losing status, leverage and in some cases their jobs. Those who remained employed often found their jobs transformed. “We as nurses were expected to get ’em out fast and move on,” Elizabeth Pataki, a former nurse and labor activist (and cousin of New York’s former governor George Pataki), recalls. “It was heartbreaking to see how little care they were getting and how so many of them couldn’t pay their deductibles, how their premiums were becoming ruinous, how they would ration their medicine by breaking it in half.”

That was the landscape DeMoro encountered as she led the undersize 17,000-member California Nurses Association into the fight against what she would term “the commodification of health.” She spent hours on picket lines with the nurses and absorbed their eyewitness grievances. In the male-dominated world of union leadership, the C.N.A. president stood out. “Nurses of a certain age like me didn’t have role models back then, except perhaps nuns and teachers,” Pataki says. “But RoseAnn, for many of us, showed what it meant to be a woman of commitment, to be warm and funny but also dedicated and direct. I could see where we could go with her.”

They did not go very far at first. In 1994, DeMoro’s California-based union pushed the State Legislature to adopt a single-payer bill, to no avail. Two years later, DeMoro’s union promoted Proposition 216, which aimed to curb the ability of hospitals and H.M.O.s to restrict coverage, only to be bombarded by TV ads (paid for by a coalition of H.M.O.s and business affiliates) conceived by the same political consultants whose “Harry and Louise” ads were used to defeat Clinton’s health care initiative.

The 2008 presidential campaign offered fleeting hopes for single-payer advocates. As a state senator in 2003, Barack Obama proclaimed himself to be “a proponent of a single-payer universal health care program.” Late in the summer of 2007, DeMoro remembers receiving a call from an Obama campaign staff member. The candidate was coming to the Bay Area, the staff member said. Would she like to spend the day driving around with him and discussing health care?

DeMoro agreed. But in typical fashion, she commissioned radio advertisements on the eve of Obama’s arrival, urging the candidate to openly advocate for a single-payer system. “I got a call from one of his people, asking, ‘Did you guys do this ad?’ ” she recalled. “And when I said it was us, they canceled the visit.”

Her union, which by 2008 had grown to around 100,000 members, nonetheless held events around the country for Obama. But in office, DeMoro told me, Obama “proved that he had learned exactly the wrong lesson from Hillarycare.” Insurance and pharmaceutical companies who viewed single payer as an apocalyptic proposition were awarded seats at the table, as were Republican senators.

“Barack said, ‘I don’t want to just message this issue, I want to get something done,’ ” Tom Daschle, Obama’s early pick for Health and Human Services secretary, told me. “The view was that if we started more moderately and reached out to Republicans with something they supported in the past, we’d have something we could accomplish. There were some who believed that Medicare was a good brand that we could expand on. But he didn’t believe Republicans were likely to join that effort.”

The question was whether Republicans were likely to join any effort. The party had been staunchly opposed to government health care expansions, including Medicare, for half a century, arguing instead for market-driven solutions, tax credits and restricting malpractice claims. (An exception to this was when President George W. Bush successfully pushed to extend Medicare coverage to include prescription drugs in 2003 — an industry-friendly initiative that was interpreted by some as a means of shoring up the president’s support among senior citizens in advance of the 2004 election.)

In practice, however, Republican lawmakers have struggled to reconcile what Ronald Reagan termed “the magic of the marketplace” with tens of millions of Americans’ inability to pay for adequate health care. Obama forced the issue by proposing a health care reform built on the bones of a 20-year-old market-based proposal from the conservative Heritage Foundation. “My line at the time,” Charlie Dent, a moderate Republican congressman from Pennsylvania who retired last year, told me, “was that every American had a right to have access to affordable health care insurance.”

The more expedient option was for Dent’s party to weaponize the issue. Obama and congressional Democrats spent a year and a half trying to engage Republicans on health care, along the way discarding one preferred policy option after the next in hopes of forging a bipartisan agreement.

Max Baucus, the Montana Democrat who was chairman of the Senate Finance Committee at the time and led the negotiating effort, had visited a Canadian hospital and was an admirer of that country’s health care system. Still, when he began committee meetings on health care in late 2008, “I told them, ‘Let’s find a uniquely American solution,’ ” he recalled. “ ‘And nothing’s off the table.’ The only exception to that I made was single payer. I thought our country was just not ready for it. I assumed that if we worked together in good faith that over time, we’d naturally evolve toward that kind of system.”

A few of the Republican senators on the committee, like Chuck Grassley of Iowa and Olympia Snowe of Maine, were active participants in Baucus’s meetings. Eventually, however, the Senate minority leader Mitch McConnell made clear his desire not to hand the new president any legislative victories.

“The Republicans started calling it Obamacare,” Baucus said, “and it tapped into a significant portion of the electorate’s opposition to the president. It was political in the end: ‘Hey, we can run against this thing.’ Grassley was under immense pressure from McConnell, who threatened to primary him if he stayed with this. He told me that, flat out.” (Spokespeople for Grassley and McConnell adamantly deny that McConnell applied any pressure on Grassley.) The Affordable Care Act passed in March 2010 without a single Republican vote.

