--:-- Sean Rameswaram: Welcome to Today Explained. I'm Sean Rameswaram. Today, we're talking about Medicare for all. Senator Bernie Sanders rolled out a new Medicare-for-all bill today. Vox's Sarah Kliff explains how such a huge overhaul of the healthcare system went from fringe to mainstream.
--:-- Sarah Kliff: Thanks for having me on the show. Spring time's here, so you're going to be smiling a lot more. The Quip electric toothbrush starts at just $25, and your first refill pack is free right now at getquip.com slash explained. Again, that website is getquip.com slash explained for that springtime smile.
--:-- Sean Rameswaram: Sarah Cliff, you've been reporting on insane ER bills Americans have received in the mail. Could you tell us about the most insane of all the insane bills you've seen?
--:-- Sarah Kliff: I think the wildest one is the story of this guy named Justin Sanders, who was walking down the sidewalk in San Francisco, gets hit in the face by a pole hanging off a public bus. Ouch. Knocked unconscious, taken to the hospital by an ambulance, wakes up there, has some scans, gets some stitches for a big cut he has in his face. A few weeks later, he gets a bill for over $27,000. And he had private insurance. So this is someone with coverage. He ends up spending two years in a lawsuit suing the city to cover the bill because it was a public bus that hit him. He actually had to delay his wedding because of all these court dates. And he did win, so the bill doesn't exist anymore. But it was just mind-boggling to me that in the United States, you could be hit by a public bus, taken to a public hospital, and end up $27,000 in debt.
--:-- Sean Rameswaram: In my view, and I think I speak for everybody up here, the American people are increasingly clear. They want a health care system that guarantees health care to all Americans as a right. And we are going to deliver a Medicare for all single payer system. Thank you.
--:-- Sarah Kliff: What would Justin Sanders' experience have been under, say, Bernie Sanders' new Medicare for all bill that he introduced today? Yes. So the Sanders' experience would be quite different. Under the health care system that the Vermont senator is outlining, he would have paid zero dollars. He would have gotten his treatment. He would have walked out of the hospital. And that would have been that.
--:-- Sean Rameswaram: Let's get in that Medicare for all ambulance and take a trip. Wee-ow, wee-ow. Like my ambulance noises. Wee-ow, wee-ow, wee-ow. Wee-ow, wee-ow, wee-ow.
--:-- Sarah Kliff: Sarah, there's three of these three-word big ideas I can think of right now in our politics. There's Build the Wall, the Green New Deal, and Medicare for All. We've covered the first two, but where did Medicare for All come from?
--:-- Sarah Kliff: Yeah, it's wild to me how Medicare for All has essentially become the Democratic Party platform going into 2020. If you look back at 2008, when President Obama was running for the first time, no serious Democratic contender was talking about a plan like Medicare for All. Including President Obama. Including President Obama. They were talking about improving the private market, bringing in more government dollars, but really keeping in place the structure of the system we have.
--:-- Sarah Kliff: Yeah. Bernie Sanders wants to blow up that system. He wants to replace it with something else. And a ton of other contenders, people like Elizabeth Warren, everyone gets a right to basic health care. That's what Medicare for all is all about. Cory Booker. You must include that every American has access to quality, affordable health care. Kamala Harris. I am proud to stand with my colleagues and friends and support Medicare for all. Thank you.
--:-- Sarah Kliff: They've all endorsed Medicare for all. So it's a huge shift in politics. This is an idea that has kicked around the United States for decades. There's been this desire to create a national health care system that covers all Americans. Industry has always been incredibly opposed to it. So each time that America does health reform, you end up with something smaller. You go back to 1965, there's a push for national health insurance. But industry, you know, the American Medical Association opposes it. You end up with Medicaid, a program to cover the poor, Medicare, a program to cover the elderly, and a whole bunch of people in between those who stay in the private market.
--:-- Sarah Kliff: You go to 2010, you end up with the Affordable Care Act, a program that really just expands the private market for middle-income Americans, expands Medicaid to cover a few people. It's an idea that has kicked around American politics for decades that is getting a resurgence of interest as we head into a new election. And is Bernie Sanders the one to thank for that? Is he the OG Medicare for All proponent?
