michael barbaro

From The New York Times, I’m Michael Barbaro. This is “The Daily.” Today:

archived recording 1

I think “Medicare for all” is the right solution.

archived recording 2

I support “Medicare for all.”

archived recording 3

Oh, I believe that we need Medicare for all.

archived recording 4

We need to make sure that every American is able to get health care.

archived recording 5

We need to have “Medicare for all.”

archived recording 6

I believe we should have “Medicare for all.”

archived recording 7

This country will pass a “Medicare for all” single-payer health care system. [CROWD CHEERING]

michael barbaro

“Medicare for all.” It’s Wednesday, March 13. Margot, the 2020 Democratic primary, which is now officially underway, is very much starting to feel like the “Medicare for all” primary. Where does this idea, “Medicare for all,” come from?

margot sanger-katz

Well, I think it actually makes sense to go all the way back and think about the origin of Medicare. [MUSIC] This is actually an idea that has been kicking around in progressive politics for a very long time. It had a brief moment in the Progressive Era in 1910.

michael barbaro

Margot Sanger-Katz covers health care policy for The Times.

margot sanger-katz

Then, I think the next serious moment was actually in the New Deal.

archived recording (franklin d. roosevelt)

Two months ago, as you know, we were facing serious problems. The country was dying by inches.

margot sanger-katz

And if you think about what the F.D.R. administration was trying to do, they were trying to build a sort of basic public social safety net for people, to protect them and prevent them from falling through the cracks.

archived recording (franklin d. roosevelt)

First, we are giving the opportunity of employment to a quarter of a million of the unemployed.

margot sanger-katz

And health care was something that they considered including in the package of reforms at that time when they made social security and a lot of these other programs, but it was too controversial, and it actually dropped out of that proposal.

michael barbaro

And why would it be controversial in the New Deal period, when it seems like the idea of government taking care of people is very much in vogue?

margot sanger-katz

I think the main reason why health care at that time was so controversial is because doctors were really against it. Doctors were these small business owners, people paid them directly for medical care, and they really didn’t want the government getting involved in their business and, perhaps, making it harder for them to make a living.

archived recording (harry truman)

We are rightly proud of the high standards of medical care we know how to provide in the United States.

margot sanger-katz

So the next American president to really make a go at this was Harry Truman —

archived recording (harry truman)

The fact is, however, that most of our people cannot afford to pay for the care they need.

margot sanger-katz

— who wanted to create a universal health care program.

archived recording (harry truman)

Our ultimate aim must be a comprehensive insurance system to protect all our people equally against insecurity and ill health.

margot sanger-katz

And again, he really was stopped.

archived recording (john f. kennedy)

I believe the epic in which we’re engaged is worth the time and effort of all of us.

margot sanger-katz

Then, J.F.K. made a big move to try to expand government health insurance, at least for the elderly.

archived recording (john f. kennedy)

This is a campaign to help people meet their responsibility.

margot sanger-katz

There was a view that while health insurance was starting to become available as a way for working people to protect themselves, that once you got old and you didn’t have a job that came with insurance and you started to get sick — that no one wanted to sell you insurance. And so he proposed this idea of having a health care program that would be financed by payroll taxes like social security, but he couldn’t get it through.

archived recording (lyndon johnson)

No longer will older Americans be denied the healing miracle of modern medicine.

margot sanger-katz

It was only when Lyndon Johnson became president afterwards and after the Democrats took big majorities of Congress —

archived recording (lyndon johnson)

No longer will illness crush and destroy the savings that they have so carefully put away over a lifetime.

margot sanger-katz

— that they were finally able to pass legislation that established the program that we now call Medicare.

archived recording (lyndon johnson)

And no longer will this nation refuse the hand of justice to those who have given a lifetime of service and wisdom and labor to the progress of this progressive country. [MUSIC]

michael barbaro

And what was Medicare at this moment when President Johnson signs it into law?

margot sanger-katz

The idea was that everyone, once they turned age 65, if they had worked and paid payroll taxes, would be able to have government health insurance. They would have access to insurance that would pay for their hospital care and further visits to doctors.

michael barbaro

So it took four presidents to pass a version of government-run health care. And even then, it is afforded to a narrow group of Americans.

margot sanger-katz

That’s right. Around the same time that Congress passed Medicare, they also created a program called Medicaid that served the very poor in America. But essentially, there was a huge group of Americans in the middle who were left out of both programs.