In March 2015, Sanders paid a visit to DeMoro. Their relationship began in 1981 when DeMoro, then a graduate student at the University of California, Santa Barbara, contributed $20 to Sanders’s first campaign for mayor of Burlington, Vt. (Sanders won by 10 votes.) As mayor, Sanders became convinced, through conversations with physicians in Canada, that a single-payer system was the only sustainable means of delivering universal health care. Like DeMoro, he condemned any system that preserved a profit-dominated model, including what would later be known as the public option, as one that would inevitably shortchange patient care.

Now he told DeMoro that he was thinking seriously of running for president as a Democrat. Knowing that he would be heavily outspent by Hillary Clinton and her allies, he wanted DeMoro’s opinion as to whether he could count on grass-roots support. By that point, the California Nurses Association had joined together with other nursing unions in an umbrella organization, the more than 150,000-member National Nurses United, with DeMoro at its helm. Although DeMoro doubted that Sanders had much of a chance, she saw his candidacy as an opportunity to elevate the single-payer issue. In August, her organization became the first major union to endorse Sanders.

Sanders, as a presidential candidate, was an outlier’s outlier, and single payer had been deemed political kryptonite by the Democratic establishment. But DeMoro’s union bankrolled a series of surveys and focus groups by Sanders’s pollster Ben Tulchin. Tulchin was a rueful admirer of the conservative movement’s ability to frame policies in memorable ways: rebranding the estate tax as a “death tax,” for example, or slashing government programs for the poor in the name of promoting “freedom.” Democrats were too equivocal in how they framed their ideology, in Tulchin’s view. He sought to change that by devising a crisper way to sell a government-run health care system to the public.

The rebranding efforts by Tulchin happened to coincide with a gathering of progressive discontent. Throughout the 1990s, the left had more or less abided the Clinton administration’s apologetic view of big government as the cost of staying in power. In 2008, after eight years of Bush’s promoting tax cuts for the wealthy, threatening to constitutionally forbid gay marriage and waging two costly wars, progressives believed their moment had arrived and saw in Obama a new champion. But his legislative efforts proved to fall well short of revolutionary. While admonishing the left to play along and accept one moldy half-loaf after another — on the economic stimulus, on climate change, on gun control, on immigration and on several judicial appointments — the Obama White House’s varied attempts to attract Republican support met only scorn.

To many progressives, Obamacare represented the apotheosis of this strategic folly. The president’s health care initiative played by the private sector’s rules, to the pharmaceutical industry’s conspicuous benefit. And then free-market Republicans rewarded this gesture of conciliation by bashing Democrats as socialists while methodically eviscerating the program on both the state and federal levels. When in 2012 it appeared that the conservative-dominated Supreme Court might declare the A.C.A. to be unconstitutional, DeMoro led the nurses’ union on a bus tour to make the case that the time had arrived for a robust, lawsuit-proof single-payer system. The campaign was premature, however: Chief Justice John Roberts cast the tiebreaking vote in favor of Obamacare, and again progressives were compelled to leave the fight. They watched red-faced in the 2014 midterms as some of the Democratic Party’s most cautious-minded legislators were labeled big-government liberals, enabling the G.O.P. to retake the Senate. By the time the party machinery began clearing the way for Hillary Clinton’s nomination, the left had grown tired of shutting up and was now looking to a dyspeptic 74-year-old Vermont socialist as their avatar.

As Tulchin conducted his public-opinion research to address the question of how Sanders might frame his health care initiative, he hit on an answer that was hiding in plain sight. It came from the legacy of Lyndon B. Johnson, who as president had pushed Medicare and Medicaid through Congress. As Tulchin told me: “The reality is, people know what Medicare is, and it’s very popular and seen as very effective. It’s a true success story for the left. Whereas no one knows what single payer is.”

Tulchin’s findings convinced the Sanders campaign to recast single payer as “Medicare for All” — a name that had previously appeared on a 2006 health care bill written by Senator Edward M. Kennedy that included a role for private insurers. (Kennedy had been an early proponent of single payer but had come to believe that opposition from the insurance industry would doom its chances.) Sanders and DeMoro knew that the word “Medicare” would register favorably among older Americans. They had not anticipated the issue’s overwhelming popularity — close to 70 percent, according to recent polling — among millennial voters. “This had been a gray-haired movement for decades,” DeMoro told me. “It surprised all of us how resonant the issue was with young people.”

Sanders’s early campaign events were packed, in no small measure because of the mobilizing efforts of the ubiquitous union members dressed in National Nurses United’s trademark red hospital scrubs. The union’s political-action committee purchased more than several million dollars’ worth of print and TV ads. Sanders, meanwhile, occasionally called DeMoro from the campaign trail to enlist her help in demystifying the arcane mechanics of the health care industry. “When a single-payer system is finally enacted in the U.S.,” he told an aide, “RoseAnn DeMoro and the nurses are going to be the heroes of this fight.”

Although the Democratic platform committee shunted aside Medicare for All in favor of preserving the Affordable Care Act, Trump’s shocking victory in November shifted the ground again. The longstanding efforts by G.O.P. state officeholders and the Republican-controlled Congress to chip away at the A.C.A. now had an eager partner in the White House.