--:-- Sarah Kliff: I think he is. He is someone who really brought it into the discussion, particularly in the 2016 primary he was running on this. We've got to join the rest of the industrialized world. Healthcare for all is a right. And we can save the middle class families thousands of dollars a year in their healthcare costs. And it didn't have nearly as much support at that point.
--:-- Sarah Kliff: And then I think Medicare for all actually has Republicans to thank for its popularity too. When they started working on Obamacare repeal, that really energized a lot of Democrats to say, Republicans are never going to accept the Affordable Care Act. If they're constantly going to try and repeal it, why not just go for broke? Like, why not go for the healthcare system we really, really want in our heart of hearts? And that is a national system. It's not this combination of private insurance for some and Medicaid for some and Medicare for others.
--:-- Sarah Kliff: So this Republican push to appeal the Affordable Care Act, in my view, it kind of had this unintended consequence of firing Democrats up to really pursue Medicare for all. And Bernie Sanders is definitely the politician who was kind of there saying, I have a plan. Like, I have this plan. I've been working on kind of introducing session after session, you know, introduced again today in this session, but now getting a whole lot more sponsors than it's ever had before.
--:-- Sarah Kliff: This is not just an idea that Kirsten or Jeff or I and a few others thought of. This is a struggle for the heart and soul of who we are as American people. So Bernie's got his plan that he introduced today, but there's a whole bunch of other plans, right? How do we make sense of them all?
--:-- Sarah Kliff: Yeah, so I think buckets are helpful here. I think there are two buckets of plans floating around the Capitol right now. Medicare for all buckets. Yes. So bucket one is really true medicare for all single payer so this is the Sanders plan it's a plan offered by Pramila Jayapal in the house where she co-chairs the progressive caucus this is a plan where all of us go on government insurance there is no private health insurance market anymore so instead of getting our insurance through Vox we would now be medicare enrollees.
--:-- Sarah Kliff: Okay. That's bucket one. Bucket two is letting us have the option to enroll in Medicare, but keeping private health insurance still in place. Okay. And there's a lot of different versions of this. You know, I count about seven different plans in Congress and think tanks that have different parameters. But essentially, we would be given the choice. We could stay on our insurance here at Vox, or we could buy into the government plan. And maybe we want to buy into the government plan because it has a lot of enrollees and it can negotiate low prices and it has really low overhead. It doesn't have a profit motive that most private insurers do.
--:-- Sarah Kliff: So those are the two options really sitting in front of Democrats. But even that support for these Medicare buy-ins, you'll also hear them referred to as a public option, is a real shift to the left for Democrats. There was a real push to include something like that in the Affordable Care Act, and they just couldn't get it over the finish line. It seemed too liberal. Insurance industry was really, really opposed to having a public competitor in their space. And now all of a sudden the buy-in becomes kind of the more centrist position when during the Affordable Care Act, the buy-in was the really far left position.
--:-- Sean Rameswaram: Okay, so let's get into those two buckets a little more. So let's talk first about the Bernie Sanders-esque one where you just have government-provided health care. How does that work? I mean, it sounds kind of simple.
--:-- Sarah Kliff: It does. And, you know, the plan that Sanders has outlined, I think it's an insurance plan most people would love. You know, no deductibles, no copayments, no premiums. You just walk in. No networks. You know, every when the government is the only insurer, every doctor is on the network. So that means like like any medical center, walk in clinic, hospital you would go to, those would still exist, but they just be funded and covered by the government.
--:-- Sean Rameswaram: Well, that's a good question. Would they all exist? So let's get into some of the kind of open questions about this. One of the ways that the Sanders plan would reduce health care costs, which is a key motivation of this, is by regulating health care prices. So let's think back to Justin Sanders. There would probably be a government board that says a CAT scan and some stitches, that can't cost $27,000. So maybe you see a few hospitals who say, we're getting out of the hospital business. We can't make ends meet. And so you kind of think about these hospitals that have built businesses around the fact they can charge whatever they want to someone like Justin who comes into the hospital literally unconscious, not a great shopper.
