By Lambert Strether of Corrente.

Here’s a quick review of Monday’s health care debate on CNN, which was so one-sided as to be dull. (During the debate, Yglesias tweeted: “The problem with Lindsey Graham debating health policy on national television is he doesn’t know anything about it.”) One-sided in favor of Sanders, I mean. I put Sanders on one side, and Graham, Cassidy, and Klobuchar on the other, not merely because he is an independent, and they are not, but because they put markets first, albeit in different ways, and Sanders puts people first (and mostly working class people, since there are more of them, and all would benefit from a universal program like Medicare for All.

Here’s the transcript. From the many rich exchanges, I’ll select and briefly annotate three topic areas, each of which illustrate wily veteran Sanders and his debating skills (in one case, simply evading an important issue).

1) Democratic Splits on Medicare for All (or, watch Sanders steal the liberal Democrats’ clothes)

2) Everybody Hates the Insurance Companies (or, watch Sanders turn an admission to his own advantage)

3) “States’ Rights” Is Lousy Health Care Policy (or, watch Sanders let Graham hang himself)

(1) Democratic Splits on Medicare for All

Here’s Sanders on the relation between the (now-defeated) Graham-Cassidy bill, ObamaCare (the ACA), and Medicare for All (S1804). He makes the same argument three times in different ways, and I’m quoting at length so you can see how he does it (and maybe deploy your own talking points).

SANDERS: We are looking at legislation supported by the majority[1] party which is opposed by every major health care organization in the country…. So our job right now short term is to defeat this proposal, and with a little bit of luck, that’s what we’ll do. But that is not good enough. Our job now is to come together to craft serious short-term solutions that addresses the real problems that exist, high deductibles, high copayments, high premiums, high cost of prescription drugs. But longer term [2], we have got to come together and finally conclude that as a nation we cannot be the only nation, major nation on Earth not to see health care as a right.

Version two:

SANDERS: [O]ur job now is to defeat this disastrous proposal, get back to the drawing board, see if we can work together for some short-term fixes. Long term, in my view — I speak only for myself — this country has got to join the rest of the industrialized world, guarantee health care as a right of all people.[3]

Version three:

[SANDERS:] I don’t think Medicare for all is an extreme idea. Every other major country on Earth guarantees health care to all people as a right. We end up spending, because of the dysfunctional and complicated system that we have right now designed to make insurance company profits, we spend twice as much per capita as any other country on Earth… So to do it, every other major country on Earth is doing it. I live 50 miles away from Canada. I don’t think that that is a radical idea.[4] But clearly, Medicare for all is not going to pass so long as my Republican colleagues control the Senate and the House. So what do we do?[5] How do we work together? Well, here’s one idea. One idea is to take on the pharmaceutical industry. You’ll remember that Trump talked a whole lot during his campaign about how the pharmaceutical industry was ripping us off. He was right.[6] Let us work together. Let us have Medicare negotiate prescription drug prices. Let us have re-importation so that pharmacists and distributors can purchase lower cost medicine abroad.[7]

Now contrast Klobuchar’s incremental, Clintonian approach (Klobuchar, note well, is not a sponsor of S1804).

KLOBUCHAR: And I think every mom and dad should be able to take care of their kids that way and be able to have insurance. I believe politics is about making people’s lives better. But this bill, it doesn’t do that. It kicks millions of people off insurance. It raises the premiums. It basically passes the buck to the states, but doesn’t give them the bucks to cover people. So that’s why[8] I think we need to work together on the plans that are already underway to fix the Affordable Care Act and put the politics aside and focus on people first.

And:

KLOBUCHAR: What could we do immediately?[9] And that is the work that’s being led by Republican Senator Alexander, Democratic Senator Patty Murray to come together to say, look what they did just now in Minnesota. Republican legislature, my state, Democratic governor came together[10] and said let’s do something called reinsurance, which makes it so the most expensive person in a pool who’s had some major catastrophic health event, they get siphoned off and paid for by the government so that everyone else’s rates don’t go up. This is the kind of proposal they’re working on for the nation, along with other ways to help with co-pays and to allow states[11] to design some of their own insurance without — without — making the drastic cuts that we see in the bill that my colleagues have proposed.

And:

KLOBUCHAR: [Y]ou can have things available to you like treatment, right, but if it’s too expensive, is it really available to you? And if you see a Ferrari in a car lot, well, it’s available to you, but you can’t really buy it. And that is the problem if the prices skyrocket. So it’s doing something immediately to stabilize these prices, but then in the long term making sure we can make health care more affordable. Bernie has one idea; I have some others. And we can talk about them later .[12]

NOTES to Section (1)

[1] Wretched framing. You’re not on the Senate floor now, Bernie!

