National

Rep. Alexandria Ocasio-Cortez (D-N.Y.) conceded Thursday that Sen. Bernie Sanders' signature Medicare for All proposal would face congressional roadblocks if he was elected president, telling HuffPost: “A president can’t wave a magic wand and pass any legislation they want."

Why it matters: Ocasio-Cortez is a vocal proponent of Medicare for All and one of Sanders' highest-profile surrogates. She told HuffPost: "The worst-case scenario? We compromise deeply and we end up getting a public option. Is that a nightmare? I don’t think so."

More moderate 2020 candidates like Pete Buttigieg have faced criticism from the left on their health care proposals, despite endorsing a public option. Buttigieg has framed his "Medicare for All Who Want It" as a more practical pathway to Medicare for All.

Ocasio-Cortez argued that even if Medicare for All is unrealistic in Sanders' first term, having an ambitious progressive platform is still important to help push the party further left. 

Where it stands: Out of the 2020 Democratic candidates, only Sanders and Elizabeth Warren support Medicare for All. 

All other 2020 Democrats support plans that allow Americans to keep private insurance unless they want to choose coverage from a public plan.

The health care industry, particularly hospitals, opposes a public option almost as fiercely as it opposes single-payer — and would fight it in Congress with just as much help from Republicans, according to Axios' Sam Baker.

Go deeper: Democrats like both Medicare for All and a public option

AOC concedes Sanders may have to compromise on Medicare for All

“A president can’t wave a magic wand and pass any legislation they want."

In this image, Bernie Sanders and AOC stand in front of a crowd with a Bernie 2020 sign in front of them attached to a podium.

Ocasio-Cortez and Sanders rally in Durham, New Hampshire, on Feb. 10. Photo: Joseph Prezioso/AFP via Getty Images

Politics

Alexandria Ocasio-Cortez

Health Care

Medicare for All

The U.S. faces a range of health care flashpoints — unaffordable drugs, opioids, vaping — as we debate whether to adopt universal care. For now, the Affordable Care Act is the law of the land, but Republicans want to issue it a final death blow.

Health

Iowa Democrats reported Monday that their biggest priorities were beating President Trump and health care — but the meltdown of their election reporting systems left their presidential choices unresolved.

Why it matters: We've been writing for months that Democrats have a major choice ahead, either picking an advocate of Medicare for All — and siding with the plan that's less popular with the rest of the country — or a public option advocate.

The Iowa debacle means the path the party will take won't be clear for a while longer.

By the numbers: Several polls — including ones by NBC News, the National Exit Poll and AP Votecast — found that around four in 10 caucus voters said health care was their top issue.

Previous polling has found that Medicare for All is less popular overall than a public option, but both were popular among Democratic caucus-goers last night.

Seven in 10 said they back a single-payer plan, and almost nine in 10 said they support a public option, per AP Votecast, which was conducted by NORC at the University of Chicago for The Associated Press and Fox News.

Yes, but: Caucus-goers said they prefer a Democratic candidate who can beat Trump over one that agrees with them on issues, CNN reports.

The big picture: Republicans are more than happy to talk about Medicare for All — and its subsequent tax increases and expanded government role in health care — instead of protecting and building on the Affordable Care Act.

Whereas the former gives them an opportunity to go on offense, the latter puts the GOP on defense against its 2017 repeal-and-replace efforts and ongoing lawsuit that would strike down the whole health care law, including its protections for pre-existing conditions.

The health care debate we ought to be having

40% of Iowa caucusgoers said health care was their top priority

But they still have to decide between Medicare for All or a public option.

Sen. Bernie Sanders at his caucus night watch party in Des Moines, Iowa.

Bernie Sanders at his caucus night party in Des Moines, Iowa. Photo: Alex Wong/Getty Images

Iowa Caucus

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2020 election

President Biden has made the COVID-19 crisis and a post-Trump return to national unity and traditional democratic ideals his top priorities. From vaccinations to stimulus to schools, Biden is seeking bipartisan compromise while showing a willingness to use executive authority and bare Democratic majorities in the U.S. House and Senate to implement his policies. Republican leaders are navigating deep party divisions over if and how to move beyond former President Trump.

Politics & Policy

America's mental health care system is in dire need of an overhaul, but the any real specifics are largely missing from the 2020 debate about health care.

Why it matters: Suicide and drug overdose rates continue to rise, and the U.S. faces a shortage of mental health providers and a lack of access to treatment.

The big picture: Private insurance is plagued with holes in mental health coverage. Even even though insurers are legally required to cover behavioral health the same way as physical health, they don't. 

