After the King v. Burwell decision, GOP candidates postured all over the place, but were left without any coherent ideas to offer.
So, not surprisingly, the Republican field essentially responded to the Supreme Court upholding Obamacare by invoking the free market and related shibboleths, speaking mostly in broad terms, and getting tripped up by the truth when they tried to get specific. We’ll turn to them in a moment. But first, we should note what Bernie Sanders had to say, as he also spoke broadly, but without the deception or obfuscation. The broad statements he made could be backed up with specific facts. He also skillfully praised what Democrats had accomplished without forgetting for a moment that more remained to be done:
Today, because of the Supreme Court's decision to protect the modest gains made under the Affordable Care Act, it is a good day for millions of Americans who will be able to keep their access to health care.
It's also a good day for the small business owners who, before the passage of the Affordable Care Act, couldn't afford the escalating cost of providing insurance for their employees.
But while I am glad the Supreme Court upheld the law, in my view, the only long-term solution to America's health care crisis is a Medicare-for-all single-payer system.
In contrast to Sanders, who spoke from an understanding of how health care systems work around the world, the GOP candidates simply illustrated the limits of conservatism—they were fine in the abstract (or at least adequate), but fell completely apart on any details.
"This decision turns both the rule of law and common sense on its head,” Rand Paul said—a classic fact-free sweeping statement. “Obamacare raises taxes, harms patients and doctors, and is the wrong fix for America's health care system.”
Marco Rubio criticized the Court, saying, “they have once again erred in trying to correct the mistakes made by President Obama...and Congress in forcing Obamacare on the American people,” while calling Obamacare “a bad law that is having a negative impact on our country,” the most abstract of claims, and promising to replace it “with my consumer-centered plan that puts patients and families back in control of their health care decisions.” It was a classic conservative promise, a promise to restore the "good old days," even if they had never actually been that good for everyone.
Jeb Bush deserves a longer look, because he made a more extensive statement, overlapping with some of the above. Bush first said he was “disappointed” with the decision, but vowed that the fight wasn’t over:
"This fatally-flawed law imposes job-killing mandates, causes spending in Washington to skyrocket by $1.7 trillion, raises taxes by $1 trillion and drives up health care costs. Instead of fixing our health care system, it made the problems worse.”
"As President of the United States, I would make fixing our broken health care system one of my top priorities. I will work with Congress to repeal and replace this flawed law with conservative reforms that empower consumers with more choices and control over their health care decisions.
"Here is what I believe: We need to put patients in charge of their own decisions and health care reform should actually lower costs. Entrepreneurs should be freed to lower costs and improve access to care – just like American ingenuity does in other sectors of the economy.
The specific charges Bush leads with are all lies. Regarding job loss, Factcheck.org notes that small job losses are anticipated, but haven’t been studied much because “economists think the impact will be minimal.” It explained:
Mainly, the “job-killer” claims severely distort a 2010 nonpartisan Congressional Budget Office report that said the law would have a “small” impact on jobs. And that’s mainly from workers choosing to work less. For instance, some might work fewer hours if they receive subsidies to help them buy insurance, or those close to retirement may retire early, with some reassurance that they can buy insurance on their own.
This is actually a good thing for the workers concerned, not a bad thing, as Bush would have it. As for “spending in Washington,” the cost of Obamacare is $190 billion less than anticipated over 10 years. As for taxes, it’s a major tax cut for the middle class, and has resulted in the slowest rise in premium costs in decades.
So Bush is wrong about all the specifics. But the broad claims—to “empower consumers with more choices and control over their health care decisions.” Sounds great! But then remember what he’s talking about: improving health insurance through the “magic of the marketplace,” something that’s never happened in the decades before Obamacare. As political scientists discovered long ago, the American people are attracted to the idea of the free market, but when it fails to deliver, they are happy to have government do something instead. Which is just what the creation of Obamacare has done. The real question is how well does it stack up with what other countries have done?
This brings us back to Bernie Sanders, and what he had to say. Remember, Sanders already acknowledged that Obamacare has helped millions of Americans, a basic reality that all the GOP candidates are in denial about—similar to global warming, evolution or gay marriage. When the ruling came down, the latest figures from Gallup were 11.9% uninsured in the first quarter of 2015, down from a high of 18% before Obamacare went into effect. Since then, second-quarter figures came in at 11.4% uninsured. This is a program that's working. But it's still a far cry from what other countries have done.
