How The Democratic Position On Health Care Has Moved To The Left

NPR's Ari Shapiro speaks with Dr. Zeke Emanuel, an architect of the Affordable Care Act about the "Medicare for All" issue in the Democratic presidential debates.

ARI SHAPIRO, HOST:

Over the last two nights in Detroit, the biggest debate among Democrats had to do with health care. Some of the presidential candidates want to completely get rid of private insurance companies. Senator Elizabeth Warren of Massachusetts is in that camp.

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ELIZABETH WARREN: The basic profit model of an insurance company is taking as much money as you can in premiums and pay out as little as possible in health care coverage.

SHAPIRO: Other candidates, like former Vice President Joe Biden, want Americans to be able to choose their health care coverage.

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JOE BIDEN: No one has to keep their private insurance, but they - if they would like their insurance, they should be able to keep it.

SHAPIRO: Dr. Zeke Emanuel has heard all this before. He was part of the team that drafted the Affordable Care Act during the Obama administration. And he's here in the studio. Hey there.

ZEKE EMANUEL: Nice to be with you, Ari.

SHAPIRO: Let's start with terminology because the phrase "Medicare for All" is being used to describe a lot of different things. In its purest sense, what does true "Medicare for All" actually mean?

EMANUEL: Well, it is - that's the Bernie Sanders' sense, and that is, we get rid of private insurance. Everyone is in Medicare fee-for-service. And in Medicare fee-for-service, you get to choose your doctor. The government pays the doctor or the hospital, so there's no co-pays, no deductibles; vision, hearing aids and other things that aren't in traditional Medicare packages are covered.

SHAPIRO: Which other Democrats besides Bernie Sanders are on that end of the health care spectrum?

EMANUEL: Well, it appears that Elizabeth Warren is.

SHAPIRO: Right.

EMANUEL: Although, not necessarily all the time.

SHAPIRO: And those are really the only two. Everyone else is sort of on a scale somewhere in between those.

EMANUEL: Right, right. I might say on a scale somewhere in between, that has more government intervention than Barack Obama had in the Affordable Care Act.

SHAPIRO: Yeah.

WARREN: Everyone is further towards more - government taking more responsibility.

SHAPIRO: And I do want to ask you about why the Obama administration went the course that it did. But first, just to understand the facts, right now, when you look at American health coverage, what percentage of Americans get health coverage on the private market as opposed to some form of government-provided health care?

EMANUEL: So you have about 150 to -60 million people have employer-sponsored insurance, and then about another 15 million people have individual coverage or through the exchanges, and that gets you to something like 55 to 60% of the population has private insurance. And then you have another - call it 130 million people who have Medicaid or Medicare coverage. So that's the breakdown. And we have roughly 89, 90% of Americans have health insurance.

SHAPIRO: So when you were working on the law that became known as Obamacare, there was no discussion of totally eliminating private coverage, but there was discussion of giving everybody the option of getting on Medicare, as is known as the public option. Why didn't the Obama administration ultimately go that route?

EMANUEL: Politically impossible. The charge against it was led by Joe Lieberman, a senator from Connecticut, where a lot of health insurance companies were based.

SHAPIRO: He was an independent who caucused with the Democrats.

EMANUEL: Correct. But he wasn't the only one who was opposed to that. There were other Democrats who didn't take the lead the way Senator Lieberman did, and they were opposed. And it became clear we couldn't get that provision enacted and passed the bill. And that, I might remind the audience...

SHAPIRO: (Laughter).

EMANUEL: ...Was with 60 senators in the Senate and...

SHAPIRO: Sixty Democrats - excuse me.

EMANUEL: Sixty Democrats in the Senate, right, and an overwhelming number in the House. There are people who have other views, and they listen to their constituents. And many constituents, whether union members or people with employers who give them good benefits or, I just don't want to think about it, and I'd rather let my employer deal with it, those people actually like their system, even if they have complaints about the insurance companies now and then.

SHAPIRO: So as you point out, this debate about political viability a decade ago is happening with 60 Democrats in the Senate. Right now Democrats don't even control the Senate. We don't know what the situation will be in 2020. But what do you think the political calculus is in this moment? I mean, do you think that a public option has become more politically viable in the last decade?

EMANUEL: Absolutely. I think it is...

SHAPIRO: Even without a supermajority in Congress?

EMANUEL: I think both Republican and Democratic voters recognize that they want to have security, and a public option does communicate that security to them. It will always be there, and the government will stand behind it. And I do think that tells you - we learn from experience. If the marketplace isn't working, let's try something else. And I think that has to be the motivating factor behind any Democratic bill. We're aiming for universal coverage, and as we learn, we've got to revise and reform the system based upon how it's performing, not based upon some ideological commitment.

SHAPIRO: So how much is the debate that we're seeing this week among Democrats just about the difference between what it takes to win a Democratic primary and what it takes to actually get legislation through Congress?

EMANUEL: I think most of what we're hearing is about trying to differentiate your candidacy on health care from other candidates running. I might also say, one of the things that's been bothering me about the quality of the debate we have is it really is focused on coverage, and I think a much bigger element is affordability. We haven't had so much talk about the affordability argument, and that really has gotten a very small amount of the debate, and it needs a lot more of that debate.

SHAPIRO: Dr. Zeke Emanuel, one of the architects of the Affordable Care Act, Obamacare, and is now at the University of Pennsylvania. Thanks for coming in today.

EMANUEL: Thank you, Ari. It's been a pleasure.

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