Harris and health care
The vice president's nomination will put abortion rights, cost control and maintaining insurance coverage at the center of the fall campaign -- where they belong.
I was sorely disappointed by the health care press’s initial coverage of President Biden’s withdrawal from the race and his endorsement of Vice President Kamala Harris for the Democratic Party nomination. It left the Democratic campaign “in chaos,” Statnews declared.
A president bows to public opinion. He endorses his vice president. The convention gets to decide. This isn’t chaos. This is what democracy looks like.
If you want to understand what chaos looks like, dwell on the ramifications for the health care system if the doddering demagogue Donald Trump returns to the White House with Republicans in control of Congress. They include:
A national ban on abortion;
Restrictions on access to morning-after contraception pills;
The undermining of Medicare financing by an unleashed Medicare Advantage program;
A sharp rise in the uninsured rate; and
The defenestration of drug price negotiations.
KFF Health News did marginally better. They rightly emphasized the abortion stakes in this year’s election.
But then they pivoted to emphasize that Harris backed Medicare for All in the 2020 primaries, a point also mentioned prominently by Stat. This echoes the number one talking point for Trump and GOP candidates across the country, who are desperate for people to forget the Trump Supreme Court’s Dobbs decision that allowed 23 states to impose total or near-total abortion bans.
Yes, Harris was for M4A before she was against it. But that described a large majority of Democratic Party voters in 2020, especially those backing Vermont Sen. Bernie Sanders. Some polls, after four years of Trump, showed 55% of all voters backing single-payer health care coverage, including a third of Republicans.
But as vice president, Harris has been an active supporter of Obamacare, which preserves the role of private insurance in providing health insurance coverage. In March, she appeared alongside the president in North Carolina to tout its recent expansion of Medicaid under Democratic governor Roy Cooper. Ten states under GOP control are still denying coverage to near-poor, working-class people.
What matters more? What Harris said on the campaign trail over four years ago or what she did while in office and is saying now? It’s time for the media, especially health care-focused outlets, to begin analyzing the actual stakes in this year’s election and stop trailing after the mainstream media, which invariably sees every election as a horse race and this year mindlessly repeats outdated Republican talking points when it comes to health care or any other issue.
Issue #1 — Abortion
While Trump blithely lies about his stance on abortion (“leave it to the states”), a majority of the party he controls backs a national ban and will pass one if it wins control of Congress. If you think Democrats in the Senate can filibuster passage of such a law, remember that Senate Republicans in 2013 and 2017 used parliamentary tricks to vitiate the filibuster in order to approve ultra-conservative judges to all the federal courts, which led directly to the Dobbs decision.
Does anyone seriously think Trump would veto such legislation? Does anyone seriously think the unprincipled justices that now rule the Supreme Court would declare a national ban unconstitutional?
Legal scholars have already laid out how they might use the Commerce Clause or the 14th amendment to approve a national abortion ban. Leah Litman, a law professor at the University of Michigan, spoke with the New Yorker’s Isaac Chotiner shortly after the Dobbs decision:
Say [Congress] writes a statute that says, “No abortion can be performed if it uses any device that has travelled in interstate commerce or any medication that contains a component that has travelled in interstate commerce.”
The second basis is that Congress might say, “We are enacting this legislation under our power to enforce Section 5 of the Fourteenth Amendment. We believe that fetuses are people. Therefore, we are enforcing and protecting fetal personhood and rights to life.” Would the six conservatives conclude that Congress lacks the authority to enact either version of the statute, or reject both of those theories? I don’t think we know. Chief Justice Roberts has taken more expansive views of Congress’s power.
We may not know for certain, but we can make a well-educated guess based on recent decisions by a Roberts court dominated by anti-abortion advocates. The same can be said for a ban on use of mifepristone for abortion. Conservative think tanks are already challenging its use in court. While the high court has dismissed initial suits based on a lack of standing, that only set the stage for refiling cases once a Republican-run Congress passes a law outlawing its use.