[2] For Sanders, the strategic (“longer term”) goal is health care as a right (operationalized as Medicare for All. Short-term solutions function at the tactical level, in service of the long-term goal. Sanders, in other words, insists — and given the generally positive reaction to his performance in this debate, and on the post-election trail, proves — that it’s possible to walk and chew gum at the same time. The Democrat establishment, by contrasts, insists that it cannot. The chewing gum part (#SaveTheACA) comes before the walking part (#MedicareForAll). But what if they never stop chewing their gum?

[3] Same tune with different lyrics: “industrialized world” vs. “major nations”, “see” vs. “guarantee”, “right” vs. “right of all people.” (Personally, I’m suspicious of rights-based framing, simply because we have a Bill of Rights, which suggests it would take a Constitutional Amendment to pass Medicare for All. Surely the universal concrete material benefit is enough?

[4] Same tune, different lyrics, with an overture making the case that it’s our system that’s the extreme, the outlier (though I think it would have made sense to mention that Canada not only has half the costs, it has equal or better health outcomes; superior longevity, for example, where in some areas of the United States longevity is actually decreasing.

[5] Sanders again brings strategic thinking forward: long term vs. short term. This is an effective debating tactic, since Sanders frame any incremental fix as a tactical maneuver within his larger strategy. (Clinton’s vicious memoir characterizies this as the “six minute abs” approach. Clearly, it annoyed her, probably because the tactic takes her incremental proposals and reframes them as mere steps toward a larger goal she does not accept. In other words, Sanders is “stealing her clothes,” as the old political saying goes; taking his opponents talking points and adapting them to his own purposes, leaving them defenseless. (This is the “gone swimming, clothes stolen” trope (although the site doesn’t list a political usage, oddly.)

[6] Ouch!

[7] Medicare negotiating drug prices is, of course, a proof of concept for cost savings under Medicare for All. On drug reimportation, Graham actually says: “[L]et me think about that. John McCain says it’s a good idea.”

[8] “That’s why” (we need to make incremental changes to ObamaCare). No, it isn’t1 Klobuchar doesn’t give a reason! There is no why (although she does get in a subtle dig against Sanders, implying that he’s not putting people first.

[9] Unlike Sanders, Klobuchar never goes beyond “immediately” to anything other than the health care system we have, incrementally improved. In other words, there really is a split within the Democrat Party, as shown clearly by the Senators who signed up for S1804, and those who (like Klobuchar) did not. Since Medicare for All is popular with the Democrat base and independents, it’s a wedge issue, and what Sanders needs to do is make it as easy as possible for Senators to come over from the dark side. (Hence complexities in S1804 like a lengthy phase-in, a public option, starting out by lowering eligibility, insuring children immediately, and so on.)

[10] I don’t make a fetish of bipartisanship. The AUMF was bipartisan. The USA PATRIOT Act was bipartisan. The Grand Bargain is bipartisan by definition.

[11] Klobuchar is closer to Graham and Cassidy’s “states’ rights” position than she is to Sanders (and the co-sponsors of S1804).

[12] “We can talk about them later.” This is why we can’t have nice things.

(2) Everybody Hates the Insurance Companies

I’ve helpfully underlined Graham’s admission immediately below. Now watch what Sanders does with it>\:

GRAHAM: The biggest winner under Obamacare is insurance companies, not patients . And I intend to change that. SANDERS: Whoa, whoa, whoa. (APPLAUSE)[13] I like that. GRAHAM: All right, good…. SANDERS: See, Lindsey, there it is. You actually said something that was right. I knew it would happen.[14] GRAHAM: I was due, Bernie. SANDERS: What he pointed out — I’m extrapolating a little bit, Lindsey — but what he pointed out is, why do we have — why do we end up spending twice as much per capita on health care as any other country? And Lindsey is right. This system is designed to make billions of dollars in profits for the insurance industry. We spend 12 percent to 18 percent to administer the incredibly complex hundreds of plans that we currently have[15]. And with these guys, if they got their way, there would even be more plans, more bureaucracy, more complexity, more money going to the insurance companies. Medicare, the administration of Medicare costs approximately 2 percent . So if we are serious about moving to a cost-effective universal health care, yeah, we do have to take on the insurance companies. They do not play a role in providing health care. Our money should be going to doctors, to nurses, to hospitals, not to the insurance industry or, in fact, the drug industry, which is charging us by far the highest prices in the world. BASH: Senator Graham, you were shaking your head. Is the bromance[16] over already? GRAHAM: Oh, no, no. No, Bernie is the most honest person in the Senate because he believes in government running health care from cradle to grave[17]. All I would say is that Medicare is coming unraveled. By 2038, the trust fund is going to run out of money[18].

NOTES to Section (2)

[13] The rumpled and uncharismatic Sanders does very well with crowds.

[14] Impressive improvisation from Sanders.

[15] Sanders, unlike the others, uses data well. Some would, however, choose to say that profit as such is the problem, and not only administrative costs. But Sanders doesn’t go there.

[16] Personal note: I loathe that portmanteau word.

[17] A very dishonest description of single payer, which is just that: Single payer. Globally, single payer is the centrist position, with Britain’s cost- and medically effective National Health Service, where doctors are government employees, being much more like the Graham’s bugaboo.