Shortly after the election, Sanders persuaded the Senate minority leader, Chuck Schumer, to borrow a page from Sanders’s 2016 campaign and stage pro-Obamacare rallies across the country. Those health care events — the first of them on Jan. 15, 2017, with Sanders, Schumer and other Democrats speaking before 6,000 people in Warren, Mich. — began a counteroffensive that ultimately thwarted the G.O.P.’s ambitions of repealing Obamacare.

The rallies, and the crowds they drew, suggested how the politics of health care were changing, and how quickly. Trump and congressional Republicans spent most of his first year in office working relentlessly to repeal Obamacare, an effort that barely fell short in the Senate in August. Republican governors picked up the gauntlet: by December 2018, 20 states had joined a lawsuit seeking to weaken Obamacare.

The imperiling of the Affordable Care Act had unintended consequences. One was that, after years of unpopularity, the law began polling favorably. In the 2018 midterms, it was the Republicans who were on the defensive and stammering that, well, sure, there were a few good things about Obamacare and they could be counted on to protect those things. “I’m taking on both parties and fighting for those with pre-existing conditions,” the California Republican congressman Dana Rohrabacher claimed in a TV ad, despite having voted repeatedly to gut or repeal Obamacare. Voters did not seem to buy the G.O.P.’s protestations. Exit polls following the November 2018 midterm elections, in which Republicans lost 38 seats — including Rohrabacher’s — and control of the House, showed that health care was the top concern.

But the vulnerability of Obamacare also served to underscore the case for a more resilient and comprehensive health care system of the sort that Sanders had been calling for. Medicare for All had become not merely a pet cause among the party’s progressive base but a defining one. It had also become a succinct representation to voters of what Democrats aspired to do for them that Trump’s Republicans would not.

That it had fallen to Sanders to rally Democrats to save what he found an inferior health care policy was a peculiarity not lost on Sanders, who growled to me: “I don’t think anyone will tell you that in any way single payer was seriously considered. In fact, until this year there’s never even been a goddamned hearing on single payer!” The first such hearing took place on April 30, but under the auspices of the House Rules Committee, which has no legislative jurisdiction on health care. A more meaningful second hearing was convened before the powerful House Ways and Means Committee two months later.

‘It surprised all of us how resonant the issue was with young people.’

The hearings were in a sense a validation of Medicare for All’s newfound legitimacy within the mainstream of the party, but they also demonstrated the party leaders’ wariness of the idea. The Democratic Ways and Means chairman, Richard Neal — who received nearly $550,000 in the 2018 election cycle from the health insurance and pharmaceutical industries — had already stated his preference for “a little more incremental” expansion of health care. According to The Intercept, Neal urged his fellow Democratic committee members beforehand to consider using phrases like “universal health coverage” rather than “Medicare for All.”

On one level, these are academic debates. Unless Democrats can break the Republican lock on the Senate in 2020 — a longer-odds proposition than winning the presidential election — they will have no chance of passing any laws, let alone an overhaul of health care far more sweeping than the A.C.A., which Democrats barely managed to enact with a majority in the Senate.

But on another level, the debate isn’t academic at all. It is in fact at the core of the liberal-versus-pragmatic argument among the Democratic presidential candidates, with the former vice president Biden on one end, flashing his battle scars from the Obamacare fight, and Sanders and Warren on the other, arguing that a populist movement now demands more than minor tweaks to a fundamentally flawed health care system. And indeed, on Aug. 21 Sanders tacitly acknowledged the challenge in passing so drastic a change in policy: His campaign announced that his Medicare for All plan had been modified to ensure that union workers who had already negotiated satisfactory health-insurance plans would be compensated for whatever wage increases they had sacrificed in the process.

Several health care experts with whom I spoke consider the Sanders plan, strictly as a matter of policy, to be an entirely reasonable health care solution for America. “The U.S. is an outlier in the rest of the developed world in not having universal coverage and for having such high-cost health care,” Larry Levitt, the nonpartisan Kaiser Family Foundation’s executive vice president for health policy, told me.

Sanders’s proposal “would be an enormous shift in how we pay for health care, and you have to make a lot of assumptions about how that would work, with a lot of uncertainty,” Levitt continued. “For example, how far down could prices for hospitals, physicians and drugs be pushed? How much more health care would people use if we had universal coverage with no deductibles and co-pays? And how well could the supply of hospitals and doctors adjust to an increase in use of health care? There’s a lot of uncertainty to how all of this would play out. But there’s a fair amount of consensus among economists who’ve looked at it that we could provide universal coverage through a Medicare-for-All-type plan and not pay much more for than we’re currently paying.”

Still, the change would be monumental. “The Sanders proposal would leapfrog every country in the world in creating a more liberal health care system,” Levitt said. “Every other system with universal coverage has at least some out-of-pocket costs for patients. And almost every other country still allows for private insurance.” And insurance companies in Europe, for instance, are often nonprofit, highly regulated and with little to no political power. American insurance companies are a different story, and it seems fair to conjecture that they will not forsake their billions in net earnings without a fight.

