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TRNN Debate: What’s The Best Route to Single-Payer?

As Senate Republicans renew their effort to strip millions of health insurance and President Trump threatens to “let Obamacare fail,” Dr. Bill Bronston of Physicians for a National Health Program and economist Dean Baker debate the best path forward for universal healthcare

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Story Transcript

AARON MATE: It’s The Real News. I’m Aaron Maté.

Senate Republicans have renewed their effort to strip millions of their health insurance and hand a massive tax cut to the wealthy. But after voting to open the debate, the first repeal and replace bill failed to receive enough support. The Senate will take up several more proposals to undo Obamacare in the coming days.

Even if they fail, President Trump has already previewed his healthcare plan going forward–let Obamacare collapse on its own.

DONALD TRUMP: I’ve been saying that, Mike, I think you’ll agree, for a long time. Let Obamacare fail, it’ll be a lot easier. And I think we’re probably in that position where we’ll just let Obamacare fail. We’re not going to own it. I’m not going to own it. I can tell you the Republicans are not going to own it. We’ll let Obamacare fail, and then the Democrats are going to come to us, and they’re going to say, “How do we fix it? How do we fix it? Or how do we come up with a new plan?”

AARON MATE: One way Trump could do that is refuse to make the subsidy payments to insurance companies who cover Obamacare recipients. The White House has made those payments for July but hasn’t made a commitment beyond that. So what does the future hold for Obamacare and the healthcare fight?

Joining me are two guests. Dr. Bill Bronston is a member of Physicians for a National Health Program, and Dean Baker is co-director of the Center for Economic and Policy Research. Welcome to you both. Dean, I’ll start with you. Talk to us about where we’re at right now with this Republican effort to repeal Obamacare.

DEAN BAKER: They did accomplish a big step in this effort in getting the discussion going. They brought in Senator McCain who, as you know, is suffering from serious brain cancer. Not a good story for him. In any case, he came to Washington, cast the deciding vote, so they’re starting that now. The question is, can they get anything approved?

It seems their strategy at the end of the day just get something voted out from the Senate. Then, they’ll go to a conference committee, and then they’ll say, “Here it is,” and basically do everything they can to lean on both the members of the House because they have to get re-approved there and then get their 50 votes in the Senate with Pence casting the deciding vote. Whether they can do that or not, who knows? But they obviously think they have a shot or they wouldn’t be doing this.

AARON MATE: President Trump’s suggestion that he just wants to just let Obamacare fail, do you think he’s being serious there? And if he is, could that include not making these critical payments to insurance companies that cover the subsidies for Obamacare recipients?

DEAN BAKER: He could well be serious. We should just be really clear, he’s killing it. It’s kind of like if I have someone in my house, I lock them in a room, and I give them no food or water, and I go, “Well, I’m just going let them die.” No, I killed that person. That’s what we’re talking about here.

So part of the Affordable Care Act is the subsidies for the insurance companies to provide lower-cost care to moderate income people. Part of the story is having the mandates. He’s talking about not enforcing the mandates so people won’t buy insurance if they don’t feel like it. They’ll wait until they’re sick. That’s a great way to destroy the market. And of course, he’ll do nothing to promote that. As I understand, if you call healthcare.gov they tell you about how bad Obamacare is. In other words, you don’t get information about the system.

So they can kill it, and he may well try to do that. But we should just be clear, that’s Donald Trump killing the Affordable Care Act.

AARON MATE: Dr. Bill Bronston, you’re with Physicians for a National Health Program, and as the name suggests, you want to go beyond saving the Affordable Care Act and actually instituting single-payer. Your sense right now of where things are at.

W. BRONSTON: We’re facing, without question, the greatest assault on behalf of the 1% against the 99% concedable in our society. Healthcare is America is not for sale. All that’s for sale is our hostage and ransom relationship to the medical delivery system, which is all privately provided in a large percentage.

So the question that we really have to deal with is whether or not the people of America will understand that unless we have a universal, rightful healthcare delivery system that is essentially aimed at providing a single-payer care that excludes nobody, that is based on prevention and early intervention and includes dental care, visual care, rehab services, long-term care, and that covers issues of workers’ comp and health benefits all in one package, that we will have continued profound suffering and a profound discombobulation of our society. The 1% is being spoken for by Trump and his minions.

All that will fail in Obamacare is the loss of insurance companies who were jacking up the general public and the government in order to increase the money that they would be getting. We don’t need the insurance industry, and single-payer would outlaw the entire private insurance industry completely from the marketplace, leaving a private delivery system in place in America but a public payer that would provide us with the most profound transformation, a paradigm shift in social policy and in the lives of Americans imaginable.

