In an extraordinary magic trick, performed on a national scale, Hillary Clinton's healthcare platform has been disappeared. While policy analysts, news anchors, and columnists have been engaged in an intense debate over Bernie Sanders’s “Medicare for All” proposal, Clinton’s incremental alternative has escaped almost all scrutiny - even among those who say they prefer it.
Combining the election-season writings of our most prolific, liberal-leaning columnists at the New York Times, Huffington Post, Vox, Mother Jones, Politico, The American Prospect, etc. you’ll find dozens of articles critiquing Sanders's single-payer plan. None have mentioned a single Clinton healthcare proposal as a point of comparison - merely that she supports a philosphy of incremental reform.
Take Paul Krugman, a high-profile advocate of Clinton's approach to healthcare reform. Krugman has published two op-eds in the New York Times and five additional blog posts arguing that "[progressives] should seek incremental change on health care... and focus their main efforts on other issues - that is... Bernie Sanders is wrong about this and Hillary Clinton is right." In all seven pieces, Krugman focuses exclusively on Sanders's single-payer proposal and fails to mention even a single Clinton policy.
The disappearance of the Clinton healthcare platform has even been carried out by pollsters. The Kaiser Health Tracking Survey included a bizarre question