Clinton, Finally Forced to Confront a Single Payer Advocate in Debate, Can’t Win on Policy, Falls Back on Demagoguery and Distortion

By Lambert Strether of Corrente.

Most of the post-Democratic debate analysis has focused Clinton’s response to Sanders’ challenge on her Wall Street ties; a response that was, to put it charitably, confused. There has been little focus on her exchange with Sanders on health care which, from a pure public policy standpoint — that is, leaving aside corruption — is arguably more important. So, despite DNC Chair Debbie Wasserman Schultz’s successful suppression of viewership, the debates really are doing what they are supposed to be doing: Allowing voters to compare and contrast the candidates. Now, we remember from 2014 that Clinton, despite her lofty claims to an evidence-based approach to policy, refused to even mention single payer in two back-to-back major speeches on health care. So let’s see how she did in the debate on this topic, when faced with Sanders, a single payer advocate. Spoiler alert: Badly. First I’ll take a look at the debate transcript, and then I’ll take a quick look at the Sanders plan. Spoiler alert: Not all one might wish.

The Debate

To the transcript! Sanders comes first, so I’ll pick his performance apart first. Then Clinton brings the demagoguery. (Recall that the debate location was held at Drake University in Des Moines, Iowa, the first caucus state in 2016. That will become important in one of Clinton’s responses to Sanders.)

NANCY CORDES: Back to healthcare by popular demand. First to you, Senator Sanders. You prefer to scrap ObamaCare and move to a single-payer system, essentially Medicare for all[1]. You say you wanna put the private insurance companies out of business. Is it realistic to think that you can pull the plug on a $1 trillion industry?[2]

BERNIE SANDERS: It’s not gonna happen tomorrow. And it’s probably not gonna happen until you have real campaign finance reform and get rid of all these super PACs and the power of the insurance companies and the drug companies.[3] But at the end of the day, Nancy, here is a question. In this great country of ours, with so much intelligence, with so much capabilities, why do we remain the only (UNINTEL) country on earth that does not guarantee healthcare to all people as a right?[4]

[1] A CBS analyst just treated “single payer” “Medicare for All” as a not-insane policy proposal. That’s called dragging the Overton Window left (which has been my sole criterion for success from a Sanders campaign).

[2] The “health insurance industry” is not, following Veblen, an industry; unlike health care, it creates no value; it is wholly parasitic and should not exist. “One does not improve a tapeworm; one removes it.” Pragmatically, I grant it’s not possible for anybody to answer Cordes’s question in those terms on national television, even on a Saturday night in Des Moines, but Sanders doesn’t even address it (though Clinton, in another sign of inattention or confusion, doesn’t call him on that). Somebody on the Sanders team needs to figure this out, because people will have noticed, and the question will come up again.

[3] Tactically, Sanders keeps hammering Clinton on corruption. Strategically, “these are our demands” is always a good thing to be able to say. Howeve, at least to Sanders, the missing agency in “happen” can only be a movement outside the party structure, which he doesn’t mention here (and only mentions elsewhere). To be fair, time constraints are clearly a concern for all the candidates;  CBS ran the debate well, and didn’t let them filibuster.

[4] A rhetorical question (in fact, anacoenosis). And a powerful one, especially because Clinton can’t ask or answer it. However, Sanders — and we all love Bernie, but some of us love a killer instinct, too, especially in debate — might have driven the knife home by adding something like “and this is a question I would like Secretary Clinton to answer.” (If Sanders wants to pick up a few seconds for this, he can eliminate “at the end of the day.”)

SANDERS: Why do we continue to get ripped off by the drug companies who can charge us any prices they want?[1] Why is it that we are spending per capita far, far more than Canada, which is a hundred miles away from my door, that guarantees healthcare to all people?[2][3] It will not happen tomorrow. But when millions of people stand up[4] and are prepared to take on the insurance companies and the drug companies, it will happen and I will lead[5] that effort. Medicare for all, single-payer system[6] is the way we should go. (APPLAUSE)

[1] I don’t know the Drake audience, but I’m not sure that’s the most effective appeal to students, despite the obvious villainy of Pharma. Sanders’ appeal to basic fairness probably works. It’s also, when you think about it, ridiculous that putting young adults on their parents’ health insurance policies is treated as some sort of policy triumph. Surely it’s on a par with young adults living in their parents homes because they can’t afford to move out?

[2] Presumably, then — thanks to the work of Michael Moore? — everybody in the audience knows that Canada has a health care system that guarantees health care to all, gutted the private health insurance business, and successfully bent the cost curve. So Sanders doesn’t have to unpack the detail.

[3] I’m surprised Sanders doesn’t bring in the $500 billion a year in cost savings; that’s real money, even today. This would have insulated him against any claim of reckless extravagance. In the event, Clinton made no such claim.

[4] Here Sanders adds the missing agency. 

[5] Mark “I will lead” for later.

[6] As a wonkish side note, single payer advocates have gone round and round about whether “single payer” or “Medicare for All” is the right phrase. “Single payer” accurately describes the system; “Medicare for All” is a better selling point (despite its increasing infestation by neo-liberal rent seekers). Here Sanders simply yokes both phrases together. That’s probably the way to go.