Yes, but: Medicare to All may not solve the problem, Mental Health America president and CEO Paul Gionfriddo told me.

“Medicare would need to be redesigned significantly," he said.

Medicare has its own coverage flaws. It would also be crucial to design a system that encourages preventive and early identification services rather than just post-crisis care.

There's also a shortage of mental-health providers. Paying mental health providers more could help address this, but care delivery would also need to be redesigned, Gionfriddo said.

Rural areas, for example, would likely still struggle to attract and support these providers because of their remoteness and population size.

"The big wild card is how many mental health providers would participate in a Medicare for all program or opt out of insurance entirely," said the Kaiser Family Foundation's Larry Levitt.

For Democrats who support Medicare for All, highlighting how it could help mental health care could have a political upside. 

“Talking about mental health care needs humanizes the candidates, indicts the shortcomings of private insurance and provides rationale for the need for significant reforms around the current system," Democratic health consultant Chris Jennings said. 

The bottom line: "We have a huge problem with health insurance for mental health. A major reform could be an opportunity to improve mental health services, but it could also do harm to them," Gionfriddo said. 

Go deeper: Mental health coverage is getting worse

Medicare for All's missing mental health discussion

Universal coverage alone won't solve America's mental health problems.

Illustration of a health plus on a therapist couch.

Mental health

The way the Democratic candidates talk about "Medicare for All" has shifted and sharpened over the course of the campaign — and Medicare for All has gotten less popular in the process.

The state of play: When Sen. Bernie Sanders introduced his "Medicare for All" bill in 2017, all of his likely 2020 rivals in the Senate signed on as cosponsors, and many Democrats treated Medicare for All as a catch-all or a loosely defined goal.

Sanders hasn't changed at all. He has tweaked the details of what his plan covers, but still makes the same forceful case for a national plan with no copays, deductibles, premiums or coverage limitations — paid for by tax increases.

Sen. Elizabeth Warren still backs Sanders' version of the national health plan, but has said she would pursue a public option first, then a full-scale single-payer program later.

Pete Buttigieg has long supported a public option, not Medicare for All, though his criticism of single-payer has gotten more aggressive as he (and Warren) have climbed in the polls.

Joe Biden also has a clear position on Medicare for All: He's against it. He, too, prefers a public option. "The party's not there. The party's not there at all," he told "Axios on HBO."

Why it matters: This is the defining debate of the Democratic primary — and it's a fight that Sanders and Biden, at least, are eager to have.

Yes, but: The powerful health care industry, particularly hospitals, opposes a public option almost as fiercely as it opposes single-payer, and would fight it just as hard in Congress, with just as much help from Republicans.

Democrats are divided over what to fight for, but it would be a fight no matter what.

Special report: The coming health care collision

The urban-rural health care divide is growing

Democrats' divide on Medicare for All

This is the defining debate of the primary — and it's a fight that Sanders and Biden are eager to have.

Photo illustration of Pete Buttigieg, Elizabeth Warren, Bernie Sanders, and Kamala Harris

Photo Illustration: Sarah Grillo. Photos: David McNew/Getty Images, Drew Angerer/Getty Images, Ethan Miller/Getty Images, and Zach Gibson/Getty Images

Deep Dive - Health Care in 2020

New polling from the Kaiser Family Foundation and the Cook Political Report confirms that while Democratic voters like the idea of “Medicare for All,” it would be a risk in a general election.

Between the lines: This poll was conducted in the formerly “blue wall” states of Pennsylvania, Minnesota, Michigan, and Wisconsin.

By the numbers: 62% of Democratic voters in those states say a Medicare for All plan that eliminates private insurance is a good idea — while 62% of swing voters in these battleground states say it’s a bad idea.

Yes, but: Our poll suggests that 2020 is a referendum on President Trump, not on health policy.

By wide margins, Democrats and independents said defeating Trump was their main motivator. Keeping him in office was Republicans’ top factor.

The bottom line: If the Democratic nominee comes to be defined by the idea of Medicare for All, that could be a political problem in key battleground states.

Democrats like Medicare for All, but swing voters don't

A poll of battleground states yields mixed results.

Illustration of a health plus with a cross-out symbol as its shadow.

Sen. Elizabeth Warren's two-part plan to pass a public option as a transition into Medicare for All — and then full-blown Medicare for All a few years later — has revealed the difficulty of appealing to both the pragmatic and progressive wings of the party.

The big picture: Warren's already being criticized by progressives for not being a Medicare for All purist, and because of the realities of governing, they may have a point: Passing two major health reforms in one term is unheard of.

