Editors on the Campaign Trail: Why Bernie Sanders Is Wrong on Health Care (and Hillary Clinton Is Right)

The two candidates to the 2016 Democratic Presidential primary, former Secretary of State Hillary Clinton and Senator Bernie Sanders (I-VT), both attempt to implement the principle that health care is a basic right, but Sen. Sanders’ advocacy for single-payer health care has dominated the discussion.

On the Republican side, health care has not received much attention, besides attempts to repeal the Affordable Care Act of 2010 (ACA). Donald Trump, the presumptive 2016 Republican nominee, proposes increasing competition, block granting Medicaid, and expanding health savings accounts, all Republican boilerplate proposals. In the absence of greater specificity, there is no health care plan to discuss.

Sen. Sanders’ plan is for a federally administered, single-payer program providing universal coverage without private health insurance. Called “Medicare for all,” it differs from Medicare as it does not require out-of-pocket payments. The United States is the only industrialized nation that does not guarantee health care as a right, he argues, and our health system costs the most per capita with among the worst health outcomes. Access to care is a critical public health issue, and we have an obligation to explore the evidence that supports the candidates’ positions.

THE POLITICAL VIABILITY OF SINGLE-PAYER

There have been many unsuccessful attempts to garner political support for single-payer within the Democratic Party. In 1988, a commitment to single-payer health care was not accepted into the Party platform, and single-payer was considered but not included in the Clinton Administration’s health reform plan. In the legislative development of the ACA, single-payer was effectively blocked by conservative Democrats led by then Senate Finance Committee chairman Max Baucus (D-MT). An amendment for single-payer sponsored by Sen. Sanders did not have enough support to come up for a floor vote. A final effort to include a public option, Medicare buy-in for adults aged 55 to 64 years, was blocked by a conservative Independent who caucused with the Democrats (Lieberman; I-CT). Even with strong majorities in the House and Senate, there was insufficient Democratic support for single-payer to be included in the ACA.¹

PAYING FOR SINGLE-PAYER

Sen. Sanders proposes to finance single-payer through changes in tax policy, including new taxes on households and employers as an insurance premium, progressively higher rates and fewer deductions for the wealthy, and taxing capital gains as earned income. Tax policy, however, is the responsibility of the legislative not executive branch. Tax bills originate in the House of Representatives. Because of gerrymandering and other political factors, it is unrealistic to expect a Democratic majority in the House after the 2016 election to enact tax policies in support of a single-payer program.

THE ROLE OF THE STATES

The US government is currently responsible for nearly two thirds of national health care expenditures if one aggregates direct reimbursement for health care through public insurance such as Medicaid and Medicare, and through other government agencies; the cost of health benefits for federal, state, and local government employees; and tax subsidies for private sector employee health benefits.² In conflating federal with state and local government expenditures in their analysis, Himmelstein and Woolhandler highlighted the role of the states in a transition to single-payer.² In a key decision on the ACA, the Supreme Court allowed Medicaid expansion if states opted to do so, but found the federal requirement that states expand Medicaid to be unconstitutional.³ This ruling has been interpreted as not supporting the constitutionality of a federally declared universal right to health care.⁴ It also raises questions about the constitutionality of the federal government requiring states to abolish their Medicaid program and disenfranchise private health insurance companies that do business in their state, as would be necessary to clear a path for single-payer. There is no reason to expect all governors and state legislatures to cooperate with single-payer given the decision in 19 states to not expand Medicaid primarily at federal expense under the ACA.⁵

THE INSURANCE INDUSTRY WILL NOT GO AWAY QUIETLY

Contributing to the failure of the Clinton Administration's attempts at health reform was an unprecedented television campaign against it funded by the Health Insurance Association of America, now America’s Health Insurance Plans (AHIP). These ads, featuring “Harry and Louise,” effectively influenced Congress against health reform. The dialogue in the ads supported the goals but not the methods, foreshadowing right-wing attacks on the ACA with antigovernment language like “government monopoly” and “billion dollar bureaucracy.”⁶

While simultaneously negotiating with the Obama Administration, AHIP spent more than $100 million through the US Chamber of Commerce in a covert lobbying effort to stop health reform. The health insurance industry is well funded and adept at defending its interests. There is no reason to expect it to cooperate with its own demise, even if “we have the guts to stand up to the private insurance companies and all of their money” as Sen. Sanders suggested.⁷

HILLARY CLINTON IS RIGHT ON HEALTH CARE

Sec. Clinton maintains that attempting to implement single-payer would disrupt our current health care system, repeal the ACA, and plunge the nation back into contentious debate. The ACA expands insurance coverage as it currently exists in the United States, with 66% privately insured (mostly employer-provided) and 34% government insured. A single-payer system would cover the 11% uninsured but replace coverage and potentially disrupt health care for the nearly 90% of insured Americans and effectively repeal much of the ACA.

Sec. Clinton correctly recognizes the success of the ACA. Between October 2013 and early 2016, 20 million previously uninsured adults gained coverage, reducing the uninsured rate from 20.3% to 11.5%. African-Americans, Hispanics, and women made the greatest gains. The first group to benefit from expanded coverage—young adults—now has fewer emergency room visits, which contributes to lower overall health care costs.

CONCLUSIONS

The Sanders single-payer program would fulfill the progressive goal of universal health care as a right, if passed by Congress and successfully implemented. The evidence shows insufficient political support to pass single-payer and implementation barriers including tax policy and devolution of health policy to the states. Evidence supports Sec. Clinton’s position that building on the ACA would move us toward universal coverage but maintain progress made by the law. This approach is consistent with the politics of divided government and more likely to succeed.

The difference between the two positions may be viewed as ideology versus realism. Ideology may be more inspirational but is less likely to produce change.