In 2010, a Democratically controlled House, Senate, and president chose not to include a “public option” in the Affordable Care Act. The provision would have set up a government-run health insurance program that would compete with private health insurers. For the Democratic party of 2010, it was important to get the healthcare industry to buy into legislation.
Times have changed. Consider the candidates for New York’s 19th Congressional district: Five (Jeff Beals, Dave Clegg, Erin Collier, Brian Flynn, and Gareth Rhodes) are calling for a national single-payer system and two (Pat Ryan and Antonio Delgado) want to allow anyone to buy into Medicare, or at least a Medicare-like program.
In the House, H.R. 676, “The Expanded and Improved Medicare for All Act,” sponsored by Congressman Keith Ellison, has the support of 121 Democrats, or 60 percent. In the Senate, S. 1804, “The Medicare for All Act of 2017,” Bernie Sanders’ bill, has the support of 16 senators, including New York Senator Kirsten Gillibrand. Both bills would create a national single-payer system, though they have some differences in how they’d go about it. For example, H.R. 676 eliminates private insurance and creates a new administrative body to run the program, while S. 1804 allows private insurance to continue in supplemental form and seems to assume the existing Medicare administration can handle it. Both are relatively short for bills (29 and 96 pages) and leave many details to be worked out.
The issue is arguably the most significant policy change being debated among Democrats this election cycle. The most common name for single-payer plans, Medicare for All, capitalizes on the popularity of the existing program but undersells the extent of the changes. Medicare includes out-of-pocket expenses in the form of premiums and deductibles, but doesn’t cover dental or eye care, and often requires the purchase of additional supplemental insurance. “Medicare for All” would cover everything with virtually no out-of-pocket expense, at least from patients at the point of service. (The exception is that the Sanders bill would require co-pays on some prescription drugs.)
But that money has to be made up somewhere. According to Vox, HR 676 would “likely result in the largest tax increase in modern American history, one that would almost certainly have to hit everyone.” Similarly, most of the coverage surrounding the rollout of Sanders’ bill last September focused on its lack of near-term political prospects and epic $1.3 trillion price tag.
U.S. Rep. John Faso’s campaign provided a preview of the attacks sure to come this fall last week. The occasion was the endorsement of candidate and single-payer supporter Jeff Beals by actress Susan Sarandon.
“Jeff Beals’ government takeover of health care will force Americans into a government-run health system and eliminate their employer-provided health insurance,” Faso for Congress campaign manager Tom Szymanski said in a release titled “With Sarandon Endorsement in hand, ‘Unabashedly Progressive’ Jeff Beals Doubles Down on Single-Payer Healthcare Scheme.” The release continues: “Bernie Sanders and Congressional Progressive Caucus leader Keith Ellison might want the government making their health care decisions, but Upstate families don’t. It should come as no surprise that Beals fails to offer up any serious proposals or ideas as to how he’d pay for his extremely costly policy prescriptions. Taxpayers should beware.”
The single-payer-supporting Democratic candidates say they won’t be phased by this line of attack. They believe dissatisfaction with our healthcare system has only grown since 2010, so more Americans are inclined to support big changes.
“Ten years ago everyone was like, ‘Oh my god, socialized medicine, the worst thing ever,’” said candidate Brian Flynn. “And what you’ve seen is that the system is actually gotten worse and more expensive and more corrupt, and people are saying ‘You know what, single-payer sounds great compared to what we have now.’”
Indeed, a Washington Post-Kaiser Family Foundation poll in April found a majority of Americans (51 percent) and just under three-quarters (74 percent) of Democrats support single-payer. The candidates say that, as they travel the district, they hear more from voters who are afraid of losing the health care they have now due to Republican plans to repeal the Affordable Care Act and reduce entitlement spending overall rather than those afraid of the government becoming larger by replacing private insurance companies.
Regarding costs, single-payer supporters acknowledge that switching to a system that funds health insurance through taxes would carry a large tax hike, but they say the overall cost would be significantly less. As evidence, they point to the significantly more efficient systems in other countries, and to Medicare itself. Estimates for savings for the average family are all over the map, but generally in the neighborhood of several thousand dollars, funded by taxes weighted toward corporations and/or higher earners.