Though polling does not reflect an outpouring of love for private insurance, it is the devil Americans know. “There’s fear of change and comfort with what’s known, a bias toward the status quo, and it’s hard to quantify that,” says Topher Spiro, the Center for American Progress’s vice president for health policy. “There’s a real psychological issue that’s appropriate for policymakers to consider. I don’t think the people like us who are putting forth multipayer universal systems are doing so because we think insurers have some sort of superior efficiency or can improve the quality of care. It’s really a concern about how we get there the quickest in terms of political viability and with a minimum of disruption.”

Single-payer advocates play down the difficulty of transitioning into a government-run health care system. As Sanders puts it: “You have Medicare, a popular system that millions of people are already in. It seems to me the easiest way forward to get to universal care is to expand what’s already a popular system. I find it really amazing that people think this isn’t doable when back in 1965 they did Medicare without the technology we have today, and they were able to sign up 19 million people. So of course we can do it.”

But while the Republican efforts to gut Obamacare have bolstered support for a more ambitious health care policy, they have also clearly illustrated one potential downside of such a policy. “Medicare cuts are in Trump’s budget,” Tanden says. “If you’re worried about a Trump administration now, just imagine if the government has control of everyone’s health care. And I say that as a big-government liberal.”

The day before Sanders took to the debate stage in Detroit to defend Medicare for All, I met with him in a conference room at the Doubletree Suites hotel where he was staying. He was seated alone, wearing his customary off-the-rack navy suit and tieless white shirt, flanked by a Starbucks breakfast of coffee, granola and yogurt.

“We’ve got a health care crisis in this country,” he told me as he struggled with the plastic granola container, finally gouging it open with his car keys. Sanders has a reputation for being as beatific as a snapping turtle, but today he was happy(ish) to be discussing the topic that he and DeMoro had succeeded in crowbarring into the national debate. “You’ve heard me talk about F.D.R. in 1944 talking about economic rights as a human right,” he said. “That’s what we’re doing here, and I think with some success: changing consciousness in this country. Now everybody agrees health care is a human right. How you get there is subject to discussion. But that’s where we are.”

Recently Sanders had been campaigning in Las Vegas. While driving through the city, he marveled at the billboards advertising marijuana for sale. “Five years ago, corporations marketing marijuana would have been out of the question,” he said to the aides in his car. “Now they’re not only doing it, but it’s not even remarkable that they’re doing it. Politics change very quickly.”

A not-so-minor refinement to that thought would be: Politics change quickly as long as nothing is standing in the way. Nearly three decades have passed since Sanders and DeMoro began doing battle with the health industry and the political system. “What they do have is, they lie and they have an enormous amount of money — I get that,” Sanders conceded. “But I do think we’re at a moment in history where the American people are sick and tired of the insurance companies and drug companies. And I do believe we can beat them.”

For any movement, the answer to the question of how is not really legislative. The Rev. Martin Luther King Jr. had his dream. RoseAnn DeMoro told me hers recently. “I think it’s time now,” she said, smirking a bit as she studied her glass of white wine. “I think America needs to say to these C.E.O.s: ‘You’ve had your day. You’ve bought your 50 frigging yachts. But it’s over. Now let’s have health care in this country.’ ”





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

Image result for conflict of interests

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.

In Wednesday’s second Democratic debate, 7 of 10 candidates support Medicare for All

Democratic candidates take the stage during first debate in June.

Expanding coverage, lowering healthcare costs, central to Democratic agenda.

Tonight, Joe Biden, Kamala Harris, Cory Booker, Andrew Yang, Julián Castro, Tulsi Gabbard, Michael Bennet, Jay Inslee, Kirsten Gillibrand, Bill de Blasio take the stage for round two of the Democratic presidential debates.

Seven support Medicare for All. The others – Biden, Bennett and Inslee have come out in favor of a public option. Here, in no particular order, is a look at where each candidate stands on healthcare coverage.

Joe Biden

As vice president to President Barack Obama, former Senator Joe Biden carries into this election the legacy of the Affordable Care Act. As president, Biden said he would protect the ACA and prevent further Republican attempts to dismantle it.

Unlike many of his Democratic rivals, Biden does not support full Medicare for All. Instead of getting rid of private insurance, Biden said he would build on the ACA through the Biden Plan to create a public health insurance option. As in Medicare, costs would be reduced through negotiating for lower prices from hospitals and other providers.

He also has a plan to increase the value of the ACA tax credits by eliminating the 400% income cap on tax credit eligibility and lowering the limit on the cost of coverage from 9.86% of income to 8.5%. This means that no one would spend more than 8.5% of their income on health insurance. Additionally,  Biden would base the size of tax credits on the cost of the higher-tiered gold plan, rather than silver plan.

Biden also supports premium-free access to the public option for individuals in the 14 states that have not expanded Medicaid under the ACA. States that have already expanded Medicaid would have the choice of moving the expansion population to the premium-free public option, as long as the states continue to pay their current share of the cost of covering those individuals.

