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.