NANCY CORDES: Secretary Clinton, back in– (CHEERING) Secretary Clinton, back in 1994, you said that momentum for a single-payer system would sweep the country. That sounds Sandersesque. But you don’t feel that way anymore. Why not–

HILLARY CLINTON: Well, the revolution never came[1]. (LAUGHTER) And I waited and I’ve got the scars to show for it[2]. We now have this great accomplishment known as the Affordable Care Act. And– I don’t think we should have to be defending it amount [sic] Democrats.[3] We ought to be working to improve it and prevent Republicans[4] from both undermining it and even repealing it.[5]

[1] First, the policy failure is nothing other than a failure of leadership (see note [5], supra) in 1994; note how the lack of agency in “never came” airbrushes this away.  It seems foolish to reproduce the failures of more than twenty years ago today. Second, I can’t help but think that “the revolution” is, in Clinton’s mind, a subconscious allusion to Ira Magaziner’s Time magazine cover, captioned “Peaceful Revolutionary,” since Clinton chose Magaziner to lead her own (butchered) health care reform effort. Third, this a sharpened version of the usual Democratic trope that this or that policy isn’t “politically feasible.” However, Democrats who make that argument can be relied upon never to have made the slightest effort to make the policy politically feasible; among such Democrats, in health care policy, Clinton.

[2] Well, no. The people who suffered or died without health care due to lack of universal coverage can be said to have scars. Clinton has the very best of health care; no scars at all.

[3] A demagogic appeal to party tribalism. Five years after ObamaCare was passed, 50% of those eligible but unenrolled have run the numbers and concluded it’s a bad deal for them (NBER). ObamaCare faces a death spiral. How is any of this defensible, especially when lives are at stake?

[4] Another demagogic appeal to party tribalism; how is ObamaCare to be “improved,” if not by making coverage universal? Clinton doesn’t say. She doesn’t even mention “my plan.”

[5] Why would passing an effective single payer Medicare for All plan be less effective than continuing to tinker with ObamaCare? FDR said: “It is common sense to take a method and try it. If it fails, admit it frankly and try another. But above all, try something.” Last I checked, FDR was also a highly effective Democratic partisan. So why can’t Clinton adopt FDR’s common sense attitude?

CLINTON: I have looked at– (APPLAUSE) I’ve looked at the legislation that Senator Sanders has proposed. And basically, he does eliminate[1] the Affordable Care Act, eliminate private insurance, eliminates Medicare, eliminates Medicaid, Tricare, children’s health insurance program. Puts it all together in a big program which he then hands over to the state to administer.

[1] Another demagogic appeal. In substance, as we shall see, Clinton’s description of the Sanders proposal is accurate. However, Clinton does two things. First, she begins with the effective use of anaphora (“eliminate… eliminate… eliminate…”) to convey the impression to the beneficiaries of each individual program that their benefits will be taken away (“eliminated”), and finishes by characterizing the universality of the Sanders program as “a big program” (as if the programs Clinton lists were not, in the aggregate, big). I grant that Clinton’s first tactic can be effective; “I’ve got mine” really is a powerful appeal, especially to somebody who’s managed to scramble to safety in some part of our terrible system. However, I’d argue that “I’ve got mine,”  in the context of electoral politics, implies “now you get yours,” which is both unworthy of a genuine Democrat and airbrushes away the very possibility of “standing up” together for something better. Second, “big program” is a right-wing dog whistle for “big gummint,” again unworthy of a genuine Democrat.

CLINTON: And I have to tell you, I would not want, if I lived in Iowa, Terry Branstad administering my healthcare.[1] (APPLAUSE) (CHEERING) I– I think– I think as Democrats, we ought to proudly support the Affordable Care Act, improve it, and make it the model that we know it can be–

[1]  Here’s why Clinton’s point appeals to the audience in Iowa. From the Des Moines Register:

Three Democratic senators will ask federal officials Wednesday to reject or delay Gov. Terry Branstad’s controversial effort to privatize management of Iowa’s $4.2 billion annual Medicaid program.

The state’s Medicaid privatization effort has been the subject of multiple challenges, including allegations that the companies picked to manage the program engaged in unethical and possibly illegal competitive bid practices. The Iowa Hospital Association has also filed a lawsuit, challenging the bid process as illegal.

Branstad’s administration must get permission from the Centers for Medicare and Medicaid Services to go forward with the plan. Mathis and Sens. Pam Jochum of Dubuque and Amanda Ragan of Mason City will meet with CMS officials Wednesday.

Dozens of providers weighed in on the plan during a conference call Tuesday with CMS, warning federal officials of concerns about contracts, unanswered questions and a general lack of notification to Medicaid recipients about the changes.

Branstad spokesman Ben Hammes accused Democrats of playing politics. Hammes noted that the governor last week met with U.S. Health and Human Services Secretary Sylvia Burwell and “remains confident” that Iowa’s plan will be approved and implemented on Jan. 1.

And here’s why Clinton’s point is pure demagoguery, even leaving aside another appeal to party tribalism. First, the Branstad plan can only be implemented if HHS Secretary Burwell — a Democrat — approves it. (Sanders might usefully have put in the shiv by saying something like “Secretary Clinton, will you join with me in demanding that Secretary Burwell reject Branstad’s plan?”) Second, Clinton sets up an opposition between (#1) ObamaCare, whose program design allowed 22 states to refuse Medicaid coverage to their citizens altogether, to the Sanders plan, where (#2) Branstad would at least be required to deliver Medicare to all, and under Federal supervision. Granted, I don’t like Door #2 all that much (see below), but surely imperfect universal coverage is much better than no coverage for poor people in 22 states?