Biden also promises to stop surprise billing, tackle market concentration, repeal the exception allowing drug companies to avoid negotiating with Medicare over drug prices and limiting the launch price for drugs that face no competition, among other actions.

In his words: “When we passed the Affordable Care Act, I told President Obama it was a big deal – or something to that effect.”

Kamala Harris

California Senator Kamala Harris often refers to her mother’s diagnosis of colon cancer and her Medicare coverage for treatment as an example of why all Americans should have Medicare for All.

Harris is looking to eliminate premiums and out-of-pocket costs through government insurance that guarantees comprehensive care including dental and vision and coverage. Harris gives no estimate of the cost of universal healthcare, but says taking profit out of America’s healthcare system would save money.

Her Medicare for All plan, which is similar to Senator Bernie Sanders – would cover all medically necessary services, including emergency room visits, doctor visits, vision, dental, hearing aids, mental health and substance use disorder treatment, telehealth and comprehensive reproductive care services. It would allow the Secretary of Health and Human Services to negotiate for lower prescription drug prices.

As former Attorney General of California who won a $320 million settlment from insurers, Harris said she wants to take on Big Pharma and private insurers to lower the cost of prescription drugs.

She also has strong views on prosecuting opioid makers and for preserving women’s right to healthcare and protecting Planned Parenthood from the financial cuts and policies of the Trump Administration.

She would institute an audit of prescription drug costs to ensure pharmaceutical companies are not charging more than other comparable countries, a comprehensive maternal child health program to reduce deaths among women and infants of color, and rural healthcare reforms, such as increasing residency slots for rural areas with workforce shortages and loan forgiveness for rural healthcare professionals.

In her words on the ACA: “As someone who fought tooth and nail as Attorney General and as Senator to prevent repeal, that’s exactly what I will continue to do.”

Cory Booker

Senator Cory Anthony Booker, first African-American Senator from New Jersey, and former mayor of Newark, is also a Medicare for All proponent.

He also wants to implement universal paid family and medical leave.

He supports lowering costs for prescription drugs by allowing Medicare to negotiate prices and by importing drugs from Canada and other countries, the latter a policy announced today by Health and Human Services Secretary Alex Azar.

He would also invest in ending the maternal mortality rate and work to reduce racial disparities in maternal mortality rates.

One of his big issues is expanding eligibility for long-term services and support for low and middle-income Americans needing care at home. He wants long-term care workers to be paid a minimum of $15 an hour.To limit the impact of the program on state budgets, the new costs associated with the expansion of Medicaid long-term care services and workforce standards would be financed entirely by the federal government in, effectively, a 100% match. The cost would be financed by making the tax code more progressive by reforming the capital gains, estate, and income taxes.

In his words: “Healthcare is a human right.”

Kirsten Gillebrand

Kirsten Gillebrand, U.S. Senator from New York, originally ran for a House seat in that state on a platform that supported the expansion of Medicare, a view she still holds, and in 2017 expressed support for Senator Bernie Sanders’ Medicare for All bill.

In May, Gillebrand reiterated her support, saying the best way to achieve a single-payer system is to let people buy-in over a transition period of about four to five years. She favors allowing a public option to create competition with insurance companies. Medicare needs to be fixed first so that reimbursement rates better reflect costs, she said.

In 2011 she helped pass the James Zadroga 9/11 Health and Compensation Act, which provides treatment to the first responders of the Sept. 11, 2001 terrorist attacks. The law provides health monitoring and services for 9/11-related health issues among those exposed to the debris and tainted air of the attack’s aftermath.

In her words: “Under the healthcare system we have now, too many insurance companies continue to value their profits more than they value the people they are supposed to be helping.”

Bill de Blasio

New York Mayor Bill de Blasio believes everyone, including undocumented immigrants, has a right to receive healthcare, and has repeatedly voiced his support for a national single-payer health plan.

He and rival Elizabeth Warren raised their hands during the first debate when asked if they supported Medicare for All.

One of his accomplishments as mayor was signing a bill into law that established a paid sick leave and safe leave plan for the city.

First unveiled in January, the program NYC Care, guarantees healthcare for the roughly 600,000 New Yorkers who aren’t currently insured, which de Blasio touted as the “most comprehensive health system in the nation.” He has indicated that NYC Care could become a model nationwide.

The plan encompasses primary and specialty care, pediatric and maternity care and mental health services. The idea is that NYC Care works on what de Blasio said was a “sliding scale,” in which people can essentially pay what they can for care. While the city already has a public option for healthcare, de Blasio said NYC Care will pay for direct comprehensive care for people who can’t afford insurance or who aren’t covered by Medicaid.

The program costs $100 million per year for the city — an investment the mayor expects will yield returns.

In his words: “If we don’t help people get their healthcare, we’re going to pay plenty on the back end when people get really sick,” he said recently on MSNBC’s “Morning Joe” broadcast.

Jay Inslee

Washington Governor Jay Inslee has planted a flag as “the climate change candidate” and in many ways he’s all in on that single issue, reasoning that things like healthcare policy “become relatively moot if the entire ecosystem collapses on which human life depends.”

