The Washington Post - 31.07.2019

WEDNESDAY, JULY 31 , 2019. THE WASHINGTON POST EZ M2 A

campaign 2020

BY JEFF STEIN

The Democratic presidential
debate Tuesday night showcased
intense splits between the party’s
candidates over Medicare-for-all,
as the party’s moderates worked
to undermine the liberals’ plan for
a national health insurance sys-
tem.
Sens. Bernie Sanders (I-Vt.) and
Elizabeth Warren (Mass.) mar-
shaled arguments in support of a
single-payer health system as
their debate opponents — includ-
ing former congressman John
Delaney (Md.) and former gover-
nor John Hickenlooper (Colo.) —
identified new lines of attack and
counterarguments.
Here were three of the key
Medicare-for-all disputes in the
debate and the background be-
hind each:
Would Medicare-for-all
force millions of families off
their insurance? Several candi-
dates fought Tuesday over the de-
gree to which Sanders’s plan,
backed by Warren, would amount
to throwing hundreds of millions
of Americans off their current
health insurance plan.
About half of the country —
more than 150 million people —
receives health insurance from
their employer. The other half is
covered by a public program (such
as Medicare for the elderly or
Medicaid for the poor and dis-
abled), purchases insurance di-
rectly from an insurer, or has no
insurance.

Sanders’s Medicare-for-all plan would move every American into one government insurer in four years, while providing them with medical, vision, and dental care at no cost. Advocates for such a plan, sometimes called a single-payer system, believe forcing everyone into the same pool is necessary to restrain U.S. health care costs. In theory, doing so would give the federal government leverage over health-care providers — such as hospitals — to accept lower payment rates. The United States spends far more than other coun- tries on health care, despite lag- ging behind on key health indica- tors such as life expectancy and infant mortality. But critics have latched onto the potential political ramifica- tions of mandating that millions of people with employer-based care move to a government system. They have pointed to polling suggesting majorities of Ameri- cans like their employer-provided insurance, and warn there could be a significant public blowback from such a large federal interven- tion. This debate has for months sparked fierce discussions in Democratic policy circles, and did so again Tuesday night. “We don’t have to go around and be the party of subtraction, and telling half the country, who has private health insurance, that their health insurance is illegal,” Delaney said.

Hickenlooper also argued that Sanders’s plan deprives Ameri- cans of the freedom to choose between a government and private plan: “You know, it comes down to that question of Ameri- cans being used to being able to make choices, to have the right to make a decision.” However, Sanders and Warren held their ground. They and their allies have pointed out that millions of families lose their insurance every year if they lose their job or lose eligibility under a public plan for various reasons. One study cited by the left-leaning Peo- ple’s Policy Project suggested that one in four non-elderly adults are uninsured within a given year, meaning millions of people al- ready cycle in and out of insurance. Sanders said his plan is best “if you want stability in the health- care system.” Warren similarly hit back at the accusation: “We should stop using Republican talking points in order to talk with each other about how to best provide that health care.” Would Medicare-for-all raise taxes on the middle class? Democratic presidential candidates, including Barack Obama, have traditionally shied away from embracing plans that would raise taxes on the middle class. Sanders has said that his single- payer plan would raise taxes on the middle class but that amount would be more than offset because

people would no longer pay de- ductibles, co-payments or premi- ums for health insurance. Sanders has said one option to fund Medi- care-for-all would be from a 4 percent tax on employees, ex- empting families earning less than $29,000. Warren appeared to join Sand- ers in making that argument under pressure from CNN’s Jake Tap- per to answer whether she supports raising middle-class taxes to pay for the plan. “Middle-class families are going to pay less out of pocket for their health care,” she said. Pressed again for clarification, she added, in an implicit acknowledg- ment of potential tax increases: “For middle-class families, costs — total costs — will go down.” But other candidates have sought to embrace proposals that are less expensive. Former congressman Beto O’Rourke of Texas has backed a “Medicare for Ameri- ca” plan, which would place the uninsured and those who are pub- licly insured in an expanded government program. Anyone could buy into the program but millions of Americans would not be forced to surrender their employer-spon- sored care. O’Rourke denied his health plan would raise middle-class taxes. The plan O’Rourke supports would raise taxes on income above $500,000, as well as on tobacco, beer, wine, liquor and soft drinks. It would also eliminate the 2017 Republican tax law, which cut

