A California Resolution to the Primary Debate on the Future of Health Reform

Blog post written by Anthony Wright, Executive Director of Health Access California

Since Health Access does not endorse candidates, I have refrained from commenting on the Presidential primary debates. There has been little to analyze on the Republican side, given the minimal substance on health policy, besides the standard talking points about the repeal of Obamacare.

On the Democratic side, the health care debate has been more interesting. Secretary of State Hillary Clinton has embraced the Affordable Care Act and outlined a series of proposals to not just defend it but “build on it” for increased affordability, expanded access and improved quality.

While Senator Bernie Sanders voted for and supported the Affordable Care Act, he strongly advocates for a broader revamp of our health system to create “a Medicare-for-all health care system.”

As opposed to re-litigating whether the Affordable Care Act should have been enacted in the first place, this debate on the Democratic side has been useful to begin the crucial national discussion of what should be the next steps to improve the health care system. But too often the debate, or the descriptions of it, have been stuck in pre-existing primary fight frames about incrementalism vs. revolutionary change, progressivism vs. pragmatism, broad visions vs. detailed plans, inside vs. outside–as if these concepts are necessarily opposed to each other and policy change doesn’t require some interplay between these forces. As an organization that has been involved in making real policy change that improves the lives, and health, of Californians, we know that progress requires both broad visions and detailed plans, the inside play and the outside action, and a balancing of progressive objectives with pragmatic realities. These are not either/or, making progress requires both.

While I admire both candidates, I wish they had engaged this debate a bit more constructively. Senator Sanders talks about single-payer no differently from ten years ago, as if the Affordable Care Act never passed, as if there was not just policy progress but political lessons that have been learned from the country’s decade-long grand debate on health reform. He is right to put forward a grand vision where health care is a right for all Americans, but missed an opportunity to provide not just technical and fiscal details but to lay out a strategy of how we could transition to such a system from the world we are today–both politically and policy-wise. And while Senator Clinton was right to focus on concrete, specific steps that could provide tangible and immediate benefit to consumers, she never connected her various proposals into a broader vision of quality, affordable health care for all Americans, and was too quick to dismiss single-payer as politically unrealistic. While undoubtedly true in the short term, certainly with a Republican Congress, our political vision should not be restrained by what is possible in the moment–and indeed it is the job of our political leaders to stretch the boundaries of the debate. If nothing else, she would be good if she could be clear in responding to how her agenda is any more realistic with a Republican Congress-if there is a strategy on key issues, like how hard would it be for any member to vote against additional affordability in the form of tax credits, or to point to a growing bipartisan angst on prescription drug prices.

As the primary fight winds down, there is an opportunity. Recognizing he is likely not to win the nomination, Senator Sanders seems to be focusing on influencing the party platform and its positions, including the endorsement of Medicare-for-all single payer. In addition, I agree with Jonathan Cohn of the Huffington Post, that Sanders could have an important voice on health policy in coming years, advocating for “the most successful and popular elements” that “lay the groundwork” to that goal.

What are those elements? Cohn suggests having the government negotiate on prescription drug prices, and in particular the adoption of a true “public option” that would compete with the private plans. But there is a broader agenda than just the public option, which was a rallying point that we actively organized in support of during the effort to pass the ACA.

Supporting “single payer” has become shorthand for some advocates for a range of different improvements and reforms, and politically and policy-wise it is better to spell out those goals specifically. When folks support Medicare for All, they usually are seeking a health system that is more universal, progressively financed, cost-effective, streamlined and efficient, comprehensive, and prevention-oriented. Those are goals we can make progress toward that provide policy and political momentum for additional reform. A single-payer financing system that help facilitate those goals, but it’s not the only way, and the details matter–for example, it’s technically possible to have a single-payer system that is based on regressive taxation or unaffordable cost-sharing. And making progress on specific goals are not just tangible victories that would help people, but would provide momentum and policy progress toward additional reform.

Beyond the public option, another idea would be for Clinton to adopt a goal that would be an element of a single-payer system that progressives support–that no American should have to pay more than a percentage of their income to get basic health insurance, based on a progressive sliding scale. Through the subsidies available in the exchanges, the Affordable Care Act took a dramatic step toward this goal away from the previous regressive individual market, where what you paid was based on how old and sick you were. But the ACA’s guarantees of affordability have exceptions and caveats and despite the best efforts of many, the tax subsidies were never sufficient to provide coverage as affordable as most employer coverage. Senator Clinton has already proposed increasing the subsidies and tax credits available under the ACA to provide better affordability–it wouldn’t be too far a stretch to be able to make that broad guarantee that has been the hallmark of Senator Sanders’ proposals, and that is clear and understandable as a political rallying cry and policy goal. 

In their debate about universality, one key question is how to include undocumented immigrants–a question that arises in designing a single-payer system or in each of the multiple programs that exist today. In an early debate, both Senators Clinton and Sanders endorsed the ability of immigrants being able to buy coverage in the exchanges with their own money–something California is seeking to do through SB10(Lara) and a 1332 waiver. Senator Clinton has supported allowing states to go further with immigrant inclusivity, including with 1332 waivers–but perhaps she could detail how these state efforts build toward a truly universal health system, and how that helps the health system be stronger for everyone.

Senator Clinton could also follow the California’s example by encouraging the federal and state exchanges to be active purchasers, bargaining for the best value and driving standard benefits and improved quality. The principle of increasing the bargaining power is core to single-payer proposals, but was also an essential part of the law creating Covered California that was signed by Republican Governor Schwarzenegger, and has been part of the California policy landscape for years at CALPERS and Healthy Families and Medi-Cal under Administrations of both parties. This greater negotiating leverage helps provide more oversight over the insurance industry overall as well as reducing the cost of coverage with the potential for improving health outcomes and reducing health disparities.

Similarly, using the federal government’s bargaining power to take action on prescription drug costs is likely an area of policy agreement between the two Democratic candidates. Beyond the specific policy proposals, it also would be an important test case for politicians to stand up to a big-money industry, an industry that has not been afraid to spend obscene amounts of money to get its way.

In her position papers, Senator Clinton has also identified issues about capping the cost-sharing for specialty drugs, mirroring California’s law AB339 sponsored by Health Access California. She could broaden that, as both she and Senator Sanders have talked about out-of-pocket costs broadly, from deductibles to co-pays. She could outline not just specific proposals but some general goals on unfair out-of-pocket costs–ones that could likely get bipartisan support, like our state effort has this year against surprise out-of-network medical bills.

Each of these elements by itself may not be the “political revolution” that Senator Sanders seeks. But each of them could become major fights with key parts of the health industry–whether insurers, drug companies, or providers–that provides the “what side are you on” clarity that has provided the spark of Sanders’ message. And together, these efforts would dramatically improve the health system and bring us closer to the vision. Opponents might say that the ACA and these efforts to implement and improve it are a “slippery slope” to single-payer, but I think that metaphor is reverse. Rather, advocates are scaling a mountain–we have made progress up the mountain, and we are that much closer to the peak, but let’s be clear-eyed that the air is thinner, the angles steeper. As with climbing a mountain, we need to be strategic and smart as we make additional steps up toward an improved health system.

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