michael barbaro

And why is that, Margot? Why is this idea during this period of nationalized medicine, government-run health care — why is it being limited to such small groups of Americans?

margot sanger-katz

I think the idea has always been pretty politically controversial. There are a couple of different threads of it. One is that industry doesn’t like it. So doctors are the kind of most vocal group in this period. But over time, we also have hospitals, and drug companies, and other parts of the health care industry that are wary of the government getting involved and maybe taking their dollars away from them. I think also, especially in this period, there is a real resistance to socialism and this idea that it’s not American to have the government providing these basic benefits, that the free market should work to do it instead.

michael barbaro

But what about the people who are being covered by government-run health care programs like Medicare? Do they like it? Is it working well for them in this period — the 1960s, the 1970s?

margot sanger-katz

Medicare is a uniquely popular government program. People really love it. It provides them with a lot of financial security. People pay taxes into the program, so they feel like it’s an earned benefit. It’s something that they deserve. But meanwhile, everyone else is in a health insurance program that is getting a little bit more rickety. There are some people who get really great insurance through their work, but there are a lot of other people who are sort of falling through the cracks — if they’re between jobs, if they work for a company that doesn’t provide insurance. The system for people in Medicare is that everyone gets it and they all get the same thing. The system for the rest of us is, it really depends on who you are, and who you work for, and what your financial situation is.

archived recording (ted kennedy)

I’ve been able to receive it for myself and for my family. Just like all of us who are on the tip of the iceberg, way up high in the health care services.

margot sanger-katz

And because of that, there are a bunch of proposals over the years to try to reconsider a more national health care system.

archived recording (ted kennedy)

But I want every delegate at this convention to understand that as long as I’m a vote —

margot sanger-katz

Ted Kennedy has a proposal in 1970.

archived recording (ted kennedy)

— and as long as I have a voice in the United States Senate, it’s going to be for that Democratic platform plank that provides decent quality health care. [CROWD CHEERING] North and south, east and west.

margot sanger-katz

In the 1990s, the Clintons have an idea to try to achieve universal health care. But largely for the same reasons that we had trouble with this before — concerns about socialism, industry opposition — those proposals essentially get batted down.

michael barbaro

And so what happens next?

archived recording (barack obama)

Six months ago today, a big part of the Affordable Care Act kicked in.

margot sanger-katz

So I would say the next big thing that happens in this timeline is that we get the Affordable Care Act in 2010.

archived recording (barack obama)

And millions of Americans finally had the same chance to buy quality, affordable health care, and the peace of mind that comes with it, as everybody else.

margot sanger-katz

There is a brief discussion among Democrats at that time of trying to do a single-payer system, a more universal system, where everyone gets something like Medicare, but that really, even at that time, is very much a fringe view among Democrats. The consensus idea that President Obama and the Democrats in Congress want to do is something that sort of expands on our current system, where you still have a lot of different private insurers. People have a lot of choice.

archived recording (barack obama)

7.1 million Americans have now signed up for private insurance plans through these marketplaces. [CROWD CHEERING]

margot sanger-katz

And on the socialism side, even though this was largely a private market program, it still was susceptible to those kinds of criticisms. And we heard Republicans talking about it as a government takeover, talking about as a socialist plot.

archived recording

This has to be ripped out by its roots. This is government taking over the entire health insurance industry.

margot sanger-katz

But what it tries to do is kind of patch up the holes in the existing system. And one of the ways that it does that is by vastly expanding Medicaid, that program we talked about for poor people. A lot more people get coverage through Medicaid, and then the government helps people who don’t get insurance through work with financial subsidies that allow them to buy their own insurance.

michael barbaro

So with the Affordable Care Act, once again, the concept of government-run health care is proposed and ultimately tossed aside.

margot sanger-katz

Yes and no. I think you have to see the Affordable Care Act as a sort of compromise. As a moderate proposal that expands some government health care, expands some private insurance, keeps a lot of what already exists and doesn’t take things away from people. But I also think that it did change Americans’ expectations about what the role for government was in health care, and also what kind of health care they were entitled to. So, you know, we’re moving closer to the idea that everyone should be able to have health insurance, even if they’re poor, even if they don’t get insurance through work. And there are certain guarantees in the Affordable Care Act, like the guarantee that people who have pre-existing health conditions should be able to buy insurance —

michael barbaro

Right.

