THE PROGNOSIS

Sen. Elizabeth Warren (D-Mass.) has finally detailed how she’d pay for Medicare-for-all if she wins the White House in 2020. But history says the senator's plan might not have much staying power.

If Warren won the presidency, she’d meet strong resistance from Republicans, who are favored to retain control of the Senate in the 2020 elections. And even if her party controlled both the House and the Senate, Democrats are hardly unified over whether to approve a sweeping social program like Medicare-for-all – let alone how to pay for the trillions of dollars in new spending it would require.

Just look at how the country’s biggest health insurance programs – Medicare, Medicaid and the Affordable Care Act – were created. In each case, the president proposed the basic idea behind the social programs, but gave Congress wide leeway in deciding how each  would work and be paid for as the legislation went through multiple iterations.

“What presidents propose during campaigns do not govern the policy development process once they are elected,” said David Blumenthal, who wrote “The Heart of Power,” a 2009 book that recounts how each of the presidents, starting with Franklin Delano Roosevelt, tried to expand health coverage.

“If they go forward with prioritizing health reform, the Congress takes that over, so from that standpoint you could argue it doesn’t really matter what anyone proposes in detail because Congress will take it and run with it,” Blumenthal added.

Warren – or whoever is the next president of the United States – would do well to consider how President Lyndon B. Johnson interacted with Congress as it passed Medicare in the 1960s. LBJ was as intensely involved as the House and Senate committees, working with then-House Ways and Means Chairman Wilbur Mills (D-Ark.) essentially sketched the outlines of an ambitious plan.

But the then-president was always involved as a supporter of the effort, not a controller. Rather than rolling out a detailed plan for Medicare while campaigning, LBJ stressed again and again that whatever Congress came up with, it should provide the elderly with health insurance. LBJ made clear to Mills that he wanted Congress – not the White House — to draft a bill.

Contrast that strategy with how President Bill Clinton approached health-care restructuring in the 1990s.

Clinton charged first lady Hillary Clinton and policy adviser Ira Magaziner with writing legislation to expand health coverage. But they lacked an understanding of how to work with Congress to pass it, and the whole thing fizzled when both then-House Speaker Tom Foley (D-Wash.) and then-Senate Majority Leader George Mitchell (R-Maine) concluded there wasn’t political consensus to pass it.

“[Clinton] had every clause and every period and comma and decimal point in that bill, and that was a disaster,” Blumenthal told me.

It’s easy to see how in this highly charged political environment Warren felt heavy pressure to describe how she’d pay for the generous benefits envisioned under Medicare-for-all. But the Democratic debate over whether to eliminate private insurance while guaranteeing government-sponsored health-care coverage for everyone sidesteps the very rocky path taken to approve the Affordable Care Act in 2010, and its numerous challenges since then.

A Democratic-controlled House and Senate barely approved the ACA -- and in doing so, gave away one of the biggest items on the wish list of health-care progressives: a public option. Now, Joe Biden is arguing the ACA should be expanded and a public option should be included and that's viewed as the more moderate position in the 2020 contest.

The ACA hasn't always been popular, and President Trump has eased back its regulations and worked to undermine it legally, with a court decision soon expected that could eliminate the ACA entirely. That could make a debate moot over an even more ambitious plan like Warren's.

Nonetheless, Warren’s plan, released Friday, generated a lot of buzz over the weekend, including a skit starring Saturday Night Live’s Kate McKinnon:

To pay for Medicare-for-all – the bill written by Sen. Bernie Sanders (I-Vt.) that Warren has fully embraced – she would mainly target corporations and the wealthy. The richest 1 percent of Americans would pay $3 trillion in new taxes, including an expanded wealth tax. Warren is also proposing to collect $3 trillion from “large corporations,” $2.3 trillion in new tax collections by improving enforcement and about $1 trillion from a new Wall Street tax. She’d also cut military spending.

The largest portion of revenue would come from employers. They would no longer have to fund private plans for their workers, but those savings would be offset by $8.8 trillion in new federal taxes. This approach allows Warren to avoid directly raising taxes on middle-class workers, but it could indirectly affect them by suppressing wages and discouraging firms from hiring.