some middle-class taxes. “The middle class will not pay more in taxes in order to ensure that every American is guaranteed world-class health care,” he said, later adding: “I have a better path.” Pete Buttigieg, the mayor of South Bend, Ind., who has been vague about the details of his plan, sidestepped the question of whether his legislation would in- crease middle-class taxes. Butt- igieg earlier in the campaign said he supports Medicare-for-all, but has since said he supports a public option in which the government would offer a public plan that competes with private insurers, rather than outright replaces them. “Clearly the candidates did not want the talking point that middle-class taxes would go up,” said Larry Levitt, senior vice presi- dent at Kaiser Family Foundation. “Tax increases are a potent line against Medicare-for-all, though it would likely lead to the middle- class paying less for health care overall.” Would single-payer devas- tate rural hospitals? Opponents of Medicare-for-all gave dire warnings about its potential im- pact on hospitals, arguing they would be at risk of further closures under a government-run system. One key selling point of Medi- care-for-all is that it would allow the United States to lower medical spending by reducing payment rates for hospitals and physicians. But many hospitals barely break

even and rely on payments under private insurance — which are higher than those of Medicare — to survive. At the first debate, Delaney claimed that all hospitals would close under single-payer, a claim dismissed by fact-checkers. But how to prevent hospitals from closing would be a difficult policy challenge under Medicare-for-all, said Harold Pollack, a health-care expert at the University of Chica- go, who noted that many rural hospitals survive only because of high private insurance rates. Last year, a record 46 percent of rural hospitals across America lost money, while more than 400 are at “high risk of imminent fail- ure.” “It is a very real challenge,” Pollack said. “If we went to a single-payer system, we would have to figure out how to support these institutions another way.” Delaney pared back his argument Tuesday, but maintained that single-payer would force hospitals “into an underfunded system.” Sanders responded that hospitals would save significant amounts of money under single- payer because they will no longer have to spend “a fortune doing billing and the other bureaucratic things that they have to do today.” Sanders has also recently pro- posed a fund that would allow local governments to purchase hospitals in financial distress. [email protected]

Medicare-for-all: Candidates split over tax hikes, job-based insurance loss

telling them “their health care is illegal.” Montana Gov. Steve Bullock called it “wish-list economics” and said Democrats were promoting the type of “repeal and replace” strategy Republicans have. Former Texas congressman Beto O’Rourke said it would be “taking away people’s choice.” Rep. Tim Ryan (D-Ohio) said the plan would tell union members who have negotiated their private insurance that they “will lose their health care because Washington is going to come in and has a better plan.” Sanders and Warren pushed back and got applause. If the crowd mirrors the electorate, they will be just fine — but it won’t exactly. The question is whether this presages a reexamination of this issue or whether this was just a fluke thanks to some of the most moderate candidates being put on a stage with Sanders and Warren. Beto O’Rourke: Anonymous in the first debate. Lackluster second quarter of fundraising. Falling poll numbers. Anonymous at the second debate. The magic hasn’t re- materialized for him. Steve Bullock: The Montana governor was the new entry in the debates, after getting a late start on qualifying for the first one. And he cued up a contrast with Sanders, saying in his opening statement that struggling Americans “can’t wait for a revolution.” But he didn’t really deliver on that angle and often stumbled over his words. Delaney wound up being the foil to Sanders and Warren that Bullock aspired to be. [email protected]

a cease-fire. At one point when Sanders was being attacked, Warren tried to cut in to (apparently) defend him. Another time, Sanders attempted to return the favor. Warren was asked if her statement that she was a capitalist was meant to contrast herself with Sanders, the democratic socialist, and she demurred. At another point, Sanders said of Warren, “Elizabeth is exactly right.” They may have to joust eventually, but it wasn’t happening Tuesday night. The format: What CNN’s moderators gave, the format took away. CNN spent about 20 minutes at the start on candidate introductions, a commercial break and then (canned) opening statements. And then they held to a very rigid time limit on rebuttals, often cutting substantive responses short. The first debate, put on by MSNBC, was better about getting right to it. Maybe spend less time on the buildup and allow a little more response time. Medicare-for-all: Single- payer health care has been on the march in the Democratic Party. But on Tuesday night, it got some pushback — a lot of pushback — from Democratic presidential candidates. The first 25 minutes of the debate was devoted to the topic, and the also-rans of the Democratic contest used it to argue that the likes of Sanders and Warren were promoting pie in the sky. In fact, those two were generally outnumbered. Delaney said moving Americans from private to government insurance would be