Issue #2 — Out-of-Pocket Costs
Recent polling confirms rising out-of-pocket costs has become the most important health care issue for 75% of voters. The Biden/Harris administration has done a poor job communicated its successes like drug price negotiations (which won’t start until 2026) and the No Surprises Act. That failure left the field wide open to demagogic claims that “only I can fix it.”
There has been almost no discussion during this campaign about the root causes of rising out-of-pocket costs. Surprise out-of-network bills and rising drug prices are only part of the problem.
The main issue is the proliferation of high-deductible plans, including Bronze plans on the Obamacare exchanges. People are attracted to the high-deductible plans offered by employers (or on the exchanges) because they have lower monthly premiums. They only discover the actual costs when they need to use their health insurance.
In addition, many employer-based plans set co-pays at a percentage of the total cost of the hospital stay, doctor visit, test or drug. As the underlying prices of those services rise, so do the co-pays, all too often to unaffordable levels when a third of the population has insufficient savings to pay an unexpected $500 expense (the “half the population can’t afford a $400 expense” claim used by many politicians, including Harris, is outdated, thanks in large part to an improving economy).
Any solution to the out-of-pocket cost problem will require legislative solutions. Those could include a hard cap for households for all out-of-pocket costs (premiums, co-pays and deductibles), which should be set at a fairly low percentage of annual income. It could include drug price negotiations for many more drugs. And it will ultimately require better controls on health care service prices, especially at hospitals. Needless to say, none of that is remotely possible during a second Trump term, which will inevitably result in special interests controlling the political process.
Issue #3 — Coverage
The Biden/Harris administration has overseen a large expansion of sign-ups for health plans on the Obamacare exchanges after four years of stagnation and decline under Trump. The biggest boost came after the administration used the Covid relief bills to expand subsidies, which made plans much more affordable for low- and moderate-income families and individuals.
Those increased subsidies expire in 2025. What are the odds of a Republican Congress and president renewing them when they are hellbent on giving more tax breaks to corporations and the rich?
Moreover, a second Trump presidency will reprise its use of executive powers to limit sign-ups by cutting back support for navigators that help people sign up for coverage. It will end public advertising about the plans, as it did during his first term in office. And it will alter the Biden administration’s rules that limit private insurers’ ability to sell junk plans, which leave consumers with huge bills whenever they actually need to use their insurance.
Issue #4 — Gutting government programs
More than half of seniors on Medicare have joined the privatized plans better known as Medicare Advantage. These plans, which attract beneficiaries through their low- or no-upfront costs and added benefits, are highly profitable for insurers, which use of narrow provider networks, prior authorization and hitting patients with unexpected co-pays to lower their costs. Traditional supplemental plans, which nearly 90% of beneficiaries in the fee-for-service program buy, limit those restrictions and expenses.
Those high insurer profits are costly for the traditional FFS program. The government’s cost per beneficiary in MA plans is 4% higher than in FFS Medicare even though the illness incidence among the two groups is roughly similar. These higher costs are due to insurers claiming their members are sicker than they really are. Analysts say this “up-coding” could cost the government and taxpayers over $1 trillion over the next decade if it isn’t addressed.
There will be plenty of ups and down over the next few weeks leading up to the Democratic Convention in Chicago. Democracy can be a messy process. But whatever its outcome, that messiness will be nothing compared to the health care chaos caused by Republican control of the White House and Congress.
As a hyperactive, healthy 85 year-old, I've been urging President Biden to pass the torch to a younger generation for nearly two years and am thrilled that he finally placed country above personal preference for the power of the presidency. He chose not to be RBG thank God.
As a strategic move, his timing was right. Biden's decision has changed the dynamics of the campaign 180 degrees. Trump’s selection of J. D. Vance is already hurting his chances. The anti-immigrant white supremacist wing of the Republican Party considers his partly South Asian children “mongrels.” Harris is both African-American and South Asian. Meanwhile the media focus on “too old to run” shifts to the word salad guy who would be 82 at the end of his term.
Excellent reporting and analysis Merrill.
Another seriously troubling Trump policy would be the lifetime limits on Medicaid as revealed in Project 2025. Combine that with block grants and all states will soon look like Mississippi.