There is some debate among the candidates over whether one can support single-payer without supporting H.R. 676. As we all remember from civics class (or perhaps Schoolhouse Rock), the legislative process for a bill starts in the House of Representatives. After that, the Senate passes its version of that bill. Any differences are worked out in a conference committee, and the unified bill is kicked back to the House and Senate for the final vote.
“No one here is running for Senate,” said Gareth Rhodes. “We’re running for the House. So you’re going to be elected to the House and you’re going to be presented with a bill to co-sponsor, H.R. 676, and the question is will you or won’t you co-sponsor it. And the answer is yes or no.”
“Legislation is passed by passing legislation,” said Jeff Beals. “The only difference between a supporter of Medicare for All and a non-supporter of Medicare for All is whether or not they will co-sponsor H.R. 676. Not whether or not they think it’s a good idea. Everybody [thinks it’s a good idea], so don’t be duped.”
Brian Flynn supports the Sanders bill. He also has some “tweaks.” They include points like “Our plan includes initiatives to ensure a gradual transition from our current system to Medicare for All, with immediate availability of the program to all, gradual increase in benefits, gradual decrease in support for private insurance, and measures to ensure competitive premiums” and “Comprehensive coverage that is critical to improved access to care and lowered healthcare costs will be ensured and offered early in the transition.” “We’re just being specific,” said Flynn. “There are things that are vague and we’re just trying to make things less vague.”
We asked if voters who support single-payer should be concerned; after all, politicians sometimes express support for an idea while simultaneously tacking on a few additional concerns, thereby giving hope to both supporters and opponents. “I’m not hedging here,” he said. “I think this idea that because you say ‘oh, the bill is imperfect,’ you’re equivocating, no, quite the opposite. I call it advocating. I’m saying no it’s not good enough. It doesn’t do enough. And we need to take it to the next level.”
Two of the seven candidates, Antonio Delgado and Pat Ryan, aren’t sold on single-payer, at least not yet. Instead, they speak of reaching “universal coverage” by allowing anyone to buy into Medicare (or a Medicare-like program), while allowing those who like their existing private insurance to keep it. Both support lifting the ban on the government negotiating prescription drug prices for Medicare patients.
“We need to get the profit motive out of our health care system and move in the direction of a single-payer system like Medicare for All,” said Delgado. “A good, achievable first step is to allow everyone to buy into Medicare through a public option on the ACA exchanges. This would expand access and lower premiums and deductibles. It ensures that health care is universal, accessible, and affordable.”
Ryan supports lowering the age for regular Medicare to 55 and allowing those under 55 to join a Medicare-like program. He pointed to the “Medicare X” proposal by senators Tim Kaine and Michael Bennet, which slowly phases in a public-option program, as something he could support, though he’d like to see the rollout sped up. He says he’s spoken with voters who ask if he can guarantee they’d receive the same level of coverage they currently enjoy if a bill like H.R. 676 passed, and he said he couldn’t. Another concern is what might happen if everyone switches over to a government-run system, and a subsequent Congress decides to defund it, leaving everyone “hanging.”
“Any major change to any major program is going to happen over time,” said Ryan. “Frankly, I think that some folks have tried to set up a false kind of, a binary choice here, either we do it immediately or we don’t do it at all, and it’s sort of selling out. When in reality I think everyone, if they were to take a step back, would recognize that to do this responsibly it takes some amount of time.”
Ryan and Delgado share this position with the politician who is probably still the most popular Democrat in the nation: former President Obama. After minimizing the importance of the public option when passing his signature legislation, Obama affirmed his support for it in a 2016 article in The Journal of the American Medical Association. As would be the case with Medicare X, which was unveiled last fall, Obama said the public option should begin in underserved rural areas and be expanded from there. There are “simpler approaches at both ends of the political spectrum: the single-payer model vs. government vouchers for all,” wrote Obama. “Yet the nation typically reaches its greatest heights when we find common ground between the public and private good, and adjust along the way.”
But that was summer 2016. Since then, the parties have become more polarized. And while most of the nation’s attention has been consumed by investigation of and social media posts by President Donald J. Trump, the once-radical idea of nationalizing the health insurance industry has become a mainstream position for one of our two major political parties.
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