BERNIE SANDERS: Right.[1] Well, let me just say something–

(OVERTALK)

JOHN DICKERSON: Thirty seconds–

BERNIE SANDERS: We don’t– we don’t eliminate Medicare. We expand Medicare to all people.[2] And we will not, under this proposal, have a situation that we have right now with the Accordable Care Act. We’ve got states like South Carolina and many other Republican states that because of their right-wing political ideology are denying millions of people the expansion of Medicaid that we passed in the Affordable Care Act.[3] Ultimately, we have got to say as a nation, Secretary Clinton[4], is healthcare a right of all people or is it not?[4] I–

[1] Translation: “That’s all Clinton’s got.”

[2] Sanders swats away Clinton’s demagoguery like the fly-weight analysis it is.[2]

[3] Ditto.

[4] This direct address should have been earlier. The answer that matters is not the one the CBS moderator gives, or the audience might give, but the one that Clinton gives. If you ask the question early, you set yourself up to point out, later, that she hasn’t answered it.

The Bill

Here’s a very quick look at the Sanders bill. I don’t like to use campaign sites, but here’s part of the Sanders FAQ:

Does Bernie want the government to completely take over the healthcare system?

No. The United Kingdom’s National Health Service is an example of a system where the government owns and operates the public hospitals and employs the staff in those facilities. Alternatively, Bernie is proposing a Medicare-for-All system of social insurance that is found in Canada, continental Europe, and in other developed nations.

In this system, every American would be automatically enrolled into Medicare. This is commonly referred to as “Medicare for All.” Like the systems in many other industrialized countries, private practitioners could still provide care, but everyone would be covered by a national health care plan. This allows for private delivery and public financing to insure guaranteed health care for all and effective cost control. This is how Medicare is delivered today for all Americans over age 65.

(The FAQ is a useful compendium of single payer material.) However, it doesn’t cover the actual program structure (what Clinton calls “one big program”), which HealthCare Now describes as follows:

The cornerstones of the Program will be fixed, annual, and global budgets, public accountability, measures of quality based on outcomes data designed by providers and patients, a national data-collection system with uniform reporting by all providers, and a progressive financing system. It will provide universal coverage, benefits emphasizing primary and preventive care, and free choice of providers. Inpatient services, long term care, a broad range of services for mental illness and substance abuse, and care coordination services will also be covered.

The federal government would collect and distribute all funds to the states for the operation of the state programs to pay for the covered services. Budget increases would be limited to the rate of growth of the gross domestic product. Each state’s budget for administrative expenses would be capped at three percent.

Each state would have the choice to administer its own program or have the federal Board administer it. The state program could negotiate with providers and consult with its advisory boards to allocate funds. The state program could also contract with private companies to provide administrative functions, as Medicare currently does through its administrative regions. State programs could negotiate with providers to pay outpatient facilities and individual practitioners on a capitated, salaried, or other prospective basis or on a fee-for service basis according to a rate schedule. Rates would be designed to incentivize primary and preventive care while maintaining a global budget, bringing provider, patients, and all stakeholders to the table to best determine value and reimbursement.

(Health Care Now is describing the American Health Security Act of 2013, S. 1782, but it’s still current.) So Clinton is accurate in describing the Sanders single payer plan as a “big program.” She’s semi-accurate in saying the program is “handed over to the state,” since states can decide to have the Feds administer the program. But by saying “I would not want, if I lived in Iowa, Terry Branstad administering my healthcare,” Clinton veers dangerously close to outright falsehood by implying that the Sanders bill would make a bad situation worse (even assuming Branstad did not opt out of administering the program). First, Branstad will be subject to Federal review (just as he is today, even under ObamaCare). Second, Branstad’s administrative expenses are capped. And third, Branstad’s budget is determined at the Federal level, not by Branstad. (So far as I can tell from a quick scan of the S. 1782, state’s determine fee schedules, subject to mandates in the bill, and Federal review, as now.)

What worries me about the Sanders bill — and oddly, or not, Clinton doesn’t mention this — is that it still leaves a lot of fee-sucking intermediaries in place: “private companies” and “providers”; whenever you hear “stakeholders,” you should scream and run, because nine times out of ten a “stake” is a rent. And that leaves those intermediaries with the political power to sabotage (as Veblen would have it) the program for their business interests.

Conclusion

Note to Robbie Mook: Can do better.

Note to the Sanders campaign: You let Clinton get away with too much. Don’t.

And again, my takeaway is that single payer Medicare for All is being discussed, at the national level, by the political class, something the Democratic nomenklatura, aided by the career “progressives” of the time, succeeded in preventing when ObamaCare was passed in 2009 – 2010. That’s nothing other than a victory, and it would be so if Sanders shuttered his campaign, turned off the lights, and went back to Vermont tomorrow. Which I don’t expect him to do.

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.

79 comments

  1. Left in Wisconsin

    Here is an interesting development. Wisconsin Gov-doofus Scott Walker hired a consultant to figure out ways to cut health insurance costs for 250,000 public employees and the consultant just recommended cutting out the insurance companies and self-insuring. Cost savings estimated at $42 million a year, including $11 million in administrative costs and $11 million in insurance co profits.

    Of course, this being Walker, any implementation would likely be disastrous. (Also, Walker earlier this year tried the same Medicaid gambit as Branstad, turning it over to big private insurers, but did not succeed.)

    And, being Wisconsin, of course the unions are lining up against Walker and thus with the insurance companies.

    1. Lyle

      Wi is far behind many big companies where the insurance company is only a claims administrator, and the company pays the claims. So the insurance company in that case does not provide insurance, only claims processing. If large companies can do it and the law of large numbers does suggest they can then why pay for the risk avoidance that insurance is. I am suprised that most states have not done this.