margot sanger-katz

— that really didn’t exist before.

michael barbaro

So even though with the Affordable Care Act we didn’t end up with government-run health care, we end up with more government in our health care, which it sounds like is beginning to change people’s perception of what the government’s role should be when it comes to medicine.

margot sanger-katz

Exactly.

archived recording 1

Who are you guys here to see?

archived recording 2

Bernie!

archived recording 1

Who feels the Bern? [CROWD CHEERING] [MUSIC]

margot sanger-katz

And I think this lays the groundwork for Bernie Sanders when he comes forward with a proposal in 2016 that he calls Medicare for all.

archived recording (bernie sanders)

We must fight to make sure that we pass a “Medicare for all” health care system. [CROWD CHEERING]

margot sanger-katz

Medicare for all builds on the idea that everyone should have access to affordable health insurance, but it kind of turbo-charges that idea. “Medicare for all” says everyone gets the same health care.

michael barbaro

Hm.

archived recording (bernie sanders)

I happen to believe — and I know not everybody agrees with me — I believe that health care is a right of all people.

archived recording

Excuse me, where did that right come from, in your mind?

archived recording (bernie sanders)

Being a human being. Being a human being.

margot sanger-katz

Senator Sanders’s idea is that everyone in America would have access to health insurance that’s provided by the government that covers a wide array of medical services, and for which they do not have to pay any money when they go to the doctor.

michael barbaro

Wow. And what’s the reaction to Sanders’s proposal?

margot sanger-katz

It has a really mixed perception. So I think that it really speaks to some people who respond to the moral case that he’s making and to people who have really felt left behind by our current system, who are struggling with high health care costs or fighting with their insurance companies. So I think it really galvanized his campaign. It’s a central theme. Obviously, he really outperforms everyone’s expectations in the Democratic primary.

michael barbaro

Mm-hmm.

margot sanger-katz

At the same time, I think that the kinds of people who were uncomfortable with the Affordable Care Act, who were uncomfortable with some of these more universal health care systems in the past think it’s sort of a laughable idea. It’s really, really far from where we are right now, it’s far from anything that’s really been debated in a serious way in the Congress, and it would be extremely expensive to implement. It would require huge tax increases. And that is the kind of political debate that doesn’t typically get very far when it’s outside the confines of a campaign.

michael barbaro

So we know Sanders loses the primary, and so his campaign ends. What happens to “Medicare for all” after that?

margot sanger-katz

It’s really interesting. “Medicare for all” gets more popular than ever. So, you know, it’s not just that Sanders loses the primary to Hillary Clinton, who wants to do something much more moderate on health care, but also Hillary Clinton loses the election to Donald Trump.

archived recording (donald trump)

I’m going to repeal and replace your disastrous Obamacare. [CROWD CHEERING] Much cheaper, much better.

margot sanger-katz

So you might think that this sort of really left-wing idea of doing a universal health care would just go away, but instead it starts to gain in popularity, and we see this in a couple of different ways. Public opinion surveys show steady and modest increases in the number of Americans who seem interested in this idea when they’re asked about it. And the other thing that happens is we start to see way more Democrats in Congress signing on to proposals like the Sanders proposal. So Sanders himself had a bill that he had brought forward in previous Congresses and, basically, no one wanted to co-sign it. And then he brought it again in 2017, and all of a sudden he had, I think, 16 co-sponsors, including lots of really ambitious Democratic senators that we expected to run for president, and we now see are running for president. And there’s a bill in the House that had been introduced year after year with very few co-sponsors, and all of a sudden, again, in 2017, we saw the majority of Democrats in the House were signing onto this bill.

michael barbaro

How do you explain that shift?

margot sanger-katz

I definitely think that Sanders was part of it. And if you talk to him, he definitely thinks he was part of it — that he really brought this into the mainstream of our political conversation. But I think there are a couple of other factors. One is that after Trump became president, the first thing he tried to do in legislation was repeal the Affordable Care Act. And, you know, Republicans had a lot of indications that was going to be a good idea. Their voters had been telling them for years that they really didn’t like Obamacare and they wanted it to go away. But actually, that turned out to be kind of politically perilous for the Republicans.

archived recording

And today, the president summoned G.O.P. lawmakers to the White House for the second time in less than a month, after two versions of a bill to repeal and replace Obamacare failed.

