The latest dustup between Hillary Clinton and Bernie Sanders is taking place over health care policy. It's been building for awhile, and spilled onto the national stage when Chelsea Clinton made some remarks claiming that Bernie was going to repeal the ACA, CHiP, and parts of Medicare in order to implement single payer health care.
Chelsea's talking points may have come directly from Sanders' 2013 legislation proposing single payer, since that's one of the top line points in the legislative summary. But there is much more to the story. Whenever health care policy is being debated, details matter.
Bernie Sanders appeared on Chris Hayes' show Wednesday night to discuss his health care plan and push back on Hillary Clinton's criticism of it.
Alex Seitz-Wald's analysis is a good one, but I don't think it completely addresses the issue.
But like so much in politics, Clinton’s fight is not what it seems. It’s not really about about health care, but about taxes and effectiveness – with a bank shot at Sanders’ electability.
Meanwhile, Sanders has responded by trying to move the debate back to the more favorable terrain of health care. He accused Clinton of adopting “Karl Rove tactics,” as spokesperson Michael Briggs put it, to oppose universal health care, and flip-flopping on the issue to boot.
The interview Sanders gave to Chris Hayes seems to underscore Seitz-Wald's point. When pressed on specifics, Sanders agreed that single payer should be the vision for health care in America, but conceded that he would not get anything like this passed out of the gate.
When Hayes pressed him on the tax aspects, Sanders correctly noted that even if payroll taxes increased on employers and employees, it would be less of an increase than the cost of employer-provided health care. Unfortunately, employer-provided health care is only a part of the larger problem.
Sanders observed that his vision is one 81 percent of Democratic primary voters agree with, including me. But agreeing with it and actually getting it done are two different things entirely.
I've looked at Sanders' 2013 legislation, which he referred to while speaking to Chris Hayes. It is a state-based single payer plan which mandates states to terminate their ACA exchanges and all private health insurance, mandates the federal government to contribute the amount they would have paid in tax subsidies and cost-sharing assistance under the ACA to a newly-established American Health Security Trust Fund which would be used along with a payroll tax to fund single payer.
None of this is necessarily a bad thing. It does not change the consumer protections built into the Affordable Care Act. Indeed, it expands those protections into the sense of the Senate that health care is a right, not a privilege. All good.
Sanders does a great job of arguing for single payer as a concept. But the devil is in the details, so here are some questions I'd like to have answers for.
- How would the state mandates work, given the Supreme Court ruling regarding Medicaid? I've heard that the default would be back to the federal Medicare plan, but why not simply expand that existing plan to all on a federal level instead of leaving it to the states?
- How does Senator Sanders expect to move a piece of legislation like this through the Congress, given the heavy lift that the ACA was? This was a question Chris Hayes asked as well. Given that we've just been through the fires and pits of hell with Republicans on the Affordable Care Act, is it at all realistic to imagine legislation like this getting through Congress?
- How will people who are currently on Medicaid or have heavily subsidized premiums under the ACA handle the increased cost? Here I'm thinking about self-employed people, who will be asked to take on an additional 9 percent of their net income as self-employment tax on top of the 15.3 percent they already pay. For people who are independent contractors barely making a living, that's nearly 25 percent of their income in taxes for retirement and health care, which seems like a lot.
- How will self-funded plans fit into the overall picture? Many unions and large employers self-fund their health benefits. How will those be phased out?
These are questions, not criticisms. But they also illustrate the real conflict between Bernie Sanders and Hillary Clinton -- the ideal versus the practical.
After the interview with Sanders, Howard Dean came on Hayes' show to discuss why he thinks Clinton's more pragmatic approach to health care may be the better one, at least for now.
I don't have the answers one way or the other.
In principle, I support single payer, but on a federal, not state, level. I am not a fan of bringing it to the state level, mostly because I believe it muddies the waters and limits the risk pools instead of broadening them. I believe state-based Medicare would also create inequities in drug prices and care delivery. Finally, until fee-for-service is not the standard under which doctors are compensated, there's no single payer plan that will work without costing a fortune.
If we can have a federal Medicare plan for retirees, why can't we have one for everyone else? That's a vision I could support.
The bottom line for me is pretty simple. I'm a health care wonk, and I want to see the details of the plan. I'm also a realist, so I'd like that plan to be one that actually might have a chance to be implemented before I give one up that works, even with the warts that could and should be fixed.