what he’s selling? That’s another issue. Pete Buttigieg: For the second straight debate, the South Bend, Ind., mayor may not have been a standout, but he again showed himself to be a skilled debater, navigating the divide between the more moderate candidates and the liberals. He’s shown a deft touch at appealing to both wings of the party. He hasn’t built much after an early plateau, but thanks to steady debating and strong fundraising, he’ll continue to be a player. Marianne Williamson: Williamson was widely savaged for her at times bizarre performance in the first debate. But on Tuesday night, she had some of the biggest applause lines of the entire debate, including perhaps the biggest one, on reparations. When asked about the water crisis in Flint, Mich. — just up the road from Detroit — she said, “What happened in Flint would not have happened in Grosse Pointe.” (Williamson has lived in Grosse Pointe, Mich., which is far less diverse than Flint.)

Losers The big Sanders vs. Warren clash: Or not. One of the drawbacks of the crowded Democratic field is that the debates split up the leading candidates. Given that Sanders and Warren were not in the same debate last month and that Warren has risen in the polls while Sanders has fallen — while appealing to similar voters — everyone was girding for them to actually, you know, debate each other. Instead, they largely agreed to

a bit player in the 2020 race, and that was definitely the case in the first debate. At the start of Tuesday’s debate, though, Sanders was asked about Delaney’s criticisms of his health-care proposal. They went back and forth before anyone else got a chance to weigh in. At another point, Delaney earned a rebuke from Warren, too, with the senator from Massachusetts decrying Democrats like Delaney who are running “just to talk about what we can’t do and shouldn’t fight for.” It was a big applause line. But Delaney got a chance to make his case, over and over, serving as the main foil to Sanders and especially Warren. That’s about the best he could have hoped for. Whether liberal primary voters are buying

Bash and Don Lemon — challenged the candidates by accurately summarizing the arguments against their policies. The moderators did it on single- payer health care, on decriminalizing illegal border crossings, and on free college tuition and several other topics. There were also lots of substantive back-and-forths, without the constant interruptions that marred the second night of the first Democratic debate. When candidates tried to jump in to get more time, the moderators kept it moving and didn’t let themselves be bullied. There was a drawback, though, which we’ll get to. John Delaney: The former Maryland congressman has been

The candidates
seeking the 2020
Democratic
presidential
nomination began
their second
debate on Tuesday night, with
the first 10 contenders facing off
in Detroit.
Below are some winners and
losers.

Winners

Elizabeth Warren: Neither of
the two leading candidates in
Tuesday’s version of this week’s
debate — Sens. Elizabeth Warren
(D-Mass.) and Bernie Sanders (I-
Vt.) — ran into too many
problems. But on balance,
Warren seemed to be better at
enunciating her liberal policy
proposals and parrying attacks
from those challenging her. She
is also more ascendant in the
polls than Sanders, which means
a debate that more or less
adheres to the status quo suits
her.
“Republican talking point”:
Warren on two occasions struck
back at criticisms from
moderates of her policies on
health care and other issues by
characterizing them as a
“Republican talking point.” At
another point, Sanders attacked
the line of questioning from
CNN’s Jake Tapper. “And, Jake,
your question is a Republican
talking point,” he said. Both were
responding to repeated
questioning of their liberal
policies. What’s clear is that if
either of them is the Democratic
nominee, Republicans did get
some talking points out of
Tuesday’s debate.
CNN’s moderators: Sanders’s
complaint was misplaced. CNN’s
moderators — Tapper, Dana

Warren, Williamson among Night 1’s winners, while CNN debate format falters

Aaron
Blake

THE FIX

BRENDAN SMIALOWSKI/AGENCE FRANCE-PRESSE/GETTY IMAGES CNN moderators Don Lemon, Dana Bash and Jake Tapper at the first round of the Democratic primary debate Tuesday in Detroit. Sen. Bernie Sanders would later criticize Tapper for repeating what Sanders called a “Republican talking point” on health care.

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The Washington Post - 31.07.2019

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