Details: Warren's transition plan — which she said she'll try to pass within her first 100 days in office — would allow anyone over 50 to enroll in an "improved Medicare program," and "every person in America" could get coverage through a "Medicare for All option."

Coverage under the public option would immediately be free for children under 18 and families making 200% of the federal poverty level or less. Over time, it'd become free for everyone.

Then, by no later than her third year in office, Warren would push Congress to pass full-blown Medicare for All.

Reality check: The political capital that it'd take to pass Warren's public option, even through a special procedure called "budget reconciliation" that'd allow her to bypass GOP opposition, would be enormous. 

And Medicare for All supporters weren't enamored with the more incremental approach. "In my first week as president, we will introduce Medicare for All legislation," Sen. Bernie Sanders tweeted on Friday.

What they're saying: "Passing one major piece of health care legislation with a knock down, drag out fight, followed by another one three years later, sounds pretty difficult," said the Kaiser Family Foundation's Larry Levitt. 

"A more likely scenario is that a public option would pass, and be given time to work. Depending on how that debate went, Medicare for [A]ll could be a rallying cry for a reelection campaign."

The bottom line: Warren's "transition" plan — which also includes a long list of actions she'll take to protect the Affordable Care Act, aggressively enforce antitrust laws, end surprise medical bills and lower prescription drug prices — also works as a standalone health care plan. Whether that's a good thing or a bad thing depends on who you ask.

Warren's path to Medicare for All is rocky

Passing two health reforms in four years is ... a lot.

Illustration of Elizabeth Warren holding out a health plus. 

Elizabeth Warren

Sen. Elizabeth Warren's presidential campaign on Friday unveiled what would be her roadmap for overhauling the country's health care system if elected, carving out an initial public option with the promise of implementing 'Medicare for All' within her first three years in office.

Why it matters: The plan gives Warren a defense against criticism that she would abruptly strip away Americans' ability to choose their care and force them off private insurance.

The big picture: Sen. Bernie Sanders' proposal would require passing a single bill. But Warren would split the process by first expanding the reach of a more generous version of Medicaid in her first 100 days in office via a budget measure requiring only 51 Senate votes.

She would then "fight to pass legislation that would complete the transition to full Medicare for All" over her first three years in office.

Warren would keep employer-based care active throughout the process, but "the American people will have experienced the full benefits of a true Medicare for All option," which would build public support for a Medicare for All system. 

Warren bets the White House on Medicare for All

We all pay for the bloated U.S. health care system

Medicare for All's popularity may have peaked

Elizabeth Warren reveals Medicare for All roadmap

The plan offers Warren a defense against criticism that she would abruptly overhaul health care.

Elizabeth Warren. Photo: Sarah Rice/Getty Images

Former Secretary of State Hillary Clinton said during the DealBook conference in New York on Wednesday she doesn't believe 2020 candidate Sen. Elizabeth Warren's Medicare for All plan would ever be enacted.

"The smarter approach is to build on what we have; a public option is something I've been in favor of for a very long time. I don't believe we should be in the midst of a big disruption while we are trying to get to 100% coverage and deal with costs."

What she's saying: During the event in New York, Clinton said in response to a question on whether she could "get behind" the plan, "If it were to go to Senate ... if you had a president who pushed to present it, I would be very much in favor of whatever the debate was." 

The 2016 Democratic presidential candidate added that while she doesn't think it would pass, it was the "right goal" and the current health care debate among Democrats is healthy.

"The Affordable Care Act took us to 90% of coverage — the highest we had ever gotten in our country after many, many efforts including one I was involved in more than 25 years ago," Clinton said.

"We have a 10% gap to fill and we have a lot of learning to do about the best way not only to fill the gap, but then to drive down costs as much as it is possible without undermining quality advancements."

Why it matters: Clinton is the latest in a line of current and former officials and lawmakers to question how workable Warren's plan would be in practice. Warren has faced criticism from her closest Democratic presidential rivals and others on the issue of cost to taxpayers.

Per Axios' Caitlin Owens, "We've never tried any cost containment measures that are remotely close to being as aggressive as Warren's, and there could be consequences if payment rates are slashed so low."

Hillary Clinton in Conversation

Democrats' health care plans have very different costs

Elizabeth Warren's dream health care world

Podcast: Elizabeth Warren's health care revolution
 
 

Clinton: Warren's Medicare for All plan wouldn't ever get enacted

"The smarter approach is to build on what we have," she said at the DealBook conference.

Hillary Rodham Clinton attends "Hillary & Chelsea Clinton: A Conversation on "The Book Of Gutsy Women" at Riverbend Center on November 3, 2019 in Austin, Texas. 