AARON MATE: Dr. Bronston, where do you stand then on what Republicans are currently doing? Do you think it’s acceptable to let Obamacare fail as Trump wants to do?

W. BRONSTON: They’re criminal, and the issue is whatever happens at the federal level, the state of California, as you know, has generated through its Democratic leadership Senate Bill 562, which is to establish the most advanced single-payer system so far that we have seen. It is a brilliant, simple piece of legislation that essentially takes advantage of the fact that every single dollar needed in delivering medical care is already in the pot. We have to raise not a single new dollar.

What has to happen, and what is proposed in this particular piece of radical legislation coming from the center Democrats is two small taxes that would completely replace all insurance premiums, all deductibles, all copays, all fees. People would get a health card. They would essentially pay their state and federal taxes as they do now. There would be two small taxes that would be added: one for gross receipts for business, one for families that are very low level with some subsidies involved. And there would be no more out-of-pocket expenditures whatsoever for the people of California including all residents of California.

That means total comprehensive coverage for everybody for approximately 20 to 30 billion less than we currently pay and we still don’t cover close to 20% of the population either a result of no insurance or underinsurance. It’s criminal.

AARON MATE: Dr. Bronston, you talked about what’s happening right now in California with the efforts to establish a state universal healthcare system there. I’ve always wondered, though, with these efforts, are they sustainable in the absence of a federal national program? Can a state, whether it’s California that’s trying it now or Vermont that’s tried it before, can a state sustain a single-payer program on its own?

W. BRONSTON: The question is, can democracy prevail in a totalitarian, corporate culture with Citizens United and that kind of corruption? The question that you’re asking has to do with the future of America. It isn’t the issue of a finite healthcare delivery system. It has to do with all of us. The question is whether or not we can, through democratic mobilization of the public in America, defend and advance something which is a matter of life and death for us.

The opposition has limitless money, and they understand what the issue is. This is not about dollars. If this was about dollars for the 1%, we’d have had single-payer 50 years ago. It is not in the interest of the corporate community to have the kind of cost level in it from its own corporate brethren that are essentially the middle men.

AARON MATE: Dr. Bronston, Dr. Bronston, I understand your structural critique, but I’m asking you, at the state level, is a plan like this sustainable? Is it feasible? Even if it’s laudable, is it sustainable?

W. BRONSTON: The answer is yes. The answer is absolutely yes because it’s a political question. It’s a question that has to do with working through negotiations, through elections, through representation, through legislation. The solution to this problem, it’s not like throwing a switch. We have a major challenge because for 100 years, we’ve had a system that has been totally drawing blood from the American public.

AARON MATE: Okay.

W. BRONSTON: And the question of changing it over is the challenge of the day. It’s not magic, and it’s going to require awareness, it’s going to require organization, but I tell you absolutely that it is feasible and it must be done if we are to survive as a nation.

AARON MATE: Okay, Dean Baker, your thoughts on this, this approach of pursuing single-payer at the state level as at the national level things are in such chaos.

DEAN BAKER: It’s very hard to see how a state could do it by itself. It could be conceivable if you had a friendly administration in Washington. Of course, you don’t. So they’re counting on two big pots of funds, the Medicare and Medicaid pots, going to this single-payer system, which I feel comfortable that Donald Trump will be not turning those over.

But even apart from that, once push gets to shove, there’s a lot of issues that are not resolved. For example, a lot of people like their health insurance. That’s fine if you don’t, but they do. So you have to tell those people that they could keep their own doctors. In many cases, that won’t be true because they’ll stay outside the system. So when you actually try to get down to the reality, how does this look, I don’t see that happening.

I would like to see other steps, intermediate steps. We spend 200,000 a year on new cancer drugs that would cost $200 in a free market. How about an alternative mechanism for financing drug research? Same with medical equipment. Our doctors get paid twice as much as doctors in Germany and Canada. They have no reason to think they’re any better than the doctors in Germany and Canada.

So there’s lots of things we have to do to get our healthcare costs down, and these steps, they could be done with a single-payer system, but I think they could also be done apart for it, and I think they open the door for a single-payer system down the road.

AARON MATE: Dean, do you support Dr. Bronston’s ultimate goal, which is single-payer?

DEAN BAKER: Yeah, but again, I think you have to figure out how you can do that piecemeal because the idea that we’re going to do that all at once, I literally cannot imagine how that would happen. We have-

AARON MATE: So what do you think is the best approach?