      1. laughingsong

        I work for my county here in Oregon and they self-insure, having done that very analysis a while back. While they usually have to tweak the benefits every couple of years due to health-care cost inflation generally, we still have better coverage (except dental) than most public or private sector entities, and still (thank you!) no co-pay.

  2. Jim Haygood

    ‘As Democrats, we ought to proudly support the Affordable Care Act, improve it, and make it the model that we know it can be’ — HRC

    ‘Mend not end’ … hey wait, that’s the R party script!

    It’s her Goldwater Girl background shining through.

    1. Crazy Horse

      I took a job In Vancouver BC a few years ago (while an American citizen). During the first week of employment the CFO called me into the office and asked, “have you received your Care Card yet?
      When I asked how to proceed she handed me a one page form with the comment, “You are in a civilized country country now— we don’t permit people to go without heath care.”

      Quite a contrast to my experience in the US, where an operation that proceeded with no complications and was supposed to cost $11,000 was billed at $89,000 and forced a medical bankruptcy.

      In the US the medical system is a criminal extortion racket.

  3. Mike P.

    I am disturbed by Sanders response “It’s not going to happen tomorrow”. This has been a standard Democratic Party response to any threatening movement/legislation that does NOT have their banking/pharmaceutical/lawyer money support. While a third-party would have zero chance in this rigged election system/scam, it is a sure thing that the party will NOT support any such development (fight it tooth-and-nail, more likely), and will scuttle any law should it pass (or make it toothless). We are faced with a party that has and will continue to betray its “base” sniffing after big bucks so media conglomerates can make out like bandits (and cavort with them, too). I wish any TRUE social-democrat well, but the current social-democrats in Europe, Canada, and elsewhere have proven they will betray their populace without blinking. Bernie’s support for military spending domestically and his lack of insight into its effects on our politics leaves quite a bad taste for what might happen under his possible Presidency.

    1. Lambert Strether Post author

      I didn’t like it much either. And if millions are going to stand up in a movement, then we need to see some sort of sign from the Sanders operation that this is happening. It’s not enough to say “Make me do it.” We tried that.

    2. RD (Recovering Democrat)

      It’s par for the course, isn’t it?

      (To give the obligatory statement that “of course, it won’t happen, anytime soon.”)

      ;-)

  4. willf

    According to PPACA advocates, the “most progressive” part of Obamacare was the Medicaid expansion, but now we see Medicaid being privatized all across the country. I am curious if there was a Gruber-type consultant out there that knew this ahead of time? Knew that Medicaid privatization was in the wings?

      1. Oregoncharles

        Mergers and acquisitions should be completely illegal. Markets function properly ONLY if all participants are small (in relation to the market). There is no public interest in them getting bigger, especially by swallowing their competitors!

        Odd, or not, how the market-“worshippers” ignore or deny this absolutely fundamental requirement.

    1. Beans

      See DentaQuest. The are private Medicaid dental administrators as well as private Medicaid dental providers. They also are policy advocates through the DentaQuest Foundation.
      They are on both sides of Medicaid and yet no state privatizing Medicaid has a problem with it. Of course insurance companies knew and were well prepared.

    2. RD (Recovering Democrat)

      Medicaid privatization has been going on for years. So, of course, they knew, or should have known, that many conservative Governors would have used this as a bargaining chip.

  5. dk

    Just to voice a different position, calling or considering health CARE a right is generally understood to mean that access to medical assistance is a right. But our health is something we ourselves have the primary responsibility for. I can certainly (have the right to) abuse my body with something like, say, alcohol, but do I then have the right to depend on an infrastructure to provide my remedies? While continuing the abuse?

    This goes as well towards poor food quality, where a population suffers from the effects of additives (metabolically dangerous preservatives, etc) and process byproducts (like antibiotics in meat, pesticides in produce, etc), and the eventual remedy is access to treatment for the consequences, rather than addressing the primary issue of the food quality.

    Then there is the matter of the q

    There is the matter of rights evident and intrinsic, versus rights granted, I think that supervenes other considerations but I’ll not go into it here. Beyond that,

    1. jsn

      Yes, the neoliberal solution is to expedite the death of all the undeserving. And its successful too! The numbers of undeserving just keep going up and now they’re dying faster too!

      1. tegnost

        but what if the undeserving are unable to access the most damaging inputs of neoliberalism by being unable to participate (purchase) in them and end up more robust?

    2. bdy

      False dichotomy. All rights are granted. What could possibly be more “intrinsic” than life, liberty and the pursuit of happiness? But look at the core of our social contract and there they are, baked into the first paragraph.

      The right to high standard medical remedies is intrinsic to every society civilized enough to declare it granted. So yeah, you deserve to receive the best treatment for the effects of your alcoholism as cheaply as possible – which is apparently by State single payer. Let’s get there already.

      1. The Infamous Oregon Lawhobbit

        Wherein lies one of the bedrock differences between the two sides – where do rights come from? Are they “inherent to my existence as an individual” or are they “granted by others.” In shorter simpler terms – who owns me? Communitarians believe they each own the other, while individualists are responsible for themselves.

        And never the twain shall meet, I guess.

        Back to the original point, as the resident libertarian ammosexual, I’d have to say that if you’re going to do something wrong (health care provided by the State) then you should do it in the “best” way possible. Based on my time here at NC, I just do not see any “better” way to go about doing it than single payer. Free contracts between individuals are the way to go – but I think both sides can agree that getting the useless parasites out of the system is a benefit to all, regardless of WHICH system we opt for.

        I’d feel at least a LITTLE better, though, if members of the State bureaucracy (in medical as in other areas) were held far more personally accountable for their actions. Or inactions, as the case often is.

