THE PROGNOSIS

For pointers on how to attack Medicare-for-all, all President Trump needs to do is watch last night’s Democratic debate

Democrats who had been circling the ring on the Sen. Bernie Sanders's pet proposal sure jumped in last night in Detroit. 

The debate’s first 25 minutes was spent in what amounted to a boxing match between Sanders (Vt.) and Sen. Elizabeth Warren (Mass.), who want to replace private plans with generous government coverage – and most of the other Democrats onstage, who lambasted that approach as terrible policy and predicted it might even cost their party the White House. 

“We don't have to go around and be the party of subtraction, telling half the country, who has private health insurance, that their health insurance is illegal,” former Rep. John Delaney (D-Md.) told Sanders. “It’s also bad policy.”

From Politico's Dan Diamond: 

Sanders fired back: 

And he accused Democratic rivals of distorting the facts: 

The extensive volley of exchanges – in which every single one of the 10 candidates weighed in at least once – highlighted such sharp differences on the best way to achieve universal coverage that at one point, Warren even warned her fellow candidates against beating each other up too much over the issue.

“We are the Democrats, we are not about trying to take away health care from anyone,” Warren said. “That’s what Republicans are trying to do. And we should stop using Republican talking points in order to talk with each other about how to best provide that health care.”

Warren and Sanders, who stood next to each other on stage, were predictably the evening’s Medicare-for-all cheerleaders. But they were forced to defend it against an unprecedented barrage from candidates including Delaney, Sen. Amy Klobuchar (D-Minn.), Montana Gov. Steve Bullock, Rep. Tim Ryan (D-Ohio) and former Colorado Gov. John Hickenlooper, who depicted Medicare-for-all as a heavy-handed system that would deprive Americans of the ability to choose the plan they want.

To Warren’s point: The attacks could very well have been lobbed by Republicans, who frequently deploy the “no-choices” theme to hit against virtually any Democratic health-care proposal (like Obamacare).

“It comes down to that question of Americans being used to being able to make choices, to have the right to make a decision,” Hickenlooper said.

Bullock said he won’t support “any plan that rips away quality health care from individuals.”

“This is an example of wish list economics,” he said. “It used to be just Republicans who wanted to repeal and replace. Now many Democrats do, as well.”

Ryan seized the opportunity of the debate being in Detroit, home of the United Auto workers union. He pointed to union workers, who, under Sanders’ plan, would lose the health benefits negotiated with their employers in lieu of a single, national plan.

“This plan that's being offered by Senator Warren and Senator Sanders will tell those Union members who gave away wages in order to get good healthcare that they're going to lose their healthcare because Washington's going to come in and tell them they got a better plan,” Ryan said.

Sanders's retort was one of the fieriest moments of the night: 

There's also this interesting side note from my Post colleague Jeff Stein: 

And my Post colleague Matt Viser makes a bigger point:  

The division could be thought of this way: Candidates who want an “evolution” towards universal health coverage – where people are offered some combination of a public option and buying into Medicare or Medicaid – versus those who want an immediate “revolution” like what Sanders envisions.

That’s how Hickenlooper put it.

“If enough people choose it, it expands, the quality improves,” he said. “In 15 years you could get there, but it would be an evolution, not a revolution.”

Los Angeles Times's Jennifer Haberkorn:

The other main line of discussion was over whether Medicare-for-all would raise taxes on middle class Americans, a question the CNN moderators pressed several candidates on repeatedly. Sanders has proposed a 4 percent tax on employees, exempting families earning less than $29,000, as one way to pay for his plan. But he stresses the taxes would be more than offset because people would no longer have to pay premiums, deductibles and co-payments.

When moderator Jake Tapper tried to pin Warren down on whether she’d support raising taxes on middle-income earners, Warren left the door open without explicitly endorsing the idea. Overall health-care costs would go down for these people, she stressed.

“Middle-class families are going to pay less out of pocket for their health care,” she said. “For middle-class families, costs — total costs — will go down,” she said, after Tapper pressed her again.

Vice News's Elizabeth Landers: 

Not even South Bend, Indiana Mayor Pete Buttigeig was willing to say the middle class should pay higher taxes, or that people should be forced into it -- even though he appeared more amenable to Medicare-for-all than the others. (Here's a good piece from my colleague Jeff Stein over the part of the debate and some of its other finer points.)

Because the candidates had such a limited time to respond – and because they often cut in and interrupted each other – it wasn’t always entirely clear exactly how they’d present new coverage opportunities were they to be elected president.

Some said the Medicare buy-in age should be lowered. Others said the uninsured should be able to buy into it, and that it should be an option for everyone. Still others said a public option plan is the best way to go. Many wanted a combination of the two.

Buttigieg touted “Medicare-for-all-who-want-it,” where people could choose to join the program if they preferred it to commercial plans.

Former Rep. Beto O’Rourke said he wants “Medicare for America,” presumably referring to a bill in Congress allowing people to stay in qualified employer-sponsored coverage.