DEAN BAKER: I think getting the cost down in the way that I was talking about and trying to do things like having a Medicare buy-in or Medicaid, figure out which is better or we have to alter both programs. And doing things like, can we lower the age of Medicare eligibility? Currently, it’s 65. Can we make it 60, and then somewhere down the road lower it further? That would be, I think, the way to get from here to there. I just don’t see us doing this in one big step.

AARON MATE: Okay. My question hearing that is, does preserving Obamacare further that goal if it’s true that Obamacare, especially through its massive subsidies to insurance companies helping them stay in business in some ways, keeps the current system going? Dr. Bronston, your thoughts on that.

W. BRONSTON: Mr. Baker is dead wrong, and we represent a 180 degrees opposite position. If you look around the world, we are the only advanced society that is in the dilemma that we’re in. Every other country in the world … Canada began with Saskatchewan, a single province. The doctors struck, and it was a major political struggle in order to move the Canadian system into a national healthcare system. If California goes single-payer, and California will go single-payer, sooner or later the nation will change, and we will add our efforts to the world in order to humanize and to normalize and to democratize our society.

The business of incrementalism is the argument of the opposition. It’s the argument of the 1%. It sows doubt, it sows uncertainty, it sows fear, and it essentially breaks the heart of the general public that has to understand that it is only through political action, unity, political activism that we can bring this to bear. The situation is extremely clear. You cannot jump a chasm in two jumps. It is everybody in, nobody out, and now is the time that we must make this happen, and we are going to make this happen in California.

AARON MATE: Okay. Before I go to Dean for his response, Dr. Bronston, I want to ask you, how do you address those who say, “Look, sure, I might support single-payer, but it’s tough. And right now, in this country, healthcare is responsible for something like one-sixth of the economy.”

W. BRONSTON: Correct. The question of how you talk to people is precisely by offering them a comprehensive solution that has been in the works forever. If single-payer were a financial issue confronting the establishment, we would’ve had single-payer 50 years ago. It is not in the interest of the capitalist class monetarily in terms of maintaining the system.

So the question then is, why? Why does the 1% persist when it is not in their economic interest to have this program? And my contention, our belief, our understanding is that there is a higher political benefit of keeping a society frightened, divided, and insecure to make sure that they are consumer-oriented and to have a sense of hopelessness and quietism in the population.

This is a major challenge for us, and California has put together a very simple piece of legislation that for Baker to say is not feasible, is not feasible at a nationwide level because it’s coming from one state is absolutely ridiculous and unfounded in terms of any data that we have nationwide, and we have the best data in the country at PNHP.

AARON MATE: Okay. Dean Baker.

DEAN BAKER: I just gave you the data. You aren’t going to get the Medicare, and you aren’t going to get the Medicaid money. The numbers don’t add up then. So I just gave you the data.

W. BRONSTON: [crosstalk 00:14:52]

DEAN BAKER: No, let me finish, buddy. Let me finish, okay? You got a problem with that?

AARON MATE: Let’s let Dean finish. Let’s let Dean finish. Yeah. Let’s let Dean finish.

DEAN BAKER: Okay.

W. BRONSTON: [crosstalk 00:14:57]

DEAN BAKER: [crosstalk 00:14:59] finish.

AARON MATE: Let’s let Dean finish. Let’s let Dean finish.

DEAN BAKER: [crosstalk 00:15:00] talking. Is that your democracy, buddy? Okay. You don’t have the money. Yes, we need to keep people alive. It’s not good political strategy to let them die and tell them to wait for the apocalypse.

I’ve been around long enough, I remember the Clinton plan going down in flames in ’93, ’94. We didn’t see a single-payer revolution in the wake of that. We saw nothing. I remember having a conversation with Paul Wellstone, certainly the most left wing person in the Senate at the time. I asked him about healthcare. He goes, “You can’t talk about it. You get killed.” That was six years after the failure of the Clinton healthcare plan. He didn’t even want to talk about it. So the idea that somehow, if Obamacare goes down, we’re going to open the door and single-payer’s just going to sail through, I stopped taking drugs many, many years ago.

W. BRONSTON: I’m not proposing that statement. That’s your statement. I’m saying to you that single-payer is the only way that this nation can economically survive with a healthcare delivery system that’s too expensive. It’s killing our businesses, it’s undermining entrepreneurism, it’s killing the people, and we don’t have an adequate amount of coverage for a giant portion of the population.

Obamacare may or may not survive, I don’t know. But the very clear talk from more and more Democrats is that single-payer is the most economical, the most humane, the most progressive, and the most necessary reform that has to happen in the United States today.

AARON MATE: Okay, Dr. Bronston, let me ask you, even if one shares in your long-term goal, what about the immediate issue of Obamacare? The fact is, it’s the system we have right now, and it has expanded coverage to millions of people. Where do you stand on the issue of whether or not it should be protected?