    3. different clue

      The “population” does not choose shitfood. The Overclass has chosen shitfood for the population while trying to reserve shinolafood for itself. Members of the masses can certainly try to obtain what information they can about buying and preparing shinolafood in the teeth of a rigged shitfood market. Readers here probably know shitfood from shinolafood, and can be said to have a higher level of personal responsibility for seeking out the shinolafood. But how many mass mainstreamers even know NaCap exists?

  6. dk

    Just to voice a different position, calling or considering health CARE a right is generally understood to mean that access to medical assistance is a right. But our health is something we ourselves have the primary responsibility for. I can certainly (have the right to) abuse my body with something like, say, alcohol, but do I then have the right to demand that a social infrastructure provide my remedies? While continuing the abuse?

    This goes as well towards poor food quality, where a population suffers from the effects of additives (metabolically dangerous preservatives, etc) and process byproducts (like antibiotics in meat, pesticides in produce, etc), and the eventual remedy is access to treatment for the consequences, rather than addressing the primary issue of the food quality.

    Then there is the matter of the quality of the “healthcare” available (versus that provided, yet another branch to parse). Available treatment quality in the US ranges from good to very poor. A right to something mediocre or worse is a right not particularly worth having, beyond some weird punitive Purtianism.

    There is the matter of rights evident and intrinsic, versus rights granted, I think that supervenes other considerations but I’ll not go into it here.

    I think the concept of healthcare as a right is one that is not looking where it is headed. Health is a responsibility to primarily oneself; certainly my society should not recklessly inhibit my ability to fulfill that responsibility, for that society’s collateral benefit, but to attempt to transfer that responsibility primarily to the society is a mistake on several fronts.

    The position of the medical industry (lumping doctors and direct providers in with product producers) is that human physiology is so complex that an individual can’t handle it by themselves, this is utter nonsense. Yes, some understanding of basic chemistry and biology is required, such knowledge is available; access to information and education is a much more important right, and a “right” to provided healthcare strikes me as a basis for undermining the right to education and basic information.

    I’m all for scrapping ACA in favor of single-payer MedicareForAll, but I don’t think that’s the end of the story by a long shot. God bless Bernie for the old-school statesman that he is, but let’s not make a koolaide out of the level of solution he’s proposing.

    1. jsn

      And it works so poorly and is so much more expensive in every other advanced nation where it is handled as a right.

    2. Katniss Everdeen

      The explanations for why this country, which claims to want a “healthcare” system that is affordable, accessible and successful yet steadfastly refuses to implement one, are necessarily so tortured as to be virtually nonsensical.

      1. different clue

        No they aren’t. They are real simple. They are just too painful for most people to face.

        America is under Class Enemy Occupation government. We would have to reconquer our government back from the CEO FedRegime which currently occupies it. Unless we can reconquer the government and “exterminate” the Class Enemy Occupation FedRegime, we can’t have nice things.

        There. See how simple?

    3. tim s

      We do have an issue in the USA that is somewhat unique in that our capitalist system allows many who wield power over the masses, such as corporations that provide large percentages of the available food purchased in stores, to be predators in many ways of its own citizens, rather than just suppliers of goods to them. With marketing (i.e. effin’ lies), political schemes, etc. they are to make large percentages of the population relatively unhealthy. Similarly, the health care industry, being private & for-profit, is predatory in many ways. All for wealth extraction, and much to the detriment of the population’s overall health.

      Other countries until relatively recently have not had such a problem. It will be difficult to implement an effective health care system given that TPTB seem to care nothing for the health of the others. It’s abundantly clear at times that they’d just as soon see many categories of the commoners gone from the face of the earth in the 1st place.

      I agree that personal responsibility is something that needs to be stressed. If one has breath, one can have responsibility. Is ignorance an excuse? I’d say it’s a reality, but ignorance is not a permanent condition. This ignorance is ingrained through many ways, much again coming from predators. However, many people who continue to poison themselves probably have heard of healthier alternatives. Unfortunately, a mention of personal responsibility will bring out the accusations of insensitivity at best, and raceism/classism at worst.

      I know that good food can be made relatively inexpensively from basic staples and a few spices, all readily available at even the stores that service most of the poorer areas of the USA. While there will always be a percentage of the population that will not be able to do this for whatever reason, I doubt that it is a significant percentage.

      I agree that health care reform is needed, and that it needs to be accompanied by health reform, which starts with mind reform. Of course the mind must be reformed from within, but the external stimuli needs to be such to effect this change. Western stimuli is still dominated by Tony the Tiger, Ronald McD, etc,etc. So where do you start?

      And then, the corporate/predator is really the elephant in the room….

      1. hunkerdown

        Imaginary friends have a right to privacy. Isn’t that rich?

        Seems like a Russian EMP airburst or two would be the healthiest thing for the USA, but I’m certainly not calling for it.

      2. different clue

        And Obamatrade is designed to bring this corporate shitfood system to all of Europe and all of the Pacific Rim countries. The fact that THEIR mass medias don’t say that shows that THEIR mass medias are also servants of the International Free Trade Conspiracy.

    4. Will

      Shorter: “Individuals are at least as responsible for their poor health as the broken systems they’re trapped in! If they knew enough to make the ~right choices~ they wouldn’t need fancy doctors in the first place.”

    5. Oregoncharles

      Unfortunately, everything from infection to accidents has a large random component, so no matter how hard we try, we can have only so much responsibility for our health.