margot sanger-katz

They failed multiple attempts to repeal the Affordable Care Act, and its popularity got higher than ever. And there was kind of this boost among Democratic activists over health care — that they started to really care about the issue, and get organized, and get angry.

archived recording

Many of the Republican congressmen who held town halls during this recess have heard the wrath of many of their constituents.

margot sanger-katz

And I think some of those people are bringing new energy to the single-payer moment.

archived recording

In North Dakota, congressman Kevin Cramer heard from a woman with a disabled child. She asked him not to repeal Obamacare, with her family facing bankruptcy. This is what $3.5 million looks like, and she’s two years old.

margot sanger-katz

And then the third thing that I think that happens is the Democrats are kind of on their heels. They’re not in control of Congress anymore. They’re not in control of the White House. They don’t actually have to govern. And so I think that makes them a little bit more open to something that’s more idealistic, that’s more aspirational.

michael barbaro

Mm-hmm.

margot sanger-katz

When they’re in the minority, I think they can say, we want to tell you what our values are. We want to tell you what our dreams are and what we care about — equity, and we care about fairness. And they don’t really have to worry about the dirty little details.

archived recording

When our congressmen took a party-line vote that would have canceled health insurance for thousands of Virginians, I knew I had to run.

margot sanger-katz

That’s exactly what we saw happen in the midterms.

archived recording

Health care affects everyone. Making it into a partisan battle makes things worse.

margot sanger-katz

We saw a lot of Democrats all across the country running with health care as their primary message.

archived recording

I’m voting for Mikie Sherrill because I know she’ll like fight for me and my family, my daughter, and for the A.C.A.

margot sanger-katz

And it was very effective. They took over a lot of seats in the House that had previously been held by Republicans. But I think the exact message that they drew from this is a little bit mixed. I think a lot of them felt, oh, people really just want me to protect what they already have — that we have a very good message in protecting the Affordable Care Act. But some of these Democrats who won running on health care felt like this is a reason to go forward, to push further than the Affordable Care Act because the electorate really responds to this issue. And I think you can really see this now as the 2020 presidential field is starting to heat up. Senator Sanders, obviously, continues to support it. Cory Booker, the senator from New Jersey, is in favor of the Sanders proposal. Elizabeth Warren was a co-sponsor of Senator Sanders’ bill in the last Congress. But it is not universal among Democratic candidates. We saw Amy Klobuchar, a Democratic senator from Minnesota, who said, this is too aspirational. It’s too pie in the sky. We need to focus on more incremental changes that are more politically possible. They all want to make some increase for the role of government — try to have there be more health care available for more people, to make it more affordable. But there is this range from little technocratic fixes to let’s do single-payer.

michael barbaro

Well, let’s talk about that. What does it mean when a candidate for the Democratic presidential primary in this moment says “Medicare for all“? What are the actual proposals on the table?

margot sanger-katz

Who knows? I mean, we are so vague right now. I think when Bernie Sanders says “Medicare for all,” we know what he means because he talked about it in 2016 and he has a legislative proposal. I think with a lot of these other candidates, they are kind of latching onto a brand name that seems to be pretty popular with the public, that reminds them of Medicare, which a lot of people like. But we’re not in the phase of the campaign yet where we have really specific proposals that tell us exactly what it is that they want to do.

michael barbaro

To the degree that Medicare for all is an actual, credible proposal like what has been offered by Senator Bernie Sanders, how practical is it? How expensive would it be to create? How disruptive would it be to the current health care system?

margot sanger-katz

I think it’s almost hard to underestimate how disruptive it would be. Just to give one example, right now we have private health insurance companies that cover most Americans. These are big corporations. They’re among the largest and most —

michael barbaro

Aetna, Cigna, Blue Cross Blue Shield.

margot sanger-katz

Yeah. These companies would essentially be wiped out by the Sanders proposal.

michael barbaro

Wow.

margot sanger-katz

There would be no private insurance. Everyone would get their insurance directly from the government.

michael barbaro

And what about the cost?

margot sanger-katz

So this would be an enormously expensive proposal. It is not necessarily expensive compared to all the ways that Americans pay for health care now. So right now, your employer, if you get employer based insurance, they pay something towards your insurance premium, you pay something towards your insurance premium. When you go to the hospital, maybe you pay a deductible. There are kind of all of these different pots that your health care dollars come from. What the “Medicare for All” plan would do is it would say, no one’s going to pay into any of those streams — the federal government is going to pay for all the medical bills, but in order to pay that, they have to collect way more money in taxes. So various estimates say it would cost more than $30 trillion to administer something like the Sanders plan. That is a lot of money. And that is so much money that you can’t just raise it by taxing the rich. You would really have to have very broad-based taxes that would reach across the income spectrum.