That said, he has a strong case to make on healthcare by virtue of having just recently put his state’s money where his fellow candidates’ mouths are: in May he signed the country’s first public option into law in Washington.

Expect him to bring up that accomplishment — in which the state will contract with private insurers to create a public option that pays at Medicare plus 60 percent — in any conversation about healthcare, as he did in the first debate.

In his words: “We hope this will be a smashing success. We hope that it will give a shot of courage to other governors to move forward toward universal access. We were willing to take the leap and we’re gonna learn as we go along, I’m sure, and there will be some modifications. But we had to get started.”

Michael Bennet

Colorado Senator Michael Bennet supports a public option he calls Medicare-X. But where his plan stands apart from others is a strong focus on the rural-urban divide on access to care. He intends to create a healthcare policy that will ensure that all regions of the country are covered by available health plans, addressing what he calls a failure of the ACA exchanges.

His plan is unusually detailed and includes lowering prescription drug prices, closing existing gaps in care, and, yes, promoting telemedicine and other technology that can bolster rural healthcare. He also has provisions for combatting substance abuse, improving maternal and mental health, and bringing more support to senior caregivers.

In his words: “As president, I would build on the Affordable Care Act to cover everyone, rather than doing away with our current system. My Medicare-X plan gives every family the choice to buy an affordable public option or keep the plan they have today. It starts in rural areas, where there is very little competition and requires the federal government to negotiate drug prices. I have fought for this approach for almost a decade, because it is the most effective and fastest way to cover everyone and drive down costs.”

Julián Castro

The former U.S. Secretary of Housing and Urban Development and San Antonio Mayor favors a Medicare for All, single-payer system.

To pay for the system, Castro has said he would raise taxes on corporations and on the wealthiest Americans — the “0.05, 0.5 or 1%,” he said.

While he favors a single-payer system, Castro said he would allow private insurance, saying that anyone who wants their own private insurance plan should be able to have one.

In his words: Castro said at an event in Iowa that, “The U.S. should be the healthiest nation in the world.”

Andrew Yang

Entrepreneur Andrew Yang of New York is founder of Venture for America, a two-year fellowship program for recent grads who want to work at a startup and create jobs in American cities.

He supports Medicare for All and has called the Affordable Care Act a step in the right direction that didn’t go far enough because access to medicine isn’t guaranteed and the incentives for healthcare providers don’t align with providing quality, efficient care.

Doctors are incentivized to act as factory workers, he has said, churning through patients and prescribing redundant tests, rather than doing what they’d prefer–spending extra time with each patient to ensure overall health.

Medicare for All will increase access to preventive care, bringing overall healthcare costs down. Cost can also be controlled directly by setting prices provided for medical services.

He cites the Cleveland Clinic, where doctors are paid a flat salary instead of by a price-for-service model. Redundant tests are at a minimum, and physician turnover is much lower than at comparable hospitals, he said.

And the Southcentral Foundation which uses a holistic approach to treat native Alaskans with mental and physical problems by referring patients to psychologists during routine physicals.

Also, the current system of employer-sponsored insurance prevents employees from having economic mobility.

In his words: “New technologies – robots, software, artificial intelligence – have already destroyed more than 4 million U.S. jobs, and in the next 5-10 years, they will eliminate millions more.”

Tulsi Gabbard

Rep. Tulsi Gabbard of Hawaii is a military veteran who supports Medicare for All as a cosponsor of H.R.676, the Expanded & Improved Medicare for All Act.

But she is currently getting press for her lawsuit against Google claiming alleged election interference.

Following the first Democratic primary debate on June 26, many people searched her name, but “without any explanation, Google suspended Tulsi’s Google Ads account,” her office said in a statement, according to The Verge.

Tulsi claims the tech giant suspended her campaign’s Google Ads account just after that first debate.

Congress must act to prevent the tech giant from exerting too much influence, she claimed Monday on “Tucker Carlson Tonight.”
In her words: “This is really about the unchecked power these big tech monopolies have over our public discourse and how this is a real threat to our freedom of speech and to our fair elections.”


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.”



Could States Do Single-Payer Health Care?


The Affordable Care Act (ACA) transformed the US health care system by increasing coverage, expanding federal involvement in private health insurance, and changing public expectations for access to affordable coverage. Yet, the ACA did not provide universal coverage and has proven unstable under political and legal attacks since its enactment in 2010. While proposals for replacing the ACA with single-payer health care have attracted national political attention, discussions of a federal single-payer system such as “Medicare for All” remain light on specifics. At the state level, however, state legislators have drafted and introduced dozens of detailed bills to implement single-payer systems. Our study of state single-payer proposals in the ACA era highlights the extent to which states must contort their health reforms to overcome federal legal hurdles—particularly the threat of preemption by the Employee Retirement Income Security Act (ERISA) of 1974—and prompts questions about whether states can actually implement single-payer health care.

State Single-Payer Proposals (2010–19)

We define state single-payer bills as legislative attempts to achieve universal health care coverage for all residents in a state by combining financing for health care services into a single, state-administered payer. Using this definition, we collected and coded bills introduced in state legislatures since 2010, identifying the number of unique proposals by excluding substantially similar legislation introduced in different chambers or with different designations in the same session. From 2010 through 2019, legislators in 20 states have proposed 59 unique single-payer bills (Exhibit 1).