      What’s actually more powerful is addressing PUBLIC health: measures like sanitation, pollution control, and vaccinations, that mostly depend on collective measures. Indeed, one of the advantages of a single-payer system is that it has an interest in addressing those public preventive measures. Regulating the contents of food is one of them.

      1. tim s

        no matter how hard we try, we can have only so much responsibility for our health

        True, but that can be said of many things. We all can and should be held accountable for what we do with that which we can control.

        1. Lambert Strether Post author

          I don’t think we know enough to make this judgment; the closest we can come is the “Wellness” programs that ObamaCare incentivizes, and IIRC those are a scam.

          Reminds me of making people pay for their plane seats by weight.

      2. polecat

        Yes! Imagine if polio was just now being dealt with as opposed to the 50,s, when the public, through government funding and coordination, was vaccinated to eradicate the disease….you all can probably imagine what a clusterfuck that would be !!!

    6. Jeff W

      I’ve never understood the talk of health care being a “right,” No one talks about fire emergency services or rescue services as a “right”—it’s simply what is done in as part of the commons and paid for as that.

      If you talk about “rights” with regard to health care, the focus is on the person or people having the right—they “have a right to” health care—and what they are supposed to get. With a normative approach, the focus is on “the way we do things,” that is, what we as a society view is the way to act—it’s not on what people get as a result of that view. I don’t favor some single-payer-type health care plan because people “have right to” health care—I favor it because I think a civilized society does at least that.

  7. susan the other

    Hillary deflects the argument time and time again. Not just healthcare. The TPP also stands out. She doesn’t have an issue because she is a corporatist and a war monger. She carefully modulates every word hoping none of us will notice. Really, Hillary? Bernie is the only candidate in my memory who understands the reality of every issue and clearly addresses them. No BS and no time wasted. The question is, why doesn’t any other pol manage to do that? The absence of their engagement with reality says it all. It’s complete.

    1. OpenThePodBayDoorsHAL

      I have my own internal ranking system of “who will start WW III the fastest”. So far my handicapping is as follows:
      1. Hilary
      2. Cruz
      3. Rubio
      4. Trump
      5. Bernie
      (If Carly had a shot I would put her before Hilary, and if Rand had a shot I would put him after Bernie).

      Here’s the most frightening piece of Hilary war-lust I’ve seen. It’s the cackle that gets me:
      https://www.youtube.com/watch?v=xvhBoF_pCHo

  8. susan the other

    It puzzles me that our corporations think they are going to survive because they are more competitive than other internationals. I doubt they are; they have simply become ideological diehards about productivity because they get political handouts. For extracting profit from the rest of society in one way or another. Until the lowest social common denominator is reached – globally. Somehow they think, just like Hillary, they can deflect reality and fool people who already despise them. In the end the corporations will fall like trees with rotten roots.

    1. Left in Wisconsin

      But remember, per Lambert, that corporations don’t think. The executives that make corporate decisions are completely short-sighted. I asked a business professor once how long the average corporate up-and-comer stays in one job. He said no more than 18-24 months. Longer than that, you aren’t considered an up-and-comer anymore. They all know that they won’t be around to see the consequences of the decisions they make. Now that’s leadership!

  9. reslez

    Thank you for this analysis… thought provoking to unpack a few pieces of the debate and look at what the candidates are actually saying. Clinton comes across as quite defeatist, but I suppose that’s to be expected of a mainstream Democrat.

  10. Oregoncharles

    “Another demagogic appeal to party tribalism;”
    Effective strategy: Clinton is a Democrat; Sanders isn’t.

    1. nigelk

      Bernie is a paleodemocrat. If this were 1936, Bernie would be a mainstream FDR Democrat and Hillary would be an Alf Landon lass.

      1. different clue

        I like to think of Sanders as a “New Deal Reactionary” . . . like me. It would be too confusing just nowadays for him to call himself that, though.

  11. washunate

    The “health insurance industry” is not, following Veblen, an industry; unlike health care, it creates no value; it is wholly parasitic and should not exist.

    Lambert, you probably didn’t intend this consciously, but this line of reasoning has two very important problems.

    First, insurance in the US is generally considered a private transaction. We can argue whether that is good or bad, but that discussion needs to happen at the general concept of all insurance, from auto insurance to renters insurance to life insurance; it is not unique to health insurance. Insurance doesn’t “create” anything; the point is to distribute costs among a large group of people.

    Secondly, this propagates the false narrative that health insurance companies are uniquely evil. Every major actor in medicine is predatory, from universities to drug companies to device makers to hospital chains to insurance companies. Health insurance companies are too often dangled out there as useful villains to deflect attention from the rot in the entire system.

    I’m a strong advocate that the Social Security Administration is a much more efficient insurance provider than any private insurer. Indeed, I advocate that SSA replace our entire welfare state with direct cash payments to people in need. However (in part due to that familiarity with both the benefits and limitations of social insurance), it is important to realize that nationalized insurance is not a panacea in and of itself. You have to reduce payments to those other actors in order to have a meaningful effect.

    1. Oregoncharles

      Your last sentence is extremely important. I’ve heard a doctor and single-payer advocate maintain that the deeper problem is the way medicine is practiced. Between butt-covering and belief in their own god-like powers, doctors just do far too much, often without full understanding of the patient’s situation. It’s something I just experienced: several months of treatment and $350 of copays (WITH Medicare) left me worse off. Started to heal after I stopped seeing the doctor. I’ll be more sceptical next time, but it’s difficult when you’re in pain.

      Of course, remodelling health care itself is one of the potential benefits of a single-payer system. But insurance and its costs are only half the problem.

      1. Vikas Saini

        Hear Hear.

