Court Decision, Midterm Elections Drive Debate Over Medicare for All

WASHINGTON—The decision by a federal court judge on Friday to strike down the Affordable Care Act strengthens the case for "Medicare for all," according to Dr. Adam Gaffney, president of the Physicians for a National Health Program.

"The end of the Affordable Care Act would strip health coverage from millions of Americans, potentially causing the deaths of thousands of people a year," Gaffney told Capital News Service in an email. "No doubt, we have to push back against them. At the same time, these sorts of attacks are only further galvanizing people behind the cause of improved Medicare for all."

Gaffney's 20,000-member doctors' group is an advocate for government-sponsored health care.

U.S. District Judge Reed O'Connor ruled on Friday that the Obamacare law was unconstitutional, an argument made by a number of states including Texas. It appears likely the ruling will be appealed to the Supreme Court.

The ruling in a Texas courtroom is the latest milepost in a debate that played out in the midterm elections with progressive Democrats campaigning on a Medicare for all platform that would guarantee health care for everyone. That debate appears to be intensifying with new efforts to push legislation in Congress and with the approach of the 2020 presidential election.

Gress-roots efforts

Exactly one week after the midterms, the 150,000-member National Nurses United union sponsored a nationwide conference call.

Energized by what the nurses believed was a shift in attitudes during the campaign, the group launched a grass-roots effort to transform American health care. The union is marching under the Medicare for all banner.

First stop on the crusade: Capitol Hill, to move the legislative agenda forward.

One of the speakers on that post-election call was Rep. Pramilia Jayapal, D-Washington. She addressed the importance of the moment.

"It's not going to be enough to just say you support the bill—put your name on it, because we're going to be pushing for it, said Jayapal, who is co-founder of the House Medicare for All Caucus that she says has grown to 77 members.

The call for Medicare for all excited progressive Democrats in the midterm elections much like fears of a migrant invasion motivated "build the wall" conservatives. Those same conservatives also are opposed to what they say is a government takeover of health care.

At a CNN town hall event last year, Sen. Lindsey Graham, R-South Carolina, said, "if you want Medicare for all, you're going to wind up with Medicare for nobody."

Public opinion shifts

Whatever the view inside the Beltway, public opinion is now in favor of broad health care reform. According to an August Reuters-Ipsos poll, 70 percent of Americans (85 percent of Democrats and 52 percent of Republicans) now support Medicare for all legislation.

In a post earlier this month on the prestigious Health Affairs blog, Don Berwick, a physician and the former administrator of the Centers for Medicare and Medicaid Services, and his co-authors, conclude Medicare for all is finally "within the realm of political possibility."

Sen. Bernie Sanders, the Vermont independent, jump-started the latest chapter of the health policy debate during his 2016 run for the White House.

His oft-repeated theme that the nation should build a universal system by expanding Medicare, primarily a program for the elderly, captured the imagination of many millennial and progressive voters.

"This is going to be an inside, outside strategy," said Sanders, who was also on the nurses' call. He urged Democrats to maximize the opportunity afforded by their midterm election successes.

"We know that the fight for health care justice is growing, but if we're going to win, we've got to go deeper," Bonnie Castillo, executive director of the nurses' union, said during the call. "We cannot simply rely on the electoral process to make it happen."

Castillo's comment is a telling reminder that even though the Democrats flipped the House, gaining a majority in that chamber was just one step toward making the American government the single payer of almost all medical bills.

That, in sum, is what Sanders' bill in the Senate would do. It has 15 cosponsors and its close companion measure in the House has 123 backers—all Democrats except Sanders.

"We have a ways to go, but we're moving forward," says internist David Himmelstein, a distinguished professor of public health and health policy at Hunter College in New York City. A champion of single payer reform for decades, Himmelstein said he is encouraged by the growing ranks of progressive politicians.

A progressive embrace

Katie Hill, a 31-year old activist, used health care as an issue to defeat a Republican incumbent in California's 25th Congressional District. Voters in Wisconsin returned Medicare for all backer Tammy Baldwin to the U.S. Senate.

However, the midterms also resulted in some big progressive disappointments, like the Texas Senate race and contests for governor in Georgia and Florida. In the Maryland governor's race, unsuccessful Democratic challenger Democrat Ben Jealous made a state version of Medicare for all a primary issue in his campaign.

"There is a groundswell of grassroots support for improved Medicare for all," wrote Gaffney.

"Every candidate had to respond to this groundswell one way or another," he said. "That being said, not as many embraced it as I would've liked."

Meanwhile, progressives who insist on Medicare for all reform worry centrist Democrats like former California Democratic Rep. Henry Waxman. He fears that "single payer or else" advocates may split the party and hurt its overall chances of winning back both houses of Congress and the White House in 2020.

"What bothers me is that a lot of people are saying that I'm going to be for single payer or I'm going to be for Medicare for all," Waxman said. "That's fine, but they shouldn't lose sight of all the things they can be doing, by doing what they would aspire to do."

During his 40-year forty year career in the House, Waxman put his watermark on virtually every major piece of health care legislation. While he agrees health care is a right, he said a Medicare for all fight would be counterproductive now.

"That's aspirational, and it cannot be done all at once," he said, adding that the first priority should be rebuilding and improving the Affordable Care Act. In spite of Republican efforts to undo it, Obamacare has reduced the ranks of the uninsured between 17 to 20 million Americans.