Larry Levitt, the executive vice president for health policy at the Kaiser Family Foundation:

Washington Post columnist Jennifer Rubin:

Some experts have questioned whether Warren is overestimating how much these revenue streams could bring in, my colleague Jeff Stein writes.

“Warren’s plan relies on math that some economics have already begun to question, including optimistic estimates for how much revenue certain plans – like beefing up tax enforcement – would bring into federal coffers,” he writes.

Not only that, but Warren estimates Medicare-for-all would cost considerably less than what independent analysts have projected. She does this partly by assuming the government would pay doctors and hospitals less than what they’re getting now – an approach that would prompt even fiercer pushback from a health-care industry already vehemently opposed to a single-payer system.

“Citing research on the Canadian health care system, Warren proposes setting physician payment rates in line with the current Medicare system -- an effective 6.5 percent cut to doctor pay,” Jeff explains. “She would also pay hospitals 110 percent their Medicare payment rate, a cut from what they are currently paid by private insurers….Warren says these cost restraints would knock about $3 trillion off the plan’s overall price-tag.”

While multiple studies have estimated Medicare-for-all would cost more than $30 trillion over a decade, Warren’s tax proposals would raise just $20 trillion during that time frame. Kenneth Thorpe, chairman of the health policy department at Emory University, told my colleague Annie Linskey he thinks Medicare-for-all would cost more like $35 trillion over a decade.

“There’s no way it’s $20 trillion,” he said. “I don’t know why they’d put out that number. The bottom line is, even with all the big numbers she’s got in there, you’re only getting 55, 60 percent of the way there.”

Other Democrats criticized Warren on other points, including how Medicare-for-all would eliminate private health plans. CNN's DJ Judd, who talked to presidential contender Pete Buttigieg: 

The Hill's Peter Sullivan:

Health-care activist Ady Barkan had positive words:

AHH, OOF and OUCH

AHH: Health and Human Services Secretary Alex Azar has proposed reversing an Obama-era regulation that had required adoption and foster-care agencies to serve same-sex couples, even if it violated their religious belief.

"The draft says HHS will remove language introduced during the Obama administration that 'no person otherwise eligible will be excluded from participation in, denied the benefits of, or subjected to discrimination' based on a long list of characteristics including race, age, gender identity and sexual orientation," our Post colleague Ariana Eunjung Cha reports "In its place, the agency would guarantee protections required by federal statute. The Civil Rights Act of 1964, Americans With Disabilities Act of 1990 and others provide protections for everything on the Obama-era list except for sexual orientation and gender identity."

The proposed rule's most immediate impact would likely be on the nation’s $7 billion federally funded child-welfare system, including foster care and adoption programs. Faith-based agencies in several states, including South Carolina, Texas, Michigan and Pennsylvania, have argued they should not be forced to work with gay, lesbian or transgender parents against their own belief, Ariana reports.

Lori Windham, senior counsel at the Becket Fund, said HHS is repealing “a bad regulation that made it harder for faith-based foster care and adoption agencies to follow their sincere religious beliefs while serving children in need.”

But Denise Brogan-Kator, chief policy officer of the Family Equality, called the move “outrageous” and “another attack by this administration on the lives of the most vulnerable in our country under the pretense of religious freedom.”

OOF: A federal judge in Oregon temporarily blocked the Trump administration’s rule requiring immigrants to prove they have health insurance or have the financial means to pay for coverage before they acquire visas. The temporary block will be in place for 28 days.

Trump’s proclamation intended to require that immigrants “demonstrate they could obtain health insurance within 30 days of arriving in the United States — a demand that immigration and health experts said would be particularly onerous for low-income immigrants who may not be coming to the United States for a job that provided health insurance or who may be unable to pay for foreseeable medical costs,” our Post colleagues Yasmeen Abutaleb and Kayla Epstein report. The Migration Policy Institute estimated the proclamation could keep 375,000 immigrants from entering the country each year.

U.S. District Court Judge Michael Simon wrote in his order that those who brought the lawsuit demonstrated “they are likely to suffer irreparable harm in the absence of temporary relief, that the balance of hardships tips sharply toward Plaintiffs, and temporary relief is in the public interest.”

White House press secretary Stephanie Grisham called it “wrong and unfair for a single district court judge to thwart the policies that the President determined would best protect the United States healthcare system.”