--:-- Sarah Kliff: So I think there's a fair question to ask of what happens to the healthcare infrastructure of our country. I don't think it would be decimated, but you might see certain types of specialties, their numbers reduce, certain hospitals in certain places might shut their doors. So that's something you'd want to be concerned about in standing something up like this.
--:-- Sean Rameswaram: It also just sounds like it would be super expensive for the government, like in a universal basic income kind of way. Yes. Where would the money come from, Sarah?
--:-- Sarah Kliff: So that is a great question. And I think one of the things I've really noticed about the Sanders plan is it envisions this like wonderful health insurance, the most robust health insurance you could possibly imagine. No other country in the world is able to provide a health insurance plan like that. So you look at Canada, for example, our neighbor up to the north. Finally. They have universal coverage, but it covers a smaller package of benefits. The Canadian system doesn't cover prescription drugs. It doesn't cover vision. It doesn't cover dental. You have to buy a private policy and two-thirds of Canadians buy private policies. Often they get them through work just like we do to cover those things that aren't part of the benefit package.
--:-- Sarah Kliff: You hop across the pond to Europe. Most European countries include some kind of copayment when you go to the doctors. You still have to pay a small fee to go to the hospital, to go to your doctor visit. And you also have a lot of people in European countries and Australia taking out private plans to compete against the government, to get into the doctor faster, to have the nice private room. So the system that Sanders envisions, and I get the politics of this, it's kind of like the best opening offer. You just cover everything, you cover everyone, because it sounds great. But in negotiations, maybe dental falls out because it's expensive to fall for all of our teeth cleanings. And maybe vision falls out because buying all those glasses is pretty expensive. And maybe we add in co-payments because you need us kicking in a little bit to help finance the healthcare system.
--:-- Sarah Kliff: Cost is a big, big challenge that the Sanders campaign, other single payer supporters, they put out different options for financing, but they haven't actually said, OK, here's how we're going to pay for it. And I think that is the biggest unknown to me in this Medicare for all space. And this struggle will be opposed by some of the most powerful forces in the United States. The insurance companies, the drug companies, and everyone who profits off the current system will spend many, many hundreds of millions of dollars to defeat us.
--:-- Sarah Kliff: And I guess the other insurmountable blockade is the insurance companies and the health industry fighting this tooth and nail right. Yeah we currently almost two years out from the election and we already seeing health industry ramp up their campaign against Medicare for All. Let's take a look at how Americans get their health care. There's this group called the Partnership for America's Health Care Future that is a coalition of hospitals, insurance companies, drug companies, who I'm constantly getting targeted by their Facebook posts, and they're always sharing news articles about how terrible Medicare for All would be.
--:-- Sarah Kliff: A one-size-fits-all health care system will mean all Americans have less choice and control over their doctors, treatments, and coverage. It will also mean trillions in higher taxes for hardworking families, lower quality of care, and longer wait times for patients. What's more? Well, maybe that's a good transition to bucket two, which is a compromised version of the straight-up Medicare for All we see in bucket one. Yes. And bucket two is what? Everything stays sort of the same, but there's this government public option? Yes.
--:-- Sarah Kliff: So under that world, you know, we could stay in our insurance or we could go on to the government plan. That one wouldn't really require a significant tax increase because essentially like if I, Sarah Cliff, want to join Medicare, I'm paying a premium to get in. It is just like I pay a premium to my insurer. Now I would pay a premium to the federal government. So it doesn't require the work of raising a bunch of revenue. It's not quite as revolutionary though, right? It means we still have a system with a lot of private insurers.
--:-- Sarah Kliff: I will say though these coalitions of industry, they are just as opposed to those government-run health plans that compete against private insurers as a government takeover of the insurance industry. All of it is going to face pretty significant opposition from industry. Is this kind of like Obamacare Plus? Is that like a way you could think of this or is this pretty distinct from Obamacare?