A 2014 document from the Organization for Economic Cooperation and Development (OECD), comprised of 34 member countries, "How does the United States compare?", reported that "Health spending accounted for 16.9% of GDP in the United States in 2012 -- the highest share among OECD countries and more than 7½ percentage points above the OECD average of 9.3%."
This means that the U.S. spends a whopping 82% more than the OECD average—just on a GDP percentage basis. What’s more, the U.S. was a clear outlier. The No. 2 country in spending, Switzerland, spent just 11.8% of its GDP on health care. The U.S. also stood out in terms of how much money was spent privately:
In contrast to most OECD countries, health spending in the United States is split evenly between public and private sources. In 2012, 48% of health spending in the United States was publicly financed, well below the average of 72% in OECD countries.
All this excess spending might be justified if our health care system were vastly superior to all others. But in terms of the most basic measure—life expectancy—we are clearly below average:
In 2011 (latest year available), life expectancy in the United States stood at 78.7 years, 1½ years less than the OECD average of 80.2 years.
Looking at another basic figure for comparison, the percentage of people with health insurance coverage, the U.S. is once again an outlier—though not completely isolated. In 2011, 20 OECD countries had 100% health care coverage, five more had 99.9%, Turkey had 99.5%, and five more spanned 98.8% to 92.9%. The only countries with less than 90% insured were Mexico (86.7%), the U.S. (84.5%) and Chile (76.2%). Chile, of course, is notorious for being the laboratory of Chicago School free market economics following the Pinochet coup in 1973. Thanks to Obamacare, the U.S. now ranks above Mexico--we're No. 32 in terms of coverage, rather than No. 33. That’s the comparative background for what Sanders had to say as his response continued: "But while I am glad the Supreme Court upheld the law, in my view, the only long-term solution to America's health care crisis is a Medicare-for-all single-payer system."
I start my approach to health care from two very simple premises:
1. Health care must be recognized as a right, not a privilege--every man, woman and child in our country should be able to access quality care regardless of their income.
2. We must create a national system to provide care for every single American in the most cost-effective way possible.
Tragically, the United States fails in both areas.
As already noted, the idea of health care as a right possessed by all is realized by 20 OECD countries—almost 60% of them. Add in 5 more than fall infinitesimally short at 99.9%, and you include every country in Western Europe except Belgium (98.8) and Luxembourg (97.2). It very clearly is quite doable to ensure health care as a right. We simply have to make it a priority. Sanders continued:
The health insurance lobbyists and big pharmaceutical companies make "national health care" sound scary. It's not.
In fact, a large single-payer system already exists in the United States. It's called Medicare and the people enrolled give it high marks. More importantly, it has succeeded in providing near-universal coverage to Americans over age 65 in a very cost-effective manner.
It's time to expand that program to all Americans.
What Sanders is proposing is far simpler than Obamacare—simple to say, simple to understand and simple to implement, too, considering the Medicare system already in place. What’s more, the idea already enjoys significant support, despite not being widely talked about—which Sanders is doing his best to change via his campaign. In the “Big Ideas” poll commissioned by the Progressive Change Institute (featured in my previous story about Sanders), people were asked if they supported or opposed a wide range of proposals, including two important questions about expanding Medicare.
The first is basically a re-articulation of the “public option” proposal, a toned-down derivative of the single-payer position health care activists supported overwhelmingly heading into the 2008 election, which Edwards, Clinton and Obama all agreed to during the 2008 primary. But Obama never seemed to understand or appreciate it, once he took office, treating it merely as a bargaining chip to be traded away. This reflected Obama’s neoliberal mindset, completely dominated by market ideology. The proposal reads: “Give all Americans the choice of buying health insurance through Medicare or private insurers, which would provide competition for insurance companies and more options for consumers.”
While the public option enjoyed around 60% support in the polls in 2009 (see poll summary at top of a critical story here), this presentation did significantly better—71% of all respondents supported it, with only 13% opposed, including Democrats (77-9), Independents (71-13) and Republicans (63-18). At these levels, Republicans now support it more strongly than the public as a whole supported the public option in 2009. This suggests that the idea suffered from being associated with a wide-ranging ideological and partisan struggle—the remnants of which we still see in GOP hostility to Obamacare—and is actually much more popular than was realized at the time.