        The single payer movement needs to address this issue head on. The potential benefits of remodeling the system won’t happen automatically. You could get a single payer financing system without much remodeling of the current system. “Medicare for all”, in fact. Sure, some ancillary benefits from the power of the one payer’s leverage would flow there, but given that the state is not particularly democratic, rent-extraction could easily continue. All it would require is an essentially tactical move by the non-insurance business interests within healthcare to line up with business interests outside of healthcare, offer up the insurance sector as the sacrificial lamb and otherwise keep the system going as is.

        1. Mark P.

          And in fact Big Pharma and some of the medical equipment companies do make more egregious levels of profit in the U.S. system than the insurance sector does. So the scenario you propose is quite probable.

          1. washunate

            What’s exciting to me is that I think this kind of conversation has been building and makes it much more difficult for the next round of “health insurance reform” to suppress. It’s amazing looking back that even such basic things as allowing Medicare to negotiate volume discounts with vendors and allowing individuals to import cheaper medical supplies from other countries were both successfully kept out of PPACA (and NAFTA, for that matter…).

    2. marym

      http://www.pnhp.org/nhibill/nhi_bill_final.pdf

      HR 676 Expanded and Improved Medicare for all provides for a transition to not-for-profit healthcare providers (Section 103)

      No institution may be a participating provider unless it is a public or not-for-profit institution. Private physicians, private clinics, and private health care providers shall continue to operate as private entities, but are prohibited from being investor owned.

      setting reimbursement rates for providers (Section 201) and negotiating the prices for “ covered pharmaceuticals, medical supplies, and medically necessary assistive equipment” (Section 205).

      That’s not to say it’s a panacea for predatory capitalism and corrupt government but the plan itself does take these factors into account, beyond just providing the insurance layer.

        1. washunate

          That would be a very interesting discussion. Because part of the point of HR 676 was to start the journey of going beyond insurance to look at what kind of care should be provided and how to pay for it. I think part of the reason the insurance companies have been held out as punching bags is to cement this idea that ‘health insurance’ is some specific, defined product rather than a vague term dealing with a variety of different procedures and value systems. The reason people have DNRs, for example, is because they believe at a moral level that it is wrong to expend enormous resources on extending the life of an elderly person for a few months when the same amount of money could create much more value in providing food or housing or education to lots of younger people.

          There is no objective scientific answer to whether single payer ought to fund abortion or Viagra or condoms or extensive neonatal intensive care or extensive end of life care or a host of other matters over which reasonable people may disagree. Nor is there such an answer for determining an appropriate level of compensation and working conditions for the employees in the healthcare system who are for all intents and purposes government employees just like SNAP eligibility specialists and DMV staffers and Social Security claims authorizors and the myriad other publicly funded positions which pay a lot less than hospital administrators and specialist doctors and academic researchers and medical school deans and health professors and drug researchers and pharmaceutical executives and so forth.

  12. Knifecatcher

    This is a bit of a non-sequitur but it occurred to me the other day that treating health care as a marketplace can be linked directly to the proliferation of non-scientific idiocy like anti-vaxxers, supplement snake oil, etc.

    As a “consumer” I think of myself as savvy and independent, so why would I just roll over and let the doctors tell me what to do? I’m smart! I’m informed! I’ve read lots of stuff on the internet! If it’s my money, I get to decide how and where to spend it, right?

    1. hunkerdown

      Interesting angle, but I suspect your consumers are merely turning away from the arrogance and dehumanization of one corrupt institutional authority (the health-rent business) in favor of another (the market). Too bad about your loyalty to evangelical positivism.

    2. BEast

      The anti-vaxxer stuff is its own brand of irrationality, but for alternative medicine I have to figure affordability enters into it.

      In Mountains Beyond Mountains, the American doctor who’d practiced in Haiti for years was talking about the Voodoun practices Haitians would practice when they were sick, with the sacrificing of chickens, etc. etc. He said that a lot of anthropologists would write about these practices, but as far as he knew, none of them made the obvious connection — that Haitians resorted to these rituals because most of them had no access to real, meaningful medical care.

      So it’s not a matter of choosing, except insofar as desperate, poor people may choose a “witch-doctor” over doing nothing when their child is seriously ill.

      1. HotFlash

        Maya Deren in Divine Horsemen points out that Haitians mistrust the free rural medical clinics on grounds that if you do not pay, you do not have recourse if the treatment fails. With loa, on the other hand, the deal is a quid pro quo contract, and if desired results not obtained, you can complain to your houngan, who complains to her/his loa. Meanwhile, you get your money (or your chicken) back.

    3. Oregoncharles

      I’m assuming irony in your second paragraph.

      Health care is one of the best examples of market failure. Not only is there a huge imbalance of information, but the “customers” are generally in no condition to shop around, nor even, sometimes, to make their own decisions.

      If we’re making those decisions for someone else, it would be immoral, as well as impractical, to base our decisions on price. You want the best doctor, not the cheapest. And you have no good way to know who that is. Someone you get along with is pretty much where you wind up, if you’re lucky. Doc Martin would get by ONLY if he’s the ONLY doc in town – no matter how brilliant he is. Personally, I changed doctors because his front desk was undermanned and his office seemed disorganized. No idea how good his medical judgement was.

      So “markets” don’t apply, and “exchanges” are just a better way to rip you off.

    4. different clue

      What are some specific examples of supplement snake oil? Are there any specific supplements which are non-snake-oil?