--:-- Sarah Kliff: I think it is Obamacare Plus. I think it is the next step of a health insurance plan that did some pretty big things. You know, we've had about 20 million people gain health insurance because of the Affordable Care Act. But we've also seen some of the holes in the Affordable Care Act. And I see Medicare for All, you know, often filling in those holes. One of the holes that jumps out at me is these giant deductibles. On Obamacare plans, if you're an individual, you could have a deductible of $6,000. If you're a family, you could have a $14,000 deductible. Those are really, really big.
--:-- Sarah Kliff: Our prices are incredibly high. And, you know, like I wrote about Justin with his $27,000 bill. I've written about a $25,000 or MRI. And Americans are being increasingly exposed to those prices because their deductibles are so high. So the way I see the Medicare for All debate, it kind of builds on what the Affordable Care Act does. And this is one way Democrats talk about it, too. You know, when I ask, like, why is now the time to do Medicare for All? You guys just did health reform a decade ago. It was really hard. And everyone's still fighting about it.
--:-- Sarah Kliff: Everyone is still fighting about it. Like, why do you want to jump back into this shark pool? Yeah. And the thing they'll say is, you know, the Affordable Care Act created the expectation that all of us have access to health insurance, that you can't be denied for a pre-existing condition. So the access side has really been opened up, but we haven't tackled the affordability side. And it builds on the expectation Americans now have of having access to health insurance by making that health insurance more affordable to them.
--:-- Sean Rameswaram: After the break, I ask Sarah if this can actually happen. If Democrats can actually pass Medicare for All in any way, shape, or form.
--:-- Sean Rameswaram: I've been talking this week about tweets people have sent me about their toothbrushes or their desire to hear more about toothbrushes. But Raiko underscore so underscore dizzy sent me an article and said, I feel like this could be an interesting topic to have on Today Explained with relation to the tariff and the history of the auto industry with the U.S. and Japan. IDK, just tell me more about Quip toothbrushes at Ramis Firm.
--:-- Sean Rameswaram: Can do, Raiko. The Quip comes with a multi-use cover that mounts to your mirror for a less cluttered sink space. It's got a built-in two-minute timer that pulses every 30 seconds to remind you when to switch sides and guide you to a full, even clean. And it's, you know, one of the first electric toothbrushes accepted by the American Dental Association. In fact, over 20,000 dental professionals have backed the Quip, which starts at just $25. And if you go to getquip.com slash explained right now, you get your first pack of refills for free with your Quip electric toothbrush. That is G-E-T-Q-U-I-P dot com slash explained.
--:-- Sarah Kliff: Okay so Sarah we've got these two options we've got a bunch of buy-in from the people running for president in 2020 except the one guy I guess how much of America is into medicare for all how much of like the people are buying into this idea about half and it's a number that slowly crept up over two decades.
--:-- Sarah Kliff: I think as Americans are more exposed to their health care costs, as their deductibles are rising, it is becoming a more and more appealing notion to Americans. And who are these 50 percent? Are they Democrats and Republicans? Are they people with insurance and without? How does it break down? Are they poor, rich? It tends to get surprising support across the political spectrum. Democrats definitely support it more than Republicans But we even seen a few polls one from Reuters last summer which showed that a majority a small majority I believe it was 52 percent of Republicans supported the idea of a Medicare for all plan
--:-- Sarah Kliff: And, you know, it sounds a little wild, right, because like here in D.C., you're not going to hear Mitch McConnell being like, well, let's give that Medicare for all a shot. That being said, the other thing that polling tells us is Americans' opinions on this are extremely fluid right now. Like you tell them a few other things, positive or negative, and you can flip support or opposition for Medicare for all by double digit percentage points.
--:-- Sarah Kliff: Wow. What does that mean? Kaiser Family Foundation, they've done this polling where they ask people, what do you think of Medicare for all? You get like a pretty even split. And then you say, well, what would you think of Medicare for all if it meant you wouldn't be able to get your insurance at work? And support just plummets.
--:-- Sarah Kliff: We covered the Green New Deal on the show last week, and we had this guy from a DC think tank on saying that if you push industry too far, they're not going to buy in anymore. Exxon and BP can get on board with the carbon tax, but they're worried about being March the guillotine. Is there an analogous situation when it comes to the health care industry in the United States and Medicare for all?
--:-- Sarah Kliff: There totally is. I listened to the episode this morning, and Dave Roberts was talking about incrementalism. Yeah. And immediately this comparison to health care just popped into my mind. So the thing Dave Roberts said kind of countering this guy who was on the podcast was nothing is happening. It's not like everyone's on board with these small steps.
--:-- Sarah Kliff: So I think the argument I hear from people who support the Medicare buy-in is like Medicare for all is too hard. It's too disruptive. Let's do something more incremental. Let's introduce a public option. A public option could appeal to our colleagues in the Republican Party. We can work with them on it. But you don't really see that happening. I haven't heard any Republicans say like, yeah, let's work on a Medicare buy-in. Right.
--:-- Sarah Kliff: How are Republicans responding to this normalization of Medicare for all? They are just attacking it. I'm worried as much about the cost of this as I am about what happens to the quality of our health care if we go socialize. These people are perfectly OK with just taking things from people who work and giving them to people who do not work.
--:-- Sarah Kliff: How can you sell a bill that makes it illegal for most people to pay doctors out of their own pocket if they want to? That's kind of a little fascist, is it not? I think they would prefer to have a debate over Medicare for all than they would over the Affordable Care Act. You saw last week this kind of drama play out where President Trump was like, let's try and repeal the Affordable Care Act. And congressional Republicans are like, how about we didn't?
--:-- Sarah Kliff: Democrats would do really well in a debate where they're just defending the status quo. I think an easier debate for Republicans to have instead of having to talk about repealing Obamacare is just to talk about anything bad they can think of with Medicare for all. And really hit on some of the concerns Americans do have about losing their insurance at work, about their taxes going up. So Republicans are pretty enthusiastic to debate Medicare for all because they think they can stoke fears of the unknown and what might happen if you had a president, Bernie Sanders, who would try and go for something like this.
--:-- Sarah Kliff: So you've covered health care policy for like what like a decade a close to a decade yeah sorry a while did you ever think that you'd see you know a ton of candidates running for president endorsing medicare for all as a central component of their policy proposals no
--:-- Sarah Kliff: When you look at the history of major health care reform. You know, we had Medicare and Medicaid in 1965. We had the Affordable Care Act in 2010. Usually there's this like multi-decade gap between large health care programs. And I am still kind of honestly surprised to see the energy in the Democratic caucus around taking on health care again.
--:-- Sarah Kliff: And you see Democrats approaching health care really differently right now than you did with the Affordable Care Act. With the Affordable Care Act, There was this long protracted period at the start of the Obama administration where they were trying to talk to Republicans. They were trying to bring them on board, figure out a health care plan that could be supported by both parties. And this went on for about a year until it became really clear no Republicans are going to support this.
--:-- Sarah Kliff: So Democrats kind of went it alone. I think Democrats, for better or worse, they're looking at what Republicans did in 2017, where Republicans were like, we're not trying to bring Democrats along. We know they support the Affordable Care Act. We control government. We're going to try and do Obamacare repeal solo. Democrats are now looking at that and being like, maybe not a terrible idea. Like, what if we just go for broke and go for the plan we want instead of, you know, this compromise plan that didn't even bring anyone along?
--:-- Sarah Kliff: So I think Democrats are at a different starting point in this health care debate than they were in the last one. And a lot of that owes to them watching and learning from how Republicans act in this space.
--:-- Sean Rameswaram: Thanks for listening to the program today and thank you to Quip Electric Toothbrushes for their support of Today Explained. Right now, you can get a Quip electric toothbrush for $25 at getquip.com slash explained. That website, if you'd like it spelled out slower, G-E-T-Q-U-I-P dot com slash E-X-P-L-A-I-N-E-D. Goodbye.