Most, but not all, of the single-payer proposals come from states that expanded Medicaid under the ACA, leaving only a small fraction of the population uninsured. Thus, it appears that beyond achieving universal coverage, state single-payer bills also seek to control health spending through expansive rate-setting authority and streamlined administration, as well as to relieve individuals of their growing out-of-pocket expenses. These state single-payer bills share many common elements: They all provided universal eligibility for state residents, and most also included expansive provider eligibility, rate-setting for health care services and prescription drugs, low or no cost sharing for patients, comprehensive benefits, and limits on the ability of health insurers (but not employers) to offer coverage that duplicates the single-payer benefits.

Legal And Financial Hurdles For State Single-Payer Health Care

To finance these universal and comprehensive benefits, state single-payer bills use several strategies to capture health expenditures from the existing multipayer system, while navigating a number of financial and legal impediments. First, the state bills would consolidate federal funds from Medicare, Medicaid, and the ACA exchanges into the state single-payer plan using waiver provisions in those federal programs. The Department of Health and Human Services has considerable discretion to deny state applications for each of these federal waivers; however, and the state bills generally lack fallback plans for capturing federal funds should the agency deny the waivers. Nor do the state single-payer bills confront financial obstacles from state constitutional prohibitions on deficit spending, which constrain state plans when tax revenues fall during economic recession.

Second, but perhaps more crucially, state single-payer bills must find ways to redirect the employer-sponsored health plans that currently cover 49 percent of Americans—a daunting legal task under ERISA. ERISA preempts all state laws that “relate to” employer-sponsored benefits, so states cannot simply mandate that employers cease offering health benefits. States do retain broad power to regulate health care providers and health insurers, but ERISA preempts the application of state insurance regulations to employers’ self-funded health plans, which now comprise more than 60 percent of all employer-sponsored health benefits. ERISA challenges states’ abilities to capture employer health spending—a source of funding that would be critical to the viability of a single-payer system.

The labyrinth of ERISA preemption has inspired creative drafting of state single-payer bills to do indirectly what ERISA prohibits them from doing directly. Our survey revealed three strategies for state bills to capture employer expenditures and move employees into the state single-payer system: levy payroll taxes on employers and income taxes on employees; restrict providers from accepting private-insurer reimbursement; and allow the single-payer plan to pay for all eligible patients’ care, then recoup those payments from other coverage a patient may have. The taxes fund the single-payer plan’s coverage of resident employees and nudge employers to cease offering private coverage. The provider reimbursement restriction further encourages a shift to single-payer coverage by shrinking provider networks for private insurance. The pay-and-recoup provision enables those employers who wish to continue providing benefits to do so without fully eroding the administrative advantages of the single-payer system.

Nearly all states’ bills include one of these strategies; most include a combination of them. Vermont is the only state that has actually enacted single-payer legislation, before abandoning its implementation largely due to the cost of its payroll and income taxes.

The Unnecessary Uncertainty For State Single-Payer Health Care

To gird against the looming threat of ERISA preemption, state legislatures have resorted to elaborate measures that may dilute their broader aims of achieving universality, solidarity, and efficiency in health care coverage. There are strong legal arguments why provisions to capture employer health spending should survive ERISA preemption. States have wide latitude to levy taxes and regulate health care in general, and providers in particular. The bills’ provisions do not require employers to alter their employee benefit plans, they merely encourage a shift to the state’s health plan. But federal appellate courts have split over the extent to which states may use financial incentives to affect employers’ health benefit decisions. In short, state single-payer plans should survive ERISA preemption, but courts’ unpredictable applications of ERISA cast a pall of uncertainty over the viability of single-payer plans.

State single-payer proposals face formidable legal uncertainties that a federal single-payer plan would not. On the other hand, health reform of this scale presents an experiment well-suited to the laboratories of the states. States’ experimentation with single-payer care could test various models and inform federal health reform debates about the benefits of single-payer over more incremental reforms, or about structuring a single-payer system to minimize disruption for health care providers and patients. The road to reform often starts with the states. This was the path for the ACA, which was first modeled in Massachusetts, and for Canada’s single-payer system, which got its start in Saskatchewan. Significant health reforms tested at the state level may pave the road to better policy at the national level.

While ERISA preemption has bedeviled state health reforms for decades, this wave of state single-payer legislation highlights the depth of the problem. At a time when states are the engines of health policy innovation, ERISA continues to unnecessarily thwart state health reform efforts. Thus, any meaningful health reform should start with ERISA reform. For example, Congress could amend ERISA to narrow its preemption provisions or add a waiver provision similar to other federal health care statutes. While states may successfully contort their health reform efforts to avoid ERISA preemption, they should not have to do so. The time has come to remove ERISA’s obstructions and to unlock states’ capacities as laboratories of health reform.