Delaney said his plan, “BetterCare,” would give people options and wouldn’t raise middle-class taxes.

Media Matters's Matthew Gertz: 

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

GUN VIOLENCE: Bullock called for tackling gun violence as a public health issue “not a political issue,” and said that while he's a hunter and gun-owner, he was affected by gun violence when his 11-year-old nephew was shot and killed on a playground. Bullock and numerous others on the debate stage pointed to money in politics from groups like the National Rifle Association as the reason for lawmakers' inaction on the issue.

After Minnesota Sen. Amy Klobuchar criticized Trump for saying he would support universal background checks before meeting with the NRA, Buttigieg lamented what he called the “exact same conversation we've been having since - since I was in high school. I was a junior when the Columbine shooting happened. I was part of the first generation that saw routine school shootings. We have now produced the second school shooting generation in this country.” Buttigieg also suggested there was support, including from a majority of Republicans, for universal background checks, as well as “common sense solutions like red flag laws that disarmed domestic abusers and flag mental health risks and an end to assault weapons.”

HEALTHCARE FOR UNDOCUMENTED IMMIGRANTS: Some of the more moderate candidates on the stage challenged Sanders’s proposal to offer health coverage for undocumented immigrants.

Bullock said: “We’ve got 100,00 people showing up at the border right now. If we decriminalize entry, if we give free healthcare to everyone, we’ll have multiples of that.” Ohio Rep. Tim Ryan agreed with Bullock and rejected the idea of free health coverage for undocumented immigrants. “Undocumented people can buy healthcare too. I mean everyone else in America is paying for their healthcare. I think - I don't think it's a stretch for us to ask undocumented people in the country to also pay for healthcare,” he said.

Sanders defended his proposal: “I happen to believe that when I talk about healthcare as a human right that applies to all people in this country, and under a Medicare for All single payer system, we could afford to do that.”

HOSPITAL CLOSURES: Delaney claimed that “many hospitals would close” if they were paid at Medicare rates, challenging Sanders’s Medicare-for-all plan. In a fact-check, our Post colleague Salvador Rizzo points out that during the debate, Delaney scaled back a Four Pinocchio claim that all hospitals would close under such a plan, but also notes it’s not entirely clear how the Sanders plan would impact hospitals. “Health-care experts previously told us that under Sanders’s bill, some hospitals could close and some could cut staff or reduce services to cope with lower revenue from being paid at Medicare rates or at lower rates than they currently see,” Salvador writes. “Some rural hospitals are already struggling, so being paid at lower rates would compound their troubles. But some urban hospitals treating high volumes of uninsured patients could end up with more revenue. And Sanders says bureaucratic costs would decline because of reductions in hospitals’ billing-documentation requirements and red tape."

AHH, OOF and OUCH

AHH: Health and Human Services Secretary Alex Azar told CNBC the Trump administration is working on a plan to allow the United States to import prescription drugs from Canada in order to lower out-of-pocket costs for patients.

“I just got off the phone with him,” Azar said in an interview on the network, referring to Trump. “Working on a plan on how we can import drugs safely and effectively from Canada so the American people get the benefit of the deals that pharma themselves are striking with other countries.”

The latest potential proposal comes as the Trump administration has hit a number of hurdles in its efforts to tackle skyrocketing drug costs. Earlier this month, as our Post colleague Yasmeen Abutaleb, Amy Goldstein and Ashley Parker reported, the administration moved to kill a key proposal to end the practice of allowing drugmakers to give rebates to insurance middlemen.

As for the latest drug importation plan, it’s not yet clear what the details may be. “But Trump has previously supported a plan by U.S. lawmakers who have said they can lower high prescription drug costs by approving imports from Canada, where prices are lower,” CNBC’s Berkeley Lovelace Jr. reports.

While the issue of importing drugs was not specifically mentioned on the debate stage last night, Sanders -- who has introduced legislation that's cosponsored by other 2020 candidates to allow the importation of lower-cost drugs from Canada and other major countries -- mentioned traveling to Canada over the weekend with patients who were able to pay "one-tenth the price in Canada for insulin that they're paying in the United States." 

OOF: The American Civil Liberties Union and Planned Parenthood joined together to file a lawsuit against Missouri’s ban on abortions performed after eight weeks of pregnancy, a state law that does not include exceptions for victims of rape or incest.

The law is set to take effect next month in a state that’s one of six that have passed so-called “heartbeat” bills that prohibit the procedure from being performed after a fetal heartbeat is detected.  

"Many women don't even know that they are aware of their pregnancy, or may have a challenge getting into a clinic for eight weeks," Alexis McGill Johnson, the new acting president of Planned Parenthood Federation of America told CBS News’s Kate Smith. "We think that is wrong, we think it is illegal and so we are fighting, you know, we are fighting."

Meanwhile, Kate writes abortion access is already a challenge in the state. “Women seeking an abortion are required to undergo a 72-hour waiting period and receive state-mandated counseling designed to dissuade them from receiving an abortion. Various other regulations have closed all but one clinic in the state: a lone Planned Parenthood in St. Louis.”