The second proposal tested is precisely what Sanders proposes: “Enact a national health plan in which all Americans would get their insurance through an expanded, universal form of Medicare.” This had the support of 51%, with 36% opposed. Democrats supported it overwhelmingly (79-11), while independents gave it a plurality (45-43) and Republicans opposed it (23-61). That means that outside the Republican Party, it enjoyed landslide support 66-24, and Democrats supported it roughly as much as they supported the more modest public option.
This was in January 2015, well before Sanders declared and began advancing the idea as part of his campaign. It certainly can’t hurt to have Sanders out there talking about it—and presenting it as part of a whole landscape of possibilities that Europeans have long taken for granted. And that’s precisely what Sanders is doing in his campaign.
In his campaign announcement speech, Sanders said:
The United States remains the only major country on earth that does not guarantee health care for all as a right. Despite the modest gains of the Affordable Care Act, 35 million Americans continue to lack health insurance and many more are under-insured. Yet, we continue paying far more per capita for health care than any other nation. The United States must join the rest of the industrialized world and guarantee health care to all as a right by moving toward a Medicare-for-All single-payer system.
He re-echoed that call in the closing section of his speech, when he cited the right to health care as the first item defining his vision of what America could be: "The lesson to be learned is that when people stand together, and are prepared to fight back, there is nothing that can’t be accomplished."
The framework within which an idea is considered can have a considerable effect on how it is perceived, and that is the framework that Sanders invokes—a very different one than Barack Obama did when he took office in 2009.
The story cited above about polling data then on the public option, from Real Clear Politics, made this very argument about the importance of context from a conservative point of view. Ironically, the problems with their specific argument only strengthens the more general argument that framing matters in a way that favors Sanders now.
After citing roughly 60% approval for the public option from a number of different sources, covering multiple polls, the RCP story pointed to other evidence that the health care reform effort as a whole was not that popular--a fact that public option advocates also noted at the time, arguing strenuously that it should not be dropped. Broadly speaking, RCP tried to make the opposite argument—that the broad ambivalence about reform means the public option polling numbers shouldn't be believed. They even cited Obama's declining poll numbers—just as wild charges about "death panels" were starting to surge—before asking, "How can we reconcile these gloomy numbers with the sunny results on the public option?"
The answer to that question is simple: Conservatives always do best in broad terms, and worst in specifics, and the success of the broad attacks was exactly what should be expected. Obama was being demonized, and outrageous lies were being spread about Obamacare in general. These are common hallmarks of how conservatives rally support when their broad ideological edge identified by Free and Cantril comes under attack. Ronald Reagan used a similar approach attacking Medicare before it was introduced. In a 1961 recording, Reagan warned that if Medicare was implemented, “We are going to spend our sunset years telling our children and our children's children, what it once was like in America when men were free."
Extremist scaremongering like that is simply part of the package of how conservative ideological dominance is maintained. More moderate figures, like neoliberal Democrats, assist this process by not challenging it directly, by trying to respond “reasonably,” trying to compromise, and telling more committed progressives to sit down and shut up. Obamacare without the public option was the result of this strategy’s dominance in 2009—as was the loss of the House of Representatives in 2010 and the loss of the Senate in 2014.
Sanders proposes a fresh start. Instead of taking up the toned-down public option idea, he returns to Medicare for all, which Democrats support as strongly as the public option. The reasons is simple: It will get the job done. It will ensure universal health care as a right; the public option will not.
By taking up the “more extreme” position, Sanders frames the debate on his terms: Will we have health care for all Americans? Or only for a fortunate subset? (Whose numbers we have swollen lately, but could well ebb once again, particularly if GOP lawmakers have their way.) There is no question that we could have health care for all Americans—they do that in almost every country in Europe, as already noted. So let’s have the Republicans debate about who shouldn’t have health care, and why. Doesn’t that sound like a good Christian thing to do? A debate in the spirit of Matthew 25:31-46. That will be the position Republicans are in if they’re arguing against Bernie Sanders and Medicare for all, instead of against Obamacare.
That’s a debate that an ever-growing number of people would like to see.
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