  13. cripes

    Yes, privatization of medicaid to rent-seeking douchbags was the plan all along, but hidden, like cockroaches, from the light of public view.
    Worse, affordable care organizations “ACO’s” will extract +/- 10,000 annually in capitated payments for consumers they own, whether any health care is provided or not. And they exist to deny actual care
    If any of this co-called care occurs after age 54, you or your heirs are liable for the total amount paid to the insurer, not any health care you actually received.

    1. RD (Recovering Democrat)

      Thank you for making that point, cripes!

      It is rarely part of the discussion, in spite of Paul Craig Roberts’ excellent writing on this subject.

      Go figure . . .

  14. cripes

    >correction<
    That's "accountable" care organizations.
    You or your estate (not heirs) are liable for all the rents paid to rentiers, not for care received.

  15. Jim in SC

    I think the advocates of single payer have to explain why VA care is such a disaster. My uncle couldn’t get them to do anything about a benign cancer on his ear. They let it go, and go, and go…until the only thing that would save him (or his ear, there was disagreement among experts) was a $500,000 surgery at a local teaching hospital (he was eligible because he lives more than 50 miles from a VA hospital). It could have been an office procedure if it had been removed at the time he first took it to the VA.

    1. Oregoncharles

      Budget.
      Also monopoly, because patients are effectively locked in (with the exception you mention.) The Canadian system is probably better for this reason.

    2. HotFlash

      Yes, Oregon Charles (below) is quite right. Here in Canada we have single payer, as in Medicare for all, not VA for all, which is the British system, ie, govt-owned hospitals, clinics, etc.

      When the plan was proposed in Canada, the CMA vehemently opposed it as it would limit their ability to charge high fees. OTOH, a friend whose father was a general physician in a rural area at the time told me that her father fully supported it. “It means we’ll *get paid*!”

      BTW, would your uncle have fared any better under, say, ACA? I understand that many specialists are not ‘in network” — which seems to be a feature, not a bug.

    3. RD (Recovering Democrat)

      Not all VA care is a disaster.

      Sorry that your Uncle had such a horrendous experience.

    4. different clue

      A friend of mine who was a combat-arms veteran of the Vietnam War had a lymphoma kind of cancer and told me that his VA care was good in every way at every step. And he came out of it cancer-free. So there is another case of VA doing good medicine.

  16. Disturbed Voter

    There is no free lunch?

    Buyer beware?

    Physician heal thyself?

    No man is safe while the legislature is in session?

    Don’t abuse yourself?

    Accidents happen?

    Our lives are against the wall, the same wall they have been for 5,000 years. There were severe malpractice penalties against the medical community in the Code of Hammurabi. I don’t see any new solutions that didn’t exist in Hammurabi’s day … there is no lipstick that can make a pig into something attractive.

  17. Michael C.

    Having worked on single-payer nationally and at the state level here in Ohio (Single-Payer Action Nework of Ohio, SPAN Ohio) I have been bothered by Sanders inability to hit hard and explain in an easy manner just what single payer is. There are many points he could give briefly, and these points are backed by numerous studies so that he can show his ideas are not extreme ones, that would give him an opportunity to present single-payer in a way people could understand and look into. He should mention Physicians for a National Healthcare Program (PNHP) website with its information, or the Nations Nurses United ergonomic studies, or present factoids that expose the waste of the present insurance run system and the savings of single-payer.

    I know he is running his campaign without the hordes of advisors, but someone needs to talk to this guy and home his messages. He cannot keep saying the same tired phrases, whether it is about the banks, or healthcare, or the 1%.

    Also, if he is interersted in building a movement and a revolution, then he should be giving shout-outs in each state to the groups that are part of the movement and could use reinforcements (Move-to-Amend, state single payer groups, etc.), Let’s face it. Hilllary will get the nomination, and if Sanders wants a revolution, he better begin building something with some kind of infrastructure utilizing those progressive activitists already doing the diificult yeoman work of truning the tide of corporate control.I don’t seen him doing that, and if his campaign is not to be about him, as he says, then he better get smarter about helping develop the groundwork for this revolution after he becomes an also ran.

    1. Oregoncharles

      “Also, if he is interersted in building a movement and a revolution, then he should be giving shout-outs in each state to the groups that are part of the movement and could use reinforcements (Move-to-Amend, state single payer groups, etc.)”
      Raises a question, doesn’t it?

      And yes, good points all.

    2. RD (Recovering Democrat)

      Hear, hear!

      My question is:

      “How do you support and campaign for your corporatist counterpart (that you just lost to), and lead a revolution against what she stands for, at the same time?”

      ;-)

      1. different clue

        I will re-offer the theory that Sanders is preparing for a possible Party Win on his part. He is pre-emptively claiming that he will support Hillary now, and if he wins . . . he will remind Hillary of his promise and dare Hillary and the DemParty establishment to betray him the way they betrayed McGovern. It is pre-shaping the potential battlespace. But perhaps I am projecting my own desires onto a candidate who is too soft a guy to support my hard desires.

  18. Malcolm MacLeod, MD

    As a long retired general pediatrician, I’m long past about the US’s inability to
    modernize and maximize healthcare here, when the answer is so stupidly obvious,
    and has been for some time. The reason? Easy; money hungry insurers and corrupt
    federal representatives and Senators. That is actually the first and largest problem.

  19. different clue

    I suspect that Sanders has two innate problems, or handicaps . . . if one will. One is that he comes from an overly verbose overintellectualistic cultural background. The other is that he is too nice a guy to put the shiv in. He just isn’t that way.

    Ah well . . . as SecDef Rumsfeld once said: ” You go to political war with the candidate you have, not the candidate you wish you had or would have preferred to have had at some later time.”

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