[18] This is the important issue Sanders evades, and which Graham continually harps on. Funding. Of course, Canada and all the other major industrialized countries in the world manage to fund their universal programs, so it would seem strange indeed that the world’s richest country can’t fund it’s own, but let that pass. Since the Federal government is the currency issuer, it can no more “run out of money” than a bowling alley can run out of points, but since Sanders has not embraced MMT, he can’t say that. And since Sanders has not — I think wisely, from a tactical perspective — settled on a funding mechanism for S1804, preferring to issue a white paper with several options, he can’t say how he’ll “pay for” his program either (although his data strongly hints that when you consider the country as a whole system, of which government spending is one part, his program pays for itself).

(3) “States’ Rights” Is Lousy Health Care Policy

I suppose it would be possible to call Graham’s thinking Federalist, but I’d rather go on the offensive and label it “states’ rights.” Structurally, they’e the same. Sanders lets Graham hang himself on this one:

[GRAHAM:] So let’s talk about our idea to fix it. Our idea is to take basically the same amount of money we would spend on Obamacare, give it to a bureaucrat you’ll never meet or know or could care less about you, and block grant it back to the states in a fashion to give it to people closer[19] to where your daughter lives, and you can have a say about what they do for your family and there are guardrails. You can’t build football stadiums with it. You can’t build roads and bridges. You’ve got to spend it on health care. This worked in welfare reform in 1996[20] when 74 United States senators said let’s take welfare and block grant it back to the states and see if they can do a better job. Since 1996, we haven’t had one penny increase because they did a better job. … The one thing I do know, that Obamacare is going to fail and Bernie’s solution is more government, not less. I don’t see how in the world that Medicare is going to survive[21] for the next generation unless we reform it now. … BASH: Senator Sanders, would you like to respond? Senator Sanders, he invoked Senator Sanders. Senator Sanders, would you like to respond, since Senator Graham mentioned your name? SANDERS: I will just — first of all, when you ask the American people about whether or not they like Obamacare compared to your plan, overwhelmingly the American people like the Affordable Care Act.[22] GRAHAM: How many people know who Graham-Cassidy are? SANDERS: Second of all, one second. One second. Second of all, it is easy to beat up on big, bad federal government. Guys, do you know what the most popular health insurance program in America is? It’s not the private insurance industry. It is… GRAHAM: Medicare. SANDERS: Medicare, yeah! (APPLAUSE) GRAHAM: Which is falling apart. SANDERS: Senator Cassidy and I are both on the Veterans Committee. Go out and talk to veterans. And what the polls show is that veterans are very, very positive toward the V.A. Does it have problems? God knows it does. But veterans feel very good about it. It, in fact, is the second most popular health care program in the country. OK? So the point is it’s easy to say Obamacare isn’t perfect. Everybody knows that. But the truth is that what people in this country see is a health insurance system designed to make insurance companies and drug companies huge profits. They want a cost-effective system that, in fact, deals with the needs of our people and not just the CEOs of large corporations. And that is why I personally believe that if Medicare is working well for seniors right now, we can make it work for every man, woman, and child in this country through a Medicare for all program . (APPLAUSE)

NOTES to Section (3)

[19] The states being “closer” to the people is a standard “states’ rights” trope. Note that above, Klobuchar agrees with it. Of course, 50 payers have a lot less clout with vendors than a single payer does, so that closeness has a very real price.

[20] Ouch. Thank you, Bill Clinton!

[21] Graham again hammers on funding, and Sanders evades.

[22] Sanders is not directly responsive; he gives no reason why Graham is wrong in principle; he might at least ask Graham if the block grants will be counter-cyclical, so states don’t have to cut health care funding in hard times. Instead, Sanders points to programs that are Federal, and not state, that are — the standard adjective is “wildly” — popular: Medicare, and the Veterans Care.

[23] And the wrap-up. Throughout, Sanders is hammering on what works: Canada (single payer); and Medicare (single payer for 65 and over). The Federalist approach of Graham-Cassidy does not have that virtue; it’s not tested. The incrementalist (and Federalist-lite) proposals from Klobuchar might work, but they clearly don’t deliver universal concrete material benefits, and it’s not clear how much they really fix.

Conclusion

I find it fascinating that Graham-Cassidy actually propose a principled program, even if they happen to be the wrong principles. States may be different in their health care needs — think Flint and lead — but that doesn’t mean they need to be different in their standards of care, or in their back office (“single payer“) functions. Klobuchar, by contrast, seems unable to explain why her incremental approach is correct; she simply takes “never, ever” single payer as a given, and makes Graham-Cassidy’s Federalism bipartisan. Sanders, by contrast, is effective on a number of levels: Facts and figures, stealing his opponents clothes, evading attacks when overt defense wouldn’t further his case, and making an overarching strategy visible. Sanders has the strengths that many years of advocay can bring. Readers, you know my priors, but wow.