OUCH: As the Trump administration pledges to ban nearly all flavored e-cigarettes, it has renewed a debate over tobacco regulation and racial equity and health, our Post colleagues Hannah Knowles and Laurie McGinley report.

Some black health advocates are questioning whether the federal government is ignoring another flavored nicotine product – menthol cigarettes – that's particularly popular with and therefore a risk to black smokers. Others warn such a ban would be discriminatory, and would be “robbing African American smokers of their right to choose which products to use.”

“Menthol cigarettes are still popular among African Americans, 47,000 of whom die every year of smoking-related causes,” our colleagues write. “But unlike the alarm over underage use of e-cigarettes — fueled in large part by the popularity of Juul among white, middle-class teenagers — neither the Trump administration nor the Obama administration have treated the devastating health effects of menthol cigarettes on the black community as a crisis.”

A growing number of black lawmakers and activists are pushing for a ban on menthol cigarettes among other anti-tobacco efforts. “After Gottlieb said last fall he wanted to ban menthol, he drew immediate support from the late representative Elijah E. Cummings (D-Md.), then-chairman of the caucus. Several caucus members have also signed onto a bill by House Energy and Commerce Chairman Frank Pallone Jr. (D-N.J.) to ban menthol cigarettes and other flavored tobacco products, including e-cigarettes."

AGENCY ALERT

— Trump announced that he plans to nominate Texas oncologist Stephen Hahn to be the next leader of the Food and Drug Administration.

Meanwhile, instead of the current acting FDA commissioner Ned Sharpless running the agency until Hahn is confirmed, as was expected, Sharpless will return immediately to his old gig at the head of the National Cancer Institute. Brett Giroir, the current assistant secretary for health at HHS, will lead the department until Hahn is confirmed, Laurie reports.

Sharpless’s acting tenure “couldn’t be extended because the White House has not yet officially nominated Hahn, who is still undergoing a background check, officials said. When Sharpless returns to the cancer institute, Doug Lowy, acting director of the institute, will resume his work as principal deputy there,” she writes.

Sen. Patty Murray (D-Wash.), the top Democrat on the Senate Health, Education, Labor and Pensions Committee, said she was “alarmed” by the appointment of Giroir as interim FDA commissioner, pointing to a “track record of letting ideology drive decisions at the expense of women and families.” In a statement, Azar called Giroir “an indispensable leader.”

HEALTH ON THE HILL

—  A new Washington Post-ABC News poll suggests voters are concerned with the health of the candidates themselves.

Following Sanders’s heart attack last month, 45 percent of Democrats responded saying he’s not in good enough health to serve as president, our Post colleagues Scott Clement and Dan Balz report. Still, 48 percent said he is in good enough health.

During the most recent debate, the 78-year-old Sanders said he was “healthy, I’m feeling great” when asked how he can assure voters that he’s fit for enough for the task after his heart attack.

Meanwhile, there appears to be less concern about the other two septuagenarians running for the Democratic nomination. The poll found “80 percent majority of Democrats and Democratic-leaning independents say Warren is healthy enough to serve, as do 74 percent who say this of Biden.”

— And here are a few more good reads: 

TRUMP TEMPERATURE

Politics
Trump has been counseled by political advisers that gun legislation could splinter his political coalition and the White House is now focused intently on combating the impeachment inquiry.
Josh Dawsey

MEDICAL MISSIVES

Health
The outbreak, announced on Halloween, sickened 23 people across 12 states from July 12 to Sept. 8, according to the FDA.
Michael Brice-Saddler
Those who rely on plug-in health devices or medicine that requires refrigeration are scrambling to find ways to avoid potentially life-threatening disruptions now and in future fire season shutdown…
Kaiser Health News

OPIOID OPTICS

Saoirse Kennedy Hill, 22, died at the family compound over the summer.
New York Times
The opioid epidemic is seriously hurting the US economy.
Vox

DAYBOOK

Coming Up

  • The Senate Special Committee on Aging holds a hearing to examine "veteran scams, focusing on protecting those who protected us" on Wednesday.
  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on the response to lung illnesses and youth e-cigarette use on Nov. 13. 

SUGAR RUSH