Former Secretary of State Hillary Clinton in Austin, Texas, on Sunday. Photo: Gary Miller/Getty Images

Adapted from Kaiser Family Foundation; Chart: Axios Visuals

Public support for Medicare for All might have peaked, but it’s still a powerful idea among many Democrats.

By the numbers:  Support for the national health plan rose from around 40% in 2000 to a high of 59% in March of 2018, but had slipped back to 51% by October of this year.

That's still a majority, but it’s narrow and headed in the wrong direction. And polling shows that support drops much further, and opposition rises, when people hear some of the most common arguments against Medicare for All.

Between the lines: Critics, debate moderators and the media have focused largely on two unpopular tradeoffs in a Medicare for All plan: the large number of Americans who would have to give up their private coverage; and the likelihood of a middle class tax hike to finance the plan.

· Sen. Elizabeth Warren took great pains to avoid one of those criticisms in crafting her financing plan, which does not include a tax hike for the middle class, but certainly includes other potential landmines.

Much less attention has been given to potential upsides, such as eliminating out-of-pocket costs, achieving universal coverage, or reducing the complexity of the health care system.

A public option, Medicare buy-in and other more incremental, voluntary and less expensive plans that are more difficult to make look threatening are more popular than Medicare for All.

Yes but: Support for Medicare for All is still strong among Democrats at 71%, so it remains an effective rallying cry for progressive Democrats in the primary.

Sen. Elizabeth Warren's Medicare for All plan takes on every major health care industry — insurers, doctors, hospitals and drug companies — in her pursuit of expanding coverage and lowering costs for the middle class.

Why it matters: We've never tried any cost containment measures that are remotely close to being as aggressive as Warren's, and there could be consequences if payment rates are slashed so low.

The big picture: Experts say you can only wring so much money out of the system before it starts to impact the care people receive — and Warren is wringing out a lot.

Private insurance would be eliminated. Warren argues that would save hundreds of billions of dollars in administrative spending, and relieve patients of the hassle of dealing with their insurer.

Americans would no longer have to worry about reaching their deductibles or whether their doctors are in their insurance network.

They'd pay no premiums and have "virtually no" out-of-pocket costs, according to Warren. They'd have expansive health benefits, including long-term care, audio, visual and dental. 

They'd also have no choice about any of this.

To pay for all of this, providers would see drastic payment reductions.

Doctors would generally be paid at current Medicare rates — which on average are much lower than private insurance rates — although some, like primary care-physicians, would be paid more than they currently are by Medicare and others, like "overpaid" specialty doctors, would be paid less.

Hospitals would be paid an average of 110% of Medicare rates, with adjustments for rural and teaching hospitals — still much lower than what private insurance pays.

Providers wouldn't have to worry any longer about uninsured patients, nor would they have to negotiate with insurers.

"The ultimate question, which we can all guess at but can’t know for sure, is whether enough hospitals and doctors would continue delivering care to a larger number of insured patients. If not, we’d see growing waits for care," said the Kaiser Family Foundation's Larry Levitt.

The federal government would be allowed to negotiate drug prices, and penalize drug companies that refused to participate with more taxes.

Americans would pay no more for a drug than 110% of its average international price.

If negotiations don't work, Warren would override a drug's patent — allowing another company to make the drug at a lower price — or have the government manufacture the drug.

Warren suggests that no patient will be denied a drug based on its price.

Experts have warned that even less aggressive drug pricing plans would come at the cost of less innovation by drug companies, and thus fewer new cures coming to market.

The bottom line: The days of American health care as big business would likely be over. Patients may win financially, but there's no way of knowing at what cost to the quality of their care.

The days of American health care as big business would likely be over.

Data: Kaiser Family Foundation Tracking Poll; Note: ±3 percentage points margin of error; Chart: Andrew Witherspoon/Axios

Even many supporters of Medicare for All don’t necessarily know how it would work.

The big picture: That doesn’t necessarily mean more information will turn supporters into opponents, but it shows that we’re still at an early stage in this debate, in which opinions about Medicare for All are often reflections of broader political alliances, not the details of a plan.

By the numbers: In our January tracking poll, more than half (59%) of Medicare for All supporters didn’t think Medicare for All would require people to give up their employer-based insurance; 34% knew it would.

Democrats have learned more about the plan over the course of the party’s primary — 41% now know that people with employer coverage couldn’t keep it, up from 25% in June.

The big picture: People's opinions are still malleable.

