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Analysis: Elizabeth Warren Throws Down The Gauntlet

She has led the way, but all the candidates need to come clean about their health care proposals.

Sen. Elizabeth Warren at a campaign event in South Carolina last month. (Sean Rayford/Getty Images)

Laying the table for the next Democratic debate, Massachusetts Sen. Elizabeth Warren has issued a plan that explains how she would fund what she calls Medicare for All. She had studiously avoided saying whether it would raise taxes for the middle class, and in her proposal, she says (repeatedly) it will not.

It will instead be financed by a mix of wealth taxes, employer transfers of money they currently spend on health care and reductions of the many inefficiencies in our current byzantine system — among other initiatives.

But now all the candidates need to tell us more of those details about their health care strategies. It’s time for the candidates to stop talking slogans and start talking sense — or dollars and cents — so that voters can know what they mean and choose among them.

Medicare for All, Medicare for All Who Want It, a public option, improving the Affordable Care Act — those are 30,000-foot concepts that, depending on the details, could work (or not) and be popular (or not).

The candidates (including Warren) also need to say more about what they’ll do right now: In one poll, 40 percent of Americans said they had skipped a recommended test or treatment, and 32 percent said they had skipped a medicine, because of cost.

Supporters of Medicare for All want to tie their future to the popularity of the Medicare program. But Warren (and Sen. Bernie Sanders) are offering up Americans a supercharged version of the current government insurance for those over 65.

It promises to eliminate copayments for prescription drugs. (Under current Medicare, many patients contribute thousands of dollars annually.) It includes dental and long-term care — a huge expense that is conspicuously missing from current Medicare.

That ambition would make a health care plan vastly more expensive. The national health systems of Britain and Canada, both single payer systems like the Medicare for All proposal, do not offer comprehensive long-term care coverage. Canada’s system, where benefits vary somewhat by province, doesn’t generally include prescription drug coverage out of the hospital for adults under 65.

Is the financing Warren proposes going to be adequate to support the expanded goals? Economists disagree.

But in releasing her proposal, she has thrown down the gauntlet before the other candidates — who support Medicare for All Who Want It or some other type of public option — to be a whole lot clearer about what they mean.

Joe Biden, Kamala Harris, Pete Buttigieg, et al.: Does your public option — a government insurance policy that anyone may buy — resemble Sanders’s enhanced Medicare, or current Medicare or Medicaid, which is far more bare bones?

Voters need to know.

There’s another obvious reason the candidates have been so close lipped on specifics: To calculate how to pay for any of the plans, the candidates have to say how they intend to bring down prices — for hospital stays, drugs, procedures, devices, doctors’ visits, surgeries. Americans often pay two to 10 times what patients pay for these items in other developed countries.

Those prices will have to come down to make any plan viable without breaking the bank. To really assess any plan, we’ll need that kind of information.

Warren has courageously stepped into that fraught territory, with numbers that have very likely sent shock waves through the health care industry.

For example, to make her financing proposal work, she suggests paying most hospitals on average 110 percent of current Medicare rates. She suggests Americans should pay no more for drugs than 110 percent of the average international market price. That may be eminently reasonable, but is it achievable?

When Montana negotiated rates directly with hospitals for its state employees, it settled on a deal in which the state agreed to pay an average of 234 percent of Medicare rates. And it still saved money.

Setting lower prices is going to bring out strong opposition. Remember, patient (or taxpayer) savings mean loss of income for one of America’s most profitable industries, whose lobbyists spent more than half a billion dollars last year and which is flush with dark money to distribute in Congress.

To get the ACA passed, President Barack Obama gave up on a number of price-lowering ideas to get buy-in from the health care industry and its friends in Congress. These included jettisoning the idea of a public option and allowing Medicare to negotiate drug prices.

The Republicans — whose “plans” have been largely proclamations of better, cheaper health care without any strategy — will be quick to label any of the Democratic plans as a government takeover of health care, or socialism.

Remember, patient (or taxpayer) savings mean loss of income for the United States’ most robust sector in the post-recession economy. In many post-manufacturing cities like Pittsburgh and Cleveland, a single hospital system is the biggest employer. In Boston, hospitals and hospital corporations make up the top six employers. Minnesota and Massachusetts have done well with drug and device manufacturing. And let’s not start on insurers, whose lucrative health business would largely disappear.

Any plan to rein in the United States’ bloated $3.5 trillion health care system will be slow going, requiring not just a footnoted blueprint but also the taming of many opposing forces. It took years for Canada to move from a market-based system to government run health. It endured lengthy debates and doctors’ strikes.

Warren calls her proposal a “long-term plan.” But voters want to know how we get from here to anywhere else. In polls, their top health care issue is affordability — emphasis on now.

They need concrete proposals as well as long-term vision. In the next debate, how about talking about H.R. 3, a bill in Congress to curb prescription drug prices? That plan would allow the health and human services secretary to negotiate a maximum price that could be charged to Medicare for insulin and some of the most expensive medicines in the United States, based on the prices paid for those drugs in other countries.

Days before the last Democratic debate, the Congressional Budget Office said it would save $345 billion over a six-year period (2023-29).

If the bill were to move to the Senate, how would the front-runners vote? What do they have to say about that?

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Cost and Quality Elections Insurance Medicare