The Democratic Debate: Finally, Healthcare! (sort of)

After a bunch of Republican debates in which the ACA in particular and healthcare in general was barely touched upon, and only a minor mention or two of either during the first two Democratic debates, the ACA was finally front and center for one brief, glorious moment during last night's New Hampshire Democratic Primary Debate on ABC.

Unfortunately, when I was actually watching the debate, I got distracted by something and as a result, most of Hillary and Bernie's responses sounded quite solid. However, upon re-watching/reading the transcript, I'm actually kind of...disappointed by both of them, for different reasons (which is particularly stunning given that healthcare reform is such a major part of both of their platforms).

RADDATZ: And we're going to move on to health care.

Secretary Clinton, the Department of Health and Human Services says more than 17 million Americans who are not insured now have health coverage because of Obamacare. But for Americans who already had health insurance the cost has gone up 27 percent in the last five years while deductibles are up 67 percent, health care costs are rising faster than many Americans can manage.

What's broken in Obamacare that needs to be fixed right now? And what would you do to fix it?

As I noted last night:

That "27% hike" over past 5 years is weak tea. Only past 2 years are remotely fair to include.

— Charles Gaba (@charles_gaba) December 20, 2015

Tierney Sneed over at Talking Points Memo has addressed this point in further detail:

It should be noted that health insurance policies purchased in the Obamacare marketplaces -- a major element of the Affordable Care Act -- first went into effect on Jan. 1, 2014. So any discussion of costs over the last five years straddles the pre- and post-Obamacare worlds.

While it's unclear exactly the role Obamacare played, the growth of premiums has been lower in the last few years than it was in periods prior, according to a 2014 Kaiser Family Foundation report that was highlighted by FactCheck.org.

That report showed that, yes, premiums increased for covered workers with family coverage by 26 percent between 2009-2014. However, between 2004-2009 those premiums rose by 34 percent, and between 1999-2004 they rose by a whooping 72 percent.

For most of the debate, Hillary Clinton was on fire, but to be honest, her ACA response was actually kind of meh. On the one hand, she did give a solid defense of the law overall:

CLINTON: Well, I would certainly build on the successes of the Affordable Care Act and work to fix some of the glitches that you just referenced.

Number one, we do have more people who have access to health care. We have ended the terrible situation that people with pre- existing conditions were faced with where they couldn't find at any affordable price health care. Women are not charged more than men any longer for our health insurance. And we keep young people on our policies until they turn 26. Those are all really positive developments.

...and to her credit, she did honestly admit that there are still some serious issues which need to be addressed...

But out-of-pocket costs have gone up too much and prescription drug costs have gone through the roof. And so what I have proposed, number one, is a $5,000 tax credit to help people who have very large out-of-pocket costs be able to afford those.

Number two, I want Medicare to be able to negotiate for lower drug prices just like they negotiate with other countries' health systems. We end up paying the highest prices in the world. And I want us to be absolutely clear about making sure the insurance companies in the private employer policy arena as well as in the Affordable Care exchanges are properly regulated so that we are not being gamed.

And I think that's an important point to make because I'm going through and analyzing the points you were making, Martha. We don't have enough competition and we don't have enough oversight of what the insurance companies are charging everybody right now.

...however, she completely skipped over the "2 years vs. 5 years" context correction both I and TPM noted, even when the "27% over 5 years" line was repeated:

RADDATZ: Twenty-seven percent in the last five years, deductibles up 67 percent?

CLINTON: It is. Because part of this is the startup challenges that this system is facing. We have fought, as Democrats, for decades to get a health care plan. I know. I've got the scars to show from the effort back in the early '90s.

We want to build on it and fix it. And I'm confident we can do that. And it will have effects in the private market. And one of the reasons in some states why the percentage cost has gone up so much is because governors there would not extend Medicaid.

And so people are still going to get health care, thankfully, in emergency rooms, in hospitals. Those costs are then added to the overall cost, which does increase the insurance premiums for people in the private system.

UPDATE 12/21/15: I should also note that she shouldn't have agreed with the term "glitches" to describe rate/deductible hikes; that minimizes what's a legitimate issue to many people.

In addition, her line about private policy rates increasing due to states not expanding Medicaid may be true to some degree, but according to my own analysis (which has been supported by both Avalere Health as well as the Robert Wood Johnson Foundation), it's not quite as solid as that; the non-expansion states seem to have raised their rates by higher percentages than the expansion states for 2016....but the expansion states have outliers at both the lower and upper end (here's a crude chart demonstrating this):

In addition, that's only for 2016...I don't have the data for 2015, and even then you'd have to merge both years together to see any real trend. In addition, some states (Michigan, Indiana, Pennsylvania, Alaska, New Hampshire, Montana, etc) didn't expand Medicaid until long after January 2014, so it's hard to say what the impact in those states has been yet.

Anyway, I'll give Clinton a C+ for her response here; she gave a solid defense of the ACA's successes but failed to point out that the wording of the question itself was riddled with errors in the first place.

This was followed up by Bernie Sanders being asked about Single Payer, of course. Unfortunately, while he made a strong case for SP, he didn't answer the question, which was actually a reasonable one to ask...and this time, Raddatz actually framed the question properly:

RADDATZ: Senator Sanders, I want you to respond to what she was saying, but you're instead calling for single-payer health care.

SANDERS: Yes, exactly, exactly.

RADDATZ: You note people won't have to pay deductibles or premiums but they will have to pay new taxes. Can you tell us specifically how much people will be expected to pay?

SANDERS: Yes, well, roughly. Let me say this. As a member of the Health Education Committee that helped write the Affordable Care Act, much of what Secretary Clinton said about what we have done, among other things, ending the obscenity of this pre-existing situation is a step forward. Seventeen more million more people have health care. It is a step forward. A step forward.