In the complaint, the plaintiffs argue that “[f]or years, Missouri officials have engaged in a targeted campaign against abortion.”  

OUCH: Here’s what you may have seen during the debate’s commercial breaks: Partnership for America's Health Care Future, a coalition funded by pharmaceutical and hospital groups like the Pharmaceutical Research and Manufacturers of America, the American Hospital Association and the American Medical Association, is airing television ads and pushing a digital campaign to criticize the Medicare-for-all proposal that has been a key point of divison during the debates. 

The six-figure advertising campaign, the Hill’s Jessie Hellman reports, also targets the public-option plan espoused by former vice President Joe Biden, who has been sparring with Sanders in recent weeks over their diverging health-care ideas. In the ad, the coalition seeks to convince voters that the plans would increase taxes and premiums rather than improve health care.

“Rather than handing more control over to politicians and bureaucrats, we should build and improve upon what’s working in American health care, while coming together to fix what isn’t," Lauren Crawford Shaver, the Partnership’s executive director, told Jessie.

— That’s not all: The president’s reelection campaign is also planning to blast his potential Democratic rivals during the debates, specifically citing their support for providing health care to undocumented immigrants. While there were mentions of the issue last night, the ad refers back to the second night of the first set of debates in Miami, when every candidate’s hand shot up when asked if undocumented immigrants should be covered in government health plans, The HIll's Jessie reports

In an ad that’s set to air on CNN, MSNBC and Fox during both nights of the Democratic debates this week, a narrator will accuse Democrats of “putting illegal immigrants before hardworking Americans." 

"Democrats — radical, reckless, socialist," a narrator will add. "They're all the same."

AGENCY ALERT

— Lawyers for the American Civil Liberties Union say the Trump administration has separated nearly 1,000 child migrants from their parents since a federal judge ordered on June 26, 2018 that the government halt family separations at the border, our Post colleague Maria Sacchetti reports.

That’s what lawyers for the ACLU told a federal judge in a lengthy court filing in U.S. District Court in San Diego – that 911 children were separated from their families out of the tens of thousands of children who were taken into custody. The acting Homeland Security Secretary says the separations occur only when the adults pose a risk to the child, or if there is abuse or neglect, but the ACLU lawyers allege “federal immigration and border agents are splitting up families for minor alleged offenses — including traffic violations — and urged the judge Tuesday to clarify when such separations should be allowed to occur,” Maria writes The ACLU also says about 20 percent of the new separations impact children younger than 5 years old, compared with 4 percent last year.

“What everyone understands intuitively and what the medical evidence shows, this will have a devastating effect on the children and possibly cause permanent damage to these children, not to mention the toll on the parents,” ACLU lawyer Lee Gelernt told The Post.

SECOND OPINION

— Former FDA Commissioner Scott Gottlieb penned an op-ed in The Post calling on his former agency to do more to regulate cannabidiol, or CBD, and for manufacturers to work toward demonstrating the product’s safety and effectiveness.

He writes that while there’s just one legally available purified form of CBD, it “doesn’t mean there can’t be a route for CBD to be legally sold in other forms, including as a food ingredient. Nor does it mean that CBD can’t offer potential benefits. But a legal path should be based on a clear and efficient regulatory process and sound science to guide its proper use.”

He suggested the FDA can “approve the sale of some CBD products immediately, while effecting a framework for their safe and proper regulation and a pathway for an enforceable market for these goods. The FDA could put the onus on manufacturers to bring forward petitions to demonstrate that CBD can be safely added to products such as food.”

Our Post colleague Laura Reiley wrote last month about the CBD craze that includes CBD-infused food and drinks, even while the products are still illegal at the federal level.

INDUSTRY RX
Technology
Sen. Josh Hawley (R-Mo.) has proposed a bill taking on Big Tech's techniques.
Katie Mettler
True Crime
When a state drug technician was found to be getting high on the job, these prosecutors refused to share information about her drug use with the defendants whose cases she'd worked. Now they are facing bar penalties, and one faces a civil rights suit.
Tom Jackman
STATE SCAN
D.C. Politics
All 13 council members expressed concerns over the announced end of the Georgetown University partnership.
Peter Jamison
The move is the latest by a growing number of federal and state officials to scrutinize the companies over the life-saving diabetes medicine.
Stat
The state said 11 people had contracted the disease and 55 more cases were “probable.” A Sheraton hotel linked to the outbreak has voluntarily closed for now.
New York Times
REPRODUCTIVE WARS
Alexis McGill Johnson says the organization doesn't have the luxury of deciding whether the organization is a healthcare clinic or advocacy group
CBS News
DAYBOOK

Today

  • CMS Administrator Seema Verma and Sen. Mike Braun (R-Ind.) speak on Medicare-for-all at an event hosted by the Heritage Foundation.
SUGAR RUSH

Democrats spent the second debate telling each other they’re wrong:

Highlights from the post-debate spin room: