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The Health 202: It's official: Medicare-for-all is a defining issue in the Democratic primary

June 28, 2019 at 8:36 a.m. EDT

with Paulina Firozi

THE PROGNOSIS

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To socialist or not to socialist? That was a hot question at last night’s Democratic presidential debate—and it was manifested most clearly through candidates’ differences over Medicare-for-all.

The candidates disagreed over whether to cancel private health coverage for millions of Americans as part of a Medicare-for-all system, just like the previous evening. But things also got philosophical – and more heated – as they sparred over whether it constitutes socialism and whether backing it could jeopardize the Democratic Party’s one shot at ousting President Trump from the White House next year.

“If we don’t clearly define that we are not socialists, the Republicans are going to come at us every way they can and call us socialists,” said former Colorado Gov. John Hickenlooper.

“If we want to get universal health care coverage – I believe that health care is a right and not a privilege -- but you can’t expect to eliminate private insurance for 180 million people, many of whom don’t want to give it up,” he added.

NBC’s Savannah Guthrie then asked Sen. Bernie Sanders (I-Vt.), the writer of the first Medicare-for-all bill and the most vocal champion of a single-payer system what his response would be “to those who say nominating a ‘socialist’ would reelect Donald Trump.” 

“Last poll I saw had us 10 points ahead of Donald Trump because the American people understand that Trump is a phony,” Sanders responded. “He said he was going to stand up for working families. Well, President Trump, you’re not standing up for working families when you try to throw 32 million people off their health care that they have….that’s how we beat Trump: We expose him for the fraud that he is.”

The disputes over Medicare-for-all were in sharper relief on last night's debate stage than ever before, solidifying it as a top 2020 campaign issue that could help Democratic primary voters decide among nearly two dozen candidates. The topic consumed most of the debate’s first half hour, as candidates offering differing opinions on how to best get coverage to the uninsured and even drilled down into details of what a Medicare-for-all rollout would look like.

Sanders stood next to former vice president Joe Biden, who represents the other school of thought when it comes to achieving universal health coverage – that incrementalism, not overhaul, is the best answer. Biden stressed building on the gains of the Affordable Care Act, the 2010 health care law that halved the country’s uninsured rate (and which Biden once famously told President Obama was a BFD).

“The fact of the matter is that the quickest, fastest way to do it is build on Obamacare, to build on what we did,” Biden said.

Biden even warned that he’s “against any Democrat who opposes and takes down Obamacare” – perhaps hinting at a future line of attack in the primary season.

CBS New's Ed O'Keefe: 

Half of the 10 candidates on the stage have said they support Medicare-for-all or something similar. But, like Wednesday night, just two – Sanders and Sen. Kamala Harris (D-Calif.) – were willing to say they’d eliminate private coverage when that question was posed by the moderators.

Our Post colleague Chelsea Janes: 

The Post's Yasmeen Abutaleb: 

Harris appeared to walk back her support for eliminating private insurance after the debate, per NBC's Vaughn Hilliard:

The moderators asked some pointed questions of Sanders. Lester Holt pointed to his home state of Vermont – which tried several years ago to implement a single-payer system but was ultimately forced to scrap the whole thing – and noted similar efforts in New York and California.

“If politicians can’t make it in those states, how would you implement it on a national level? How does this work?” Holt asked.

“Lester, I find it hard to believe that every other major country on Earth, including my neighbor 50 miles north of me, Canada, somehow has figured out a way to provide health care to every man, woman, and child, and in most cases, they’re spending 50 percent per capita what we are spending,” Sanders responded.

But it was the two candidates from Colorado – Hickenlooper and Sen. Michael Bennet – who tried hardest to put Sanders on the defense over the details of Medicare-for-all. Both men have been sharply critical of the idea in the past, which Hickenlooper recently characterized to my colleague James Hohmann as a “massive government expansion” and Bennet calling Sanders “wrong” for proposing it.

“Bernie is a very honest person,” said Bennet, who has proposed his own legislation for adding a public option to the Obamacare marketplaces. “He has said over and over again…that this will ban, make illegal all insurance except cosmetic…everything else is banned under the Medicare-for-all proposal.”

Bennet also made the point that the uninsured population in the United States is roughly similar to Canada’s total population: 35 million. Extend a Medicare-type plan to those uninsured folks, and the U.S. would have a similar system to Canada’s while maintaining private coverage for everyone else, he said.

“I think that will be the fastest way to get where we need to go,” Bennet said.

South Bend, Ind., Mayor Pete Buttigieg seemed to take a middle route. He said he wants “Medicare-for-all who want it” but said if such a plan became popular it would be a “very natural glide path to the single-payer environment.”

