The first congressional hearing on Medicare-for-all was defined by the opening statement by activist Ady Barkan, who has ALS and used a computer system to testify to the House panel about why he believes America needs single-payer health care.
“Our time on this earth is the most precious resource we have. A Medicare-for-all system will save all of us tremendous time. For doctors and nurses and providers, it will mean more time giving high-quality care. And for patients and our families, it will mean less time dealing with a broken health care system and more time doing the things we love, together,” Barkan said.
He added: “Some people argue that although Medicare-for-all is a great idea, we need to move slowly to get there. But I needed Medicare-for-all yesterday. Millions of people need it today. The time to pass this law is now.”
What followed was a mostly civil and substantive discussion about the pros and cons of moving all Americans into a government health care plan.
Starting with Chair Jim McGovern, several Democrats on the Rules Committee — not usually a policymaking committee, but nevertheless the forum for Tuesday’s first-ever hearing — have supported a Medicare-for-all bill. They prodded the witnesses to explain how single payer could fix some of the current system’s problems and pushed back against some of the common attacks against such a proposal, like its price tag. Republicans questioned the costs attached to such a sweeping plan and warned about disruptions it could cause the 150 million Americans who currently receive health insurance through their work.
The hearing was more notable for its existence than its content, Barkan’s moving testimony aside. But there were still a few moments that shone through, digging a little deeper into the policy weeds and offering some revealing tit-for-tat that might preview the political debate to come.
1) “We only ask how we’ll pay for it when it comes to our health”
Cost is always going to be the toughest question for Medicare-for-all. The federal government would become responsible for almost all health care spending in the country (currently 18 percent of GDP) and taxes would need to be raised to fund it. Republicans happily cite outside estimates that Medicare-for-all would cost more than $30 trillion over 10 years.
Single-payer supporters argue we can actually spend about the same amount of money as the country collectively does now while covering every person and offering more generous insurance benefits — and they’ll cite the same studies to make their case.
The increase in federal spending would be dramatic but, as Republican witness Charles Blahous of the Mercatus Institute acknowledged at the hearing, much of that would just be a shift from the private sector to the public. People would pay taxes instead of health insurance premiums and existing federal funding for Medicare, Medicaid, and Obamacare would be repurposed for the national health plan.
The cost question reared its head again and again during Tuesday’s hearing. Republicans tried to sound sympathetic to the goals of single-payer while simultaneously warning about “a tremendous increase in tax burden for the country,” as Rep. Rob Woodall (R-GA) put it.
“I think we can achieve the goal of not having the underserved walk out on what ought to be an affordable procedure,” Woodall said. “Though I think we can do it without virtually doubling the federal budget.”
Barkan asked for a chance to respond and then made the case you’re going to hear a lot from Medicare-for-all supporters.
“One thing I can’t help but think about today, congressman, is how we always seem to find the money for things like tax cuts for the wealthy and for corporate tax cuts,” Barkan told Woodall. “We never ask where the money will come from when we declare war. We always seem to just find the money.”
“We only ask how we’ll pay for it when it comes to our health,” he continued. “This is such a clear problem with such a straightforward solution. We can save taxpayers money. We can save money for families.”
2) “I didn’t think Colorado on its own could undertake a Medicare-for-all system.”
Despite the insider drama over whether House Democratic leadership was trying to subversively squelch Medicare-for-all support at the hearing, the House Democrats who dominated the first few hours of the hearing were cosponsors of the current Medicare-for-all bill in the House. They teed up Barkan, the doctors on the panel, and the left-leaning experts who could parse the policy minutiae to espouse the potential positives of moving to a single-payer system.
But one of the most striking moments, to me, was a little bit of self-accountability on the part of Rep. Ed Perlmutter (D-CO). Perlmutter sponsors the Medicare-for-all legislation, but he acknowledged during his questioning that he had voted against a single-payer ballot referendum in Colorado in 2016.
“I voted against the legislation because I didn’t think Colorado on its own could undertake a Medicare for all system, that it was national in scope,” Perlmutter said.
He asked the Galen Institute’s Grace-Marie Turner, one of the Republican guests, about the experiences of Colorado and Vermont, another state with aspirations of setting up its own single-payer system that ultimately fell short.
“The feedback we continually got was people were so nervous about the taxes needed to support it,” Turner said. She said people understood some of the financing would just be moving money, from private insurance premiums to public taxes, but there was a pervasive feeling that “it just wasn’t enough.”
“And I think you’re right from a policy and a political standpoint,” Perlmutter said. “It wasn’t enough to overcome the concerns and fears.”
The exchange underscored the prevailing challenge for Medicare-for-all: Many, even most, Americans are sympathetic to the plan’s goals. But disruption in health care has proven to be a political loser more often than not. Colorado and Vermont’s failed attempts to bring single-payer health care to their citizens should be a cautionary tale, as Perlmutter’s candid comment emphasizes.
3) “The evidence does not show that private rates are higher because Medicare rates are low”
Related to, but distinct from, the cost question is the potential for payment cuts to health care providers. It’s another thorny political problem, given the outsized influence doctors, hospitals, and the pharmaceutical industry have with lawmakers.
A common Republican talking point is that Medicare-for-all would cut provider payments by up to 40 percent. Rural hospitals could close, as GOP Rep. Tom Cole warned during his time. The truth is more complicated; yes, providers would get less from Medicare than private plans, but they would also get more than they do from Medicaid or from uninsured patients who can’t afford their bills. It’s a pay cut, maybe not as deep as feared, but it could still be a challenge for providers already operating with a thin margin.
Sara Collins of the Commonwealth Fund undercut one plank of the provider payment argument against Medicare-for-all: the idea that hospitals and doctors need the higher private payments because they lose money on Medicare patients.
“The evidence really does not show that the reason that private provider prices are higher is because Medicare rates are so low,” she said.
If that were the case, we would see consistently higher margins all the way across the country. Instead, we see a lot of variability across the country. The way this works is that private providers are negotiating with their commercial carriers prices that work the best for them.
In concentrated markets, they get higher prices and insurers want them in their network. So they concede to those higher prices. They then take that negotiated rate to employers. Employers have to pay higher premiums. They reduce their workers’ wages, they increase their deductibles, and those costs get ultimately shifted to people.
So there really isn’t evidence that the cost-shift argument is the reason for higher prices. It’s really these not-transparent price negotiations that happen in the private market.
Political debates are rarely won on policy minutiae. Part of the point of Medicare-for-all is that it’s an intelligible, intuitive proposal. But Democrats will need answers to some wonky, difficult questions if they ever plan to pass single payer or something approaching it. Nuance like that captured by Collins will be important in trying to win the argument on its merits.