Majority support for Medicare for All flips to majority opposition — 58% — if people think it would eliminate private coverage. And opposition rises to 70% if people think Medicare for All would lead to delays in care.

But support rises to 67% if people hear that Medicare for All would eliminate premiums and deductibles, and to 71% if they hear it would "make health care a right."

My thought bubble: Campaigns and the media are heavily invested in these differences among Democrats’ competing health care plans, but the public’s flexible opinions and lack of knowledge are a reminder that a lot of this is about signaling priorities, rather than adherence to a specific plan.

Even supporters may not understand Medicare for All

People's opinions are still subject to change.

Data: The Urban Institute; Note: 2020 estimates assumes all reforms fully phased in and in equilibrium, "Household spending" is for those 64 and under; Chart: Andrew Witherspoon/Axios

Democrats aren't debating small differences in health policy — a public option would be radically different than a shift to a single payer system, and a new analysis by the Urban Institute and the Commonwealth Fund illustrates just how big those differences are. 

By the numbers:  A public option — even a robust one — would cost the federal government an additional $1.5 trillion over 10 years. Full-blown single payer would result in a federal spending increase of $34 trillion. 

Yes, but: More federal spending doesn't necessarily mean the health care system as a whole is getting more expensive. 

Details: The analysis doesn't look at any specific piece of legislation or any particular Democratic candidate's plan, but it covers the spectrum of what's been proposed. 

National cost savings generally come at the expense of providers, as their payment rates would be regulated under expanded government coverage.

Democrats' health care plans by the numbers

Medicare for All is very different from a public option

Forget the Affordable Care Act: The future of our health care system will be shaped by a much bigger and broader fight — one that will likely culminate with a 2020 choice between private markets and an authentic government-run program in the form of a Bernie Sanders-style Medicare for All. 

The bottom line: The cost of health care — both for individuals seeking coverage and the government seeking sustainability — promises to return as the biggest domestic issue once the Trump obsession burns off. 

This is one of America's great unsolved problems: We have the world's best care, talent and innovation. But before it gets to patients, the magic goes through a hodgepodge of inexplicable, expensive and unnecessary hurdles.

What's next: The health care debate is no longer a linear fight over a straight repeal of President Obama's health care law. Instead, it has metastasized into a multi-front war.

One of our most vital national systems is falling apart:

Medicare is running out of money faster than expected — a reminder that no one's dealing with that problem, and that there's no way to duck it in 2020. 

The opioids crisis continues, with Congress trying to pass a ton of mini-bills to look like it's doing something. A few of them might make a difference. This remains a crisis — and a costly one. 

And don't forget prices. The U.S. doesn’t use more health care than other countries — we just pay more for it. Consumers are getting sick of it, and eventually they’ll respond to politicians with plans that seek to bring down prices (as they already have on prescription drugs).

Polls show health care is at the top of the list of voters' concerns for the midterms. So look for it to dominate the early rounds of 2020.

The new battlegrounds, as sketched by Axios managing editor David Nather:

The ACA repeal fight has moved to the courts, and the Trump administration has picked a fight over preexisting conditions — one of the most popular parts of the law.

But Republicans haven't given up on repeal. A group of outside conservatives is about to unveil a new plan and push congressional Republicans to take one more vote before November's midterms — even though there's no sign that any votes have changed.

"There's going to be at least one more grassroots effort to convince them to take another run at health care" so base voters don't think Republicans have given up, said Lanhee Chen of Stanford, a former Mitt Romney adviser who's part of the group.

Democrats have moved on to Medicare for All. The fight to watch will be between establishment Democrats, who want to make it voluntary and preserve a role for employment-based private insurance, and Democrats from the Sanders wing who are ready to move everyone into a government-run system.

"Democrats have always felt that health care should be a right," and they've watched the ACA actually become more popular under attack, said Neera Tanden, a former Hillary Clinton adviser who heads the Center for American Progress.

ACA premiums are going up, and for the first time it's Democrats who will try to turn that into a campaign weapon.

But health care spending and premiums are rising for everyone else, too.

By the numbers: Where America's health care spending goes

Why the U.S. never got universal health care

Health care is top voter priority in 2018

Republicans' next war: Pre-existing conditions

The new drugs and therapies keeping us alive longer

Deep Dive: The next health care wars

The health care debate is no longer a linear fight

This shows symbols commonly associated with health care

Deep Dive - Health Care

Every fight over the Affordable Care Act is a reminder of the bigger truth about the U.S. health care system: It's really a patchwork, not a system, because we never decided what our priorities were. Here's a look at how it developed and why it's not the kind of health care safety net other countries have.

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