Sen. Kirsten Gillibrand (D-N.Y.) was one of the most vocal Medicare-for-all defenders on the stage. But even she didn’t raise her hand when asked whether she’d eliminate private coverage. Later on, she tacitly acknowledged private plans would eventually fall by the wayside, after a four-year transition period in which people could choose to buy into Medicare.

“So what will happen is people will choose Medicare, you will transition, we will get to Medicare-for-all, and then your step to single-payer is so short,” Gillibrand said.

Here are a few of the other key health care-related moments from the second round of the first Democratic debate:

UNDOCUMENTED IMMIGRANTS: For the second show-of-hands question of the night, moderators asked candidates to raise their hands if their health-care proposals would provide coverage for undocumented immigrants: Every single hand went up.

It was a moment of unity on the second night of the debate, and also represents a shift to the left for Democrats, who excluded undocumented immigrants from buying coverage in the ACA marketplaces even if they used their own money. The show of hands drew immediate criticism on Twitter from President Trump. 

“[Y]ou cannot let people who are sick, no matter where they come from, no matter what their status, go uncovered,” Biden said. “You can't do that. It's just going to be taken care of, period. You have to. It's the humane thing to do.” Buttigieg explained his stance is “not about a handout. This is an insurance program. And we do ourselves no favors by having 11 million undocumented people in our country be unable to access health care.” 

From The Post's Kevin Schaul: 

ABORTION: Just two candidates were given the chance to directly answer a question about the fate of Roe v. Wade amid an intensive state effort to restrict abortion and a new, conservative majority on the Supreme Court. Sanders reiterated a vow to “never appoint any, nominate any justice to the Supreme Court unless that justice is 100 percent clear he or she will defend Roe v. Wade.” He also said his Medicare-for-all plan “guarantees every woman in this country the right to have an abortion if she wants it.”

Gillibrand directed her remarks “to America's women and to the men who love them.” “Women's reproductive rights are under assault by President Trump and the Republican Party," she said. "I have been the fiercest advocate for women's reproductive freedom for over a decade. And I promise you as president when that door closes, I will guarantee women's reproductive freedom no matter what.”

HEALTH CARE COSTS: Harris seemed to refer to a story reported by Sarah Kliff for Vox about a mother and her sick child waiting in a car outside an emergency room because she was worried about not being able to afford the bill. “And so they get in their car and they drive and they are sitting in the parking lot outside of the emergency room looking at those sliding glass doors while they have the hand on the forehead of their child, knowing that if they walk through those sliding glass doors, even though they have insurance, they will be out a $5,000 deductible,” Harris said. “…That's what insurance companies are doing in America today.”

GUN VIOLENCE: Numerous candidates shared ideas about how to address the issue of guns, starting with Rep. Eric Swalwell (D-Calif.) who has pitched himself as a candidate focused on gun violence prevention. “I'm the only candidate on this stage calling for a ban and buyback of every single assault weapon in America,” Swalwell said. “I have seen the plans of the other candidates here. They would all leave 15 million assault weapons in our communities. They wouldn't do a single thing to save a single life in Parkland.”

Harris said she would give lawmakers 100 days to put legislation on her desk for how to address gun violence before she takes “executive action and I will put in place the most comprehensive background check policy we've had. I will require the ATF to take the licenses of gun dealers who violate the law. And I will ban by executive order the importation of assault weapons.”

Buttigieg took a jab at those who say more guns are necessary to prevent violence: “If more guns made us safer, we would be the safest country on earth. It doesn't work that way,” he said.

Biden, who said he is the “only person that has beaten the NRA nationally” also said that the National Rifle Association wasn’t the bad guy. “Our enemy is the gun manufacturers, not the NRA,” he said.

AHH, OOF and OUCH

AHH: After hours of maneuvering yesterday, the House passed the Senate’s version of a $4.6 billion emergency spending bill to address the humanitarian crisis at the border, “after Democratic leaders scrapped efforts to amend the legislation to add more restrictions on the Trump administration,” our Post colleagues Erica Werner, Mike DeBonis and Rachael Bade report.

The bill heads to the president’s desk, and Trump is expected to pass the version the Senate already approved earlier this week. The bill includes funding for agencies, including the Department of Health and Human Services, to address the overwhelming number of Central American migrants who have entered the country. House Speaker Nancy Pelosi (D-Calif.) had tried to garner support for a measure that would include additional protections for unaccompanied minors and restrictions on the administration’s use of the funds.

But Democratic leaders caved to Republicans and the moderate members of their party in passing the Senate bill. “The children come first. At the end of the day, we have to make sure that the resources needed to protect the children are available,” Pelosi said in a letter to colleagues. “ . . . In order to get resources to the children fastest, we will reluctantly pass the Senate bill.”

OOF: Abortion rights groups are calling on a judge to block Arkansas's 18-week abortion ban from going into effect next month.

The American Civil Liberties Union, its Arkansas chapter and Planned Parenthood filed a lawsuit against officials in the state over a trio of measures: A ban on abortions at 18 weeks of pregnancy, a ban on abortions that target fetuses with a Down syndrome diagnosis and a law that allows only certified OB-GYNs to perform the procedure.

“This year, Arkansas politicians sank to a new low with a trifecta of unconstitutional laws designed to eliminate access to safe and legal abortion in Arkansas — and once again, we’re taking them to court,” Holly Dickson, legal director of ACLU of Arkansas said in a statement.

“The challenge comes as several of the laws coming out of red state legislatures restricting abortion are being taken to court, with the two organizations also challenging Alabama's near-total abortion ban,” CNN’s Caroline Kelly reports. “Many conservative lawmakers anticipated the suits, having advanced the measures in hopes of eventually overturning Roe v. Wade, the landmark 1973 Supreme Court ruling that legalized abortion nationwide.”

In a statement, Arkansas Attorney General Leslie Rutledge told CNN she is “reviewing the lawsuit filed to decide appropriate next steps. As Attorney General, it is my duty and honor to defend the sanctity of life and protect mothers and their unborn children.”

OUCH: House Oversight Committee Chairman Elijah E. Cummings (D-Md.) is demanding email communications and additional information from Gilead Sciences related to its deal to provide free doses of PrEP, its HIV prevention drug, as part of the Trump administration’s push to eradicate HIV in the next decade.

In a letter released yesterday, Cummings “also asked Gilead for details of contact with the Centers for Disease Control and Prevention and other agencies over its claim that U.S. government patents are invalid for Truvada for PrEP, as the preventive use is known,” our Post colleague Christopher Rowland reports. The letter indicated Cummings wanted to understand whether the PrEP donation was “connected in any way to patents” and “whether these patents played any role in negotiations between the company and the Department of Human Services.”

The letter follows another Cummings and Sen. Debbie Stabenow (D-Mich.) sent to the Government Accountability Office last week calling on the agency to review HHS’s patent enforcement practices.

AGENCY ALERT

— Former FDA Commissioner Scott Gottlieb will join the board of directors for pharmaceutical giant Pfizer, the company announced yesterday.

Gottlieb, who left his role at FDA in April, had made speeding up approvals for generic drugs and pushing for biosimilars one of his priorities during his tenure.

“Biosimilar manufacturers, including Pfizer, have complained about roadblocks stalling biosimilars from becoming widely used. Having Gottlieb to advise the company could help Pfizer, one of the largest biopharmaceutical companies, navigate the landscape,” CNBC’s Angelica LaVito reports.

Stat's Ed Silverman also writes that the move gives "the world’s largest drug maker crucial insights into the inner workings of the Trump administration as it attempts to contain national angst over the rising cost of medicines."

“Through his work as a physician and his time at the FDA, Scott has continually demonstrated an understanding of both patients’ needs and the rapidly changing dynamics of biopharmaceutical research and development,” Pfizer's chief executive Albert Bourla said in a statement.

During a Washington Post event earlier this month, Gottlieb defended Pfizer in response to a story that alleged Pfizer didn't share data after it appeared its arthritis drug Enbrel appeared to reduce the risk of Alzheimer's disease. "I have a hard time believing that someone stumbled upon a cure for Alzheimer's and didn't try to follow it up," he said. 

— And here are a few more good reads from The Post and beyond: 

Immigration, a central issue for Trump, also key issue at Democratic debate (Maria Sacchetti)

What Castro meant when he said trans women need access to abortions (Politico )

HEALTH ON THE HILL

Backed into a corner, Pelosi faces rebellion from both centrists and liberals (Paul Kane and Rachael Bade)

What took Congress so long to make a deal to address the border crisis? (Amber Phillips)

‘Everyone hates this place’: Border bill tears apart Democratic caucus (Politico )

MEDICAL MISSIVES

Millennials have sparked a sober revolution, and alcohol brands are starting to notice (Laura Reiley)

Flu vaccine no match against bug that popped up near end (Associated Press)

STATE SCAN

Some Virginians say fighting gun violence requires more than new laws (Gregory S. Schneider)

DAYBOOK

Today

  • The Bipartisan Policy Center hosts an event: “Good Health is Good Business."
  • The American Enterprise Institute holds an event on cannabis legalization.

SUGAR RUSH

Democrats talk policy goals in post-debate spin room:

From women's rights to universal health care, 2020 Democratic presidential candidates emphasized their policy goals following the June 27 Democratic debate. (Video: The Washington Post)
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