W. BRONSTON: Certainly, the absolute commitment to expanded Medicaid in the Obamacare system and the other benefits of making sure that people are not thrown off insurance from pre-existing conditions and extending the eligibility for children to older age and covering Planned Parenthood, and the whole range of specifics that are inside Obamacare are very constructive.

However, the system is set up on a corrupt foundation of relying upon the private insurance industry when fully 70% of all the money in American medicine today comes from public tax dollars, today. The situation is insupportable, and it may or may not survive, but this is an issue that has to come back to the American people and to the lead organizers.

Whether Wellstone was supportive of single-payer in the old days, I don’t fully know. I don’t know where the people in our legislature are, but one thing for sure is the most fundamental reform that has to take place is that the people have to challenge our elected officials because our elected officials may not represent the interests of the majority of the country.

Single-payer is the test. It is the absolute litmus test for whether or not we’re going to have a democracy or whether we’re going to have a totalitarian state. The ravings from the Trump administration and the kind of criminality that Price represents as the Secretary of Health & Human Services is a cardinal, flagrant example of the terrible situation that we’re in. We have to fight back. Fight back, and California is doing that.

AARON MATE: We have to wrap, so let me ask you, Dr. Bronston, as someone who has been an advocate for single-payer, we’ve seen this explosion of activism with the Republican effort to repeal Obamacare, and I’m wondering if, as someone who’s involved heavily in this issue, you’ve seen a surge of interest and enthusiasm for single-payer at the grassroots activist level in recent months?

W. BRONSTON: It’s enormous. It’s the single most powerful mobilizing policy that we’ve ever had in California. When we ran the single-payer proposition in 1994 here in California, we had the largest number of volunteers, the largest number of activists. Now, we lost that proposition three to one, but we were outspent fifteen to one, and it was very, very difficult for the people to understand when they’re told socialism, gray death panels, loss of doctors. I mean the stuff that Dean is talking about about losing doctors, that’s crazy. That’s not what’s going to happen. People will have free choice of any physician that they will go to, and the physicians, and the physicians will have no intervention in terms of their recommendations.

In addition to that, we’re going to need some tremendous, tremendous changes in the country. We have to mobilize and train thousands and thousands of new primary care doctors. We have to deal with the fact that three out of every five people working in doctors’ offices today are essentially pushing paper to make claims happen, and the same on the insurance industry side where they’re pushing efforts to block those claims. All those people are going to be unnecessary and are going to have to be completely funded and retrained into providing healthcare. The healthcare movement in this country is going to explode, and the California population, if the bill is progressive and clear and non-incremental, mobilizes the largest number of the electorate ever in the state of California.

AARON MATE: Okay. Dean Baker, as we wrap, I want to ask you about how Obamacare is doing right now as Republicans attempt to repeal it. I think Trump makes a point when he talks about premiums rising for a large segment of people, but what often gets left out, I think, is that many Republican states chose not to take the Medicaid expansion, which could’ve covered so many more people.

DEAN BAKER: There’s a few points here. First off, the premiums were much lower when the exchanges originally started than what has been projected. So if you go back and look at what the Congressional Budget Office projects were back in 2012 for where premiums would be today, they’re pretty much right on target, so that’s pretty much in line.

In terms of, Trump’s made a big point about how a number of counties only have one insurer in the exchanges, that’s almost entirely a red state story. In other words, where you have Democratic governors that have tried to make this system work, it does work. If you live in a state with a Democratic governor, less than 2% of those people have only one insurer in the exchange.

One really good measure that I like a lot, people voting with their feet. There has been a huge increase in voluntary part-time employment. Over 2 million people are working part-time, again, voluntarily. They’re making that choice, and these are overwhelmingly parents of young children. These are people who, because of Obamacare, they don’t need employer-provided insurance. They’re able to get it either through Medicaid or through the exchanges. So those are all really good stories.

Again, if Trump doesn’t kill it, I think the program will survive. Again, we’ve got to talk about making it better, covering more people, and reducing the costs, which are too high. But that’s, again, we have to first save it and then move forward.

AARON MATE: I saw Dr. Bill Bronston nod his head to at least a part of what Dean Baker was saying there, so I’m thrilled to end this segment on that point of concord. I want to thank my guests Dr. Bill Bronston, member of Physicians for a National Health Program, and Dean Baker, co-director of the Center for Economic and Policy Research. Thanks to you both.

W. BRONSTON: Thank you.

DEAN BAKER: Thanks for having me on.

AARON MATE: And thank you for joining us on The Real News.