But this is what we also have to say. Not only are deductibles rising, 29 million Americans still have no health insurance and millions of people can't afford to go to the doctor. Major crisis and primary health care. Here is the bottom line. Why is it that the United States of America today is the only major country on earth that does not guarantee health care to all people as a right?

SANDERS: Why is it that we are -- why is it that we spend almost three times per capita as to what they spend in the U.K., 50 percent more than what they pay in France, countries that guarantee health care to all of their people and in many cases, have better health care outcomes. Bottom line.

This ties into campaign finance reform. The insurance companies, the drug companies are bribing the United States Congress. We need to pass a Medicare for all single payer system. It will lower the cost of health care for a middle-class family by thousands of dollars a year.

RADDATZ: Senator Sanders, you didn't really tell us specifically how much people will be expected to pay...

SANDERS: But they will not be paying, Martha, any private insurance. So it's unfair to say in total...

RADDATZ: But you can't tell us this specifically, even if you were...

SANDERS: I can tell you that adding up the fact you're not paying any private insurance, businesses are not paying any private insurance. The average middle-class family will be saving thousands of dollars a year.

Again, what Sanders did say was very important here...but what he didn't say was incredibly frustrating, and opened up an opportunity for Clinton to take an unfortunately disappointing and disingenuous swipe at Sanders over SP (in response to a question which was about education, not healthcare):

CLINTON: But I want to quickly say, one of the areas that Senator Sanders touched on in talking about education and certainly talking about health care is his commitment to really changing the systems. Free college, a single payer system for health, and it's been estimated were looking at 18 to $20 trillion, about a 40 percent in the federal budget.

This was a pretty low blow on Clinton's part, because she was basing that "$18 - $20 trillion" figure on an utterly absurd story in the Wall St. Journal which Paul Waldman already tore to shreds back in September:

While Sanders does want to spend significant amounts of money, almost all of it is on things we’re already paying for; he just wants to change how we pay for them. In some ways it’s by spreading out a cost currently borne by a limited number of people to all taxpayers. His plan for free public college would do this: right now, it’s paid for by students and their families, while under Sanders’ plan we’d all pay for it in the same way we all pay for parks or the military or food safety.

But the bulk of what Sanders wants to do is in the first category: to have us pay through taxes for things we’re already paying for in other ways. Depending on your perspective on government, you may think that’s a bad idea. But we shouldn’t treat his proposals as though they’re going to cost us $18 trillion on top of what we’re already paying.

And there’s another problem with that scary $18 trillion figure, which is what the Journal says is the 10-year cost of Sanders’ ideas: fully $15 trillion of it comes not from an analysis of anything Sanders has proposed, but from the fact that Sanders has said he’d like to see a single-payer health insurance system, and there’s a single-payer plan in Congress that has been estimated to cost $15 trillion. Sanders hasn’t actually released any health care plan, so we have no idea what his might cost.

But health care is nevertheless a good place to examine why these big numbers can be so misleading. At the moment, total health care spending in the United States runs over $3 trillion a year; according to the Centers for Medicare and Medicaid Services, over the next decade (from 2015-2024), America will spend a total of $42 trillion on health care. This is money that you and I and everyone else spends. We spend it in a variety of ways: through our health-insurance premiums, through the reduced salaries we get if our employers pick up part or all of the cost of those premiums, through our co-pays and deductibles, and through our taxes that fund Medicare, Medicaid, ACA subsidies, and the VA health care system. We’re already paying about $10,000 a year per capita for health care.

In other words, even if a SP system did cost $1.5 trillion per year, it would be replacing everything we spend on healthcare now...including both public programs (Medicare, Medicaid, ACA, VA, etc) and private insurance (ESI, the private market, etc). By my count, that'd be slicing the total cost for healthcare in the U.S. in half.

Hillary Clinton knows this damned well, and it was pretty lame in my opinion for her to word her response the way she did, even if her other point about Sanders plan supposedly being run by the states (?) is a valid one:

And I have looked at his proposed plans for health care for example, and it really does transfer every bit of our health care system including private health care, to the states to have the states run. And I think we've got to be really thoughtful about how we're going to afford what we proposed, which is why everything that I have proposed I will tell you exactly how I'm going to pay for it; including college.

I have no idea whether Sanders' plan would turn control over to the states, actually; Clinton has raised this a couple of times recently...does anyone know if it's accurate or not?

Anyway, Sanders accurately responded that you have to subtract the cost of the existing system from whatever his plan is...and Clinton once again mentioned the "turn it over to the states" thing:

SANDERS: ...you know, because I know you know a lot about health care. You know that the United States per capita pays far and away more than other country. And it is unfair simply to say how much more the program will cost without making sure that people know that, we are doing away with cost of private insurance and that the middle class will be paying substantially less for health care on the single payer than on the Secretary's Clinton proposal.

CLINTON: Well, the only thing - the only thing I can go on Senator Sanders...Your proposal is to go and send the health care system to the state. And my analysis is, that you are going to get more taxes out of middle class families.

Just as Clinton's responses were kind of disappointing, so was Sanders...because I actually would like to see a solid SP plan from him, as opposed to generalities. In fact, as much as he supports Single Payer Healthcare, if you visit his website, there's no actual plan posted. In fact, healthcare isn't even listed as a major issue; it's listed as just one of 13 sub-topics under his favorite issue, "Income Inequality" (although oddly, he does list "Prescription Drug Prices" as one of his major issues):

#9. Guaranteeing healthcare as a right of citizenship by enacting a Medicare for all single-payer healthcare system. It’s time for the U.S. to join every major industrialized country on earth and provide universal healthcare to all.

Gimme a plan, Bernie.