Most, but not all, of the single-payer proposals come from states that expanded Medicaid under the ACA, leaving only a small fraction of the population uninsured. Thus, it appears that beyond achieving universal coverage, state single-payer bills also seek to control health spending through expansive rate-setting authority and streamlined administration, as well as to relieve individuals of their growing out-of-pocket expenses. These state single-payer bills share many common elements: They all provided universal eligibility for state residents, and most also included expansive provider eligibility, rate-setting for health care services and prescription drugs, low or no cost sharing for patients, comprehensive benefits, and limits on the ability of health insurers (but not employers) to offer coverage that duplicates the single-payer benefits.



Democrats are making Republican arguments about health care. Why?

Image result for Democrats are making Republican arguments about health care. Why?

The Democratic argument over health care is beginning to get heated, which unfortunately means that things are becoming more problematic. In fact, the candidates making what is arguably the most sensible policy choice are justifying it with some absolutely abominable arguments — arguments that should warm the heart of the Republican Party.

Right now there’s a divide within the party, with some of the presidential candidates including Bernie Sanders and Elizabeth Warren supporting single payer (though Warren hasn’t been specific), and most of the others including Joe Biden, Amy Klobuchar and Pete Buttigieg suggesting some form of public option that would be voluntary, not Medicare For All but Medicare For All Who Want It.

I’ve come to believe that for all the benefits of a single payer system, trying to move immediately to one is a task with such overwhelming political obstacles and policy complications that it’s probably a better idea to achieve universal coverage through a dramatic expansion of public insurance while, for the moment, leaving substantial portions of the private system intact, even if that’s in many ways distasteful. I realize many readers will disagree with that, which is fine; we should continue to debate it.

But let’s at least grant that it’s a reasonable position to take. The problem with what’s happening now is that some advocates of the public option approach are sounding a lot like, well, Republicans.

Their most common talking point when defending their plan is some variation of “We can’t kick 150 million people off their insurance,” referring to the number of people who are covered by employer plans:

  • “We should have universal health care, but it shouldn’t be the kind of health care that kicks 150 million Americans off their health care,” says John Delaney.
  • Beto O’Rourke says Medicare-for-all “would force 180 million Americans off their insurance.”
  • “I am simply concerned about kicking half of America off their health insurance within four years, which is what [Medicare-for-all] would do,” says Amy Klobuchar.

The generous interpretation of this line is that it’s warning about widespread disruption; the other interpretation is that it’s meant to stoke the fear that if you now have coverage and single payer passes, you could be left with no insurance at all, which is just false. If we passed single payer, you’d move from your current plan to a different plan, one that depending on how it’s constructed would probably offer as good or better coverage at a lower cost.

The further danger is that that kind of talk inevitably leads one toward the promise that got Barack Obama into such trouble, “If you like your plan, you can keep it.” In fact, here’s O’Rourke saying that under his plan, “For those who have private, employer-sponsored insurance or members of unions who have fought for health care plans … they’ll be able to keep that.” And here’s Biden saying much the same thing: “If you like your health care plan, your employer-based plan, you can keep it. If in fact you have private insurance, you can keep it.”

Haven’t they learned anything?

While there may be political value in communicating to people that a public option would be voluntary, we have to tell them the truth, which is that if you’re going to open it to employers and not just individuals, some people will be moved to the public plan whether they want to or not, since their employers will make that choice for them. That’s how employer coverage works: What plan you’re on is seldom up to you, it’s a decision made by your employer.

And the broader truth is that no one, I repeat, no one gets to keep their plan if they like it even under the status quo. “If you like your plan, you can keep it” is a fantasy. If you have insurance through your employer, you’ve probably had the experience of your employer changing insurers or changing plans; many do it every year. Sometimes the new plan is better; often it’s not. But if you liked your plan, you didn’t get to keep it.

That’s even true of people on public insurance plans, though to a far lesser degree. Medicare and Medicaid go through changes, and benefits are added or taken away. It’s not up to you.

The trouble is that we have a situation where change is constant yet everyone is afraid of change, which makes it awfully tempting to encourage that fear. But the more we propagate the fiction that Americans, especially those with private insurance, aren’t vulnerable under the current system, the easier it will be to crush any reform effort.

Apart from the praise of the Affordable Care Act, this video could almost have been scripted by the Republican National Committee, with its paeans to private health insurance. Of particular note is the woman’s explanation of how she and her husband “earned” health coverage through decades of work, which implies that health care is not a right, as most Democrats believe, but a privilege one has to earn.

To top it off, Biden’s caption to the video says that “Because a union fought for their private health insurance plan, Marcy and her husband were able to retire with dignity and respect,” which is why Biden wants to let them stay on their existing insurance.

Let me suggest a crazy idea: What if retiring with dignity and respect wasn’t something you only got if you were lucky enough to be represented by a union (as a mere 1 in 10 American workers is, and 1 in 16 private sector workers), and only if that union happened to be successful in its fight to get you health benefits? What if everybody got dignity and respect? Isn’t that the world Joe Biden is trying to create?

You can make a strong case for both a single payer plan and one built around a public option. But please, Democrats, when you’re arguing for your preferred solution, don’t undermine the entire philosophical approach your party takes to health care. That only makes the job of reform more difficult.