Renewing an old proposal

While it's been getting a lot of attention recently, the single payer idea isn't new.

Running as a progressive candidate for president in 1912, Theodore Roosevelt proposed a plan to expand health care nationally.

President Franklin Roosevelt wanted to include universal health care coverage as a part of Social Security legislation during the Great Depression but felt it was politically unfeasible.

President Harry Truman tried to get a national insurance plan adopted after World War II but it didn't happen. In fact, Truman attended the signing ceremony for Medicare legislation in 1965—part of President Lyndon Johnson's Great Society programs that also created Medicaid insurance for the poor.

Since then, every president has proposed some way of increasing access to coverage, but progressive Democrats believe government should guarantee health care as a right and pay for it, something Republicans condemn as "socialized medicine."

Foreshadowing a potential veto of any future single-payer legislation, President Donald Trump attacked Medicare for all legislation in an October USA Today op-ed piece: "Every American will be harmed by such a radical shift in American culture and life."

"Virtually everywhere it has been tried, socialism has brought suffering, misery and decay," the president insisted.

Evolution of different systems

"The key point is that the United States has been staggering toward broader coverage for a century, taking fitful periodic steps, not quite getting to the finish line, while other countries have done so in many and various ways," writes Henry Aaron, a health care economist with the Brookings Institution, a Washington think tank. "'Single payer' is a mind-numbing slogan without clear meaning."

According to a New York State Department of Health study, 32 nations currently provide universal health health care, although their individual approaches vary. Norway was the first to do so in 1912. Japan followed suit in 1938, and the United Kingdom inaugurated its National Health Service in the wake of World War II.

By contrast, American health insurance evolved as an employee benefit, not a government commitment.

However, even though 30 million Americans are uninsured and premiums continue to rise, Aaron believes fixing Obamacare is preferable to diving into the unknowns of a single-payer system.

"The idea of turning upside down one-sixth of the U.S. economy and using up what inevitably is going to be a large proportion of the energy and physical capacity of the country to address just this problem is a severe misallocation of political and economic resources," Aaron said in an interview.

Even though Aaron predicted that single-payer cost controls would mean less lower pay for doctors, more physicians are thinking Medicare for all would will be the change that finally revolutionizes U.S. health care.

Another look from physicians

That is 25-year-old Alec Feuerbach's fervent hope.

"I had this ethical belief that your ability to pay shouldn't limit your access to care," Feuerbach said in an interview.

Originally, he was looking forward to medical school at the University of Colorado, where he could combine his studies with ski trips to the Rockies. Instead, he chose a college in New York City because he saw it as a place where his professional ambition matched his personal philosophy of providing care to the poor.

"The demographics in medicine are shifting, perhaps not as fast as they should be," said Feuerbach, now a fourth-year medical student. Because of concerns he could be misconstrued as an institutional spokesman, Feuerbach didn't want his medical school identified.

A poll done last year by Merritt Hawkins, a physician-recruiting firm, found that 56 percent of doctors now favor single-payer health care, compared to 2008 when 58 percent were opposed.

At a national meeting last June, a group of young doctors pressured the American Medical Association, the largest doctor trade group, to consider the merits of a single-payer system—something the AMA has opposed for decades as economically unsustainable.

"It's all about money," said Dr. Jim Curran, dean of the Rollins School of Public Health at Emory University and a former official at the U.S. Centers for Disease Control and Prevention. "The whole system is corrupted by, 'Let's see what we can get.'"

In Curran's view, American health care is deteriorating as companies and academic health centers consolidate the practice of medicine in the name of greater profits.

While Curran said the government should expand coverage to everyone, he believes the chances of a Sanders-type reform are "fanciful."

Not surprisingly, dollar estimates of putting single-payer health care in place vary widely depending on who is making the prediction.

Proponents of Sanders' program say their approach, if enacted now, would cost $6 trillion less than the current system during the next 10 years.

However, Aaron estimated Medicare for all would cost $1.4 trillion more per year.

A study from by the conservative Mercatus Center at George Mason University said that Medicare for all would increase government health care expenditures by $32 trillion during in the next 10 years.

"We have not yet figured out how we're going to pay for the benefits of the over-65 population," said Gail Wilensky, who ran the Medicare and Medicaid insurance programs in the George W. Bush Administration. "It's just unbelievably irresponsible to talk about expanding the access to Medicare when we're just clueless about how we're going to pay for what we've already promised."

But Dr. Oliver Fein, an associate dean at the Weill Cornel Medical College and past president of the Physicians for a National Health Program, said overhauling the current health care model would address that concern.

"There is evidence out there that if we moved toward a single-payer approach we would actually be able to reduce the cost of health care in the United States, which is double other industrialized countries largely because of the administrative costs in our system," Fein said.

Fein recalled that in 2009, when President Barack Obama was crafting the Affordable Care Act, a single-payer advocate wasn't even at the table. That's when Fein got on the phone to complain and was subsequently offered an invitation by the White House to participate in the discussion.

Obama wasn't converted at the time, but Fein has taken the long view.

"I hope to see a real understanding of single-payer that could be more meaningful," Fein said. "There may be a growing awareness of that in the next decade and possibly transformative."

He believes minds can be changed.

In a September speech, Obama noted Democratic candidates were "running on good ideas like Medicare for all."

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