Sanders vs. Clinton on health care

Sanders vs. Clinton on health care

Clash between grand vision and what's important and achievable

IT’S FUNNY HOW things turn out on the campaign trail. Since all Republican presidential candidates pledge to repeal the Affordable Care Act/Obamacare, they have little to argue about. The fireworks are among Democrats as Hillary Clinton and Bernie Sanders argue the future of US health reform and, specifically, the merits of Sanders’s new single payer/Medicare for All scheme, released Sunday evening hours before the Democrats’ final pre-primary debate.

Clinton, fighting a Sanders surge in the Iowa and New Hampshire Democratic contests, has been landing punches to throw his momentum off balance. Meanwhile, Sanders keeps humming the single payer tune that the Democratic base adores (see the Kaiser Poll below), offering some new melodies and riffs in his revised plan.

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Sanders’s proposal matters because it shows how progressive thinking has shifted and because it calls into question whether Democrats have the staying power and political will to defend one of their principal accomplishments in the past 50 years, the ACA. Here are key points about the Sanders plan:

First, it’s not Medicare for All. In a risky bet, Sanders would create one new massive federal health insurance program to provide comprehensive coverage to everyone for just about every medical service you can name, including long term and palliative care, without cost sharing, and with no evident care management. Such a program would be better for seniors than the current Medicare mess – Parts A, B, C, and D with gobs of cost sharing and coverage limits. Politically, it would frighten many older and disabled Americans to learn that they would lose Medicare. Progressives who believe “we can explain how it’s better” have no evident memory of death panels and other assorted fables that soared in the ACA political maelstrom.

Second, financially, it’s huge. Economists and number crunchers will have a field day arguing how much it would save vs. cost and this is now underway (e.g., Ezra Klein and Avik Roy). Sanders’s team says that the plan will cost “$6 trillion less than the current system over the next ten years.” The current federal estimate is $47.4 trillion in US health spending over that decade. As Vermont learned the hard way in its four-year romance with single payer that ended in divorce in 2014, rosy estimates often wilt in bright sunlight. In other words, don’t take them to the bank.

Third, politically, it’s already dead. Believe me, I hate to write these words, and they are true. Leave aside the US House of Representatives for a moment, an institution likely to remain under Republican control at least until 2022, in time for President Sanders’s final two years in office. Consider the US Senate, where not one of the other 45 members of the Senate Democratic caucus has endorsed Sanders. Democrats have a reasonable shot at taking back Senate control next November. A good showing on November 8th may yield a 51- or 52-vote Senate majority, well short of the necessary 60 votes. The chance that any Republican senator would back this scheme is zero.

When I worked in the US Senate on the ACA in 2009, Sen. Sanders pushed hard to get a floor vote on his state-based single payer plan (in his new version, states are out, reflecting the raucous state process of ACA implementation). Because Senate Majority Leader Harry Reid needed every Democratic senator’s vote, Bernie got his moment in the sun until Republican Sen. Tom Coburn  of Oklahoma (aka “Senator No”) demanded full reading of the amendment, a 15-hour task that Sanders cancelled after two hours. I remember meeting with Sanders’s health staffer to ask how many votes they had lined up. “None” was the response. We started counting and could not exceed single digits among Democratic senators.

Some say it comes down to the “vision thing.” Bernie’s got that in spades. It doesn’t matter because there is nothing to win.

Something is at stake. Earlier this month, the Republican controlled House and Senate sent to the president’s desk legislation to repeal the ACA and eliminate health insurance by 2018 for at least 22 million Americans, more than the population of 48 states. Republicans have proven that if they control the White House, House, and Senate in January 2017, they can destroy the ACA – even when advancing nothing in its place.

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This brings us to Clinton, who made the case in Sunday’s debate that the essential challenge is to defend, expand, and improve the ACA. It’s far less sexy and bold than Medicare for All. If we work together, it is achievable.

John McDonough teaches at the Harvard TH Chan School of Public Health and blogs at healthstew.com.

  • Fred Grosso

    The opposition to the ACA is still swinging for the fences. Proponants of the ACA should have started with single payer. This is a battle worth fighting. If you do not have the stomach, hit the road.