michael barbaro

So what you have described is a pretty radical idea that would upend a huge segment of the U.S. economy. It would require major changes to the tax code. So I wonder if there’s any practical chance that this actually could get through our legislative and political process to become the U.S. health care system.

margot sanger-katz

So I’m always wary of making political predictions, but it seems extremely unlikely to me right now for a couple of reasons. One is that Republicans are dead-set against this. So now we’re left with just Democrats who would have to vote for such a bill. And then you would have to imagine that they could all agree on a proposal this radical. And I don’t think that there is enough unanimity among Democrats right now on this issue. But I also think that this is a way for Democratic politicians to signal that they are signed onto a particular set of values about fairness, about affordability, about kind of all being in it together. And I think that they want to send those kind of values messages to voters, even if they’re not necessarily sending them a specific policy platform that they can deliver on. And so I think it’s a way to say, like, that’s the mountain-top goal. We’re going to get there eventually. But it’s not necessarily saying, you know, on day one, I’m going to get there right away.

michael barbaro

Well, what exactly does that path look like, then, from where we are in the minds of these Democratic candidates to a someday-world where “Medicare for all,” as envisioned by someone like Bernie Sanders, could ever be a reality?

margot sanger-katz

So I had this really interesting and instructive experience about a year ago. I went with Bernie Sanders to Toronto, and we went on a tour of the Canadian health care system. And I would say that Canada’s system is the closest analog to what a lot of these politicians are proposing. And one thing that just really struck me about Canada is that people are all in on the values piece. There is just a real sense of kind of social solidarity around the idea that health care is a right, and everyone should have it in the country, and there shouldn’t be any restrictions, and that it should be sort of radically fair. And that just struck me culturally as so different. And the thing that I couldn’t untangle when I was in Canada is, do they have those values because they have that system, or do they have that system because they already had those values? And I think, you know, part of what will be interesting if Democrats, you know, retake power, and if they start moving us on this path towards something more like single-payer is, how hard will it be to shift those values? We see them. There definitely are people in the Democratic base who believe them deeply in their hearts, but I don’t think that most Americans feel that health care is a fundamental right and that everyone should have it. And I don’t know if that will change.

michael barbaro

Right. Which comes first, the values that say that health care is a right, or the national health care system that dictates that? And from everything you’ve described, something like 80 years of U.S. history suggests that there has not been an appetite for this kind of a system. So the only way it would work is if we believe, right, that the system could come first and the values would flow from it.

margot sanger-katz

I don’t know. I almost think that the opposite thing is probably true — that it’s really hard to imagine it being possible to pass something that would be so earth-shattering, that would make so many changes to our health care system, to our tax code, to the way that health care is delivered if we don’t have buy-in. And so I think that a real challenge for politicians around this issue is really going to be winning hearts and minds and trying to convince people that this vision of how the health care system should work is worth the disruption. The people who really believe in it really believe in it, but there are a lot of people that they will have to persuade.

michael barbaro

It’s interesting. So when candidates like Bernie Sanders say “Medicare for all,” potentially, he’s actually trying to change the American culture to the point where “Medicare for all” could actually work. In other words, when he or anyone says “Medicare for all,” they’re actually calling for the cultural change required for the U.S. to get excited and adopt “Medicare for all.”

margot sanger-katz

Maybe. I mean, it could be that this is the only way that we’re going to get the kind of cultural change that would be required to make a policy change of this magnitude, but I also think that there are real risks here. It’s totally possible that America could engage with this idea, and we could have a big debate about it in a presidential election, and then could thoroughly reject it. And then we sort of end up with the kind of politics around health care that we’ve had for a long time, where these sort of universal health care proposals are put forward, it’s decided that they’re kind of too radical for where we are, and they get shelved again.

michael barbaro

Hm.

margot sanger-katz

Which would put us in kind of a familiar situation of having considered a big government-run health care system and saying, no, thanks.

michael barbaro

Margot, thank you very much. We appreciate it.

margot sanger-katz

I’m so happy to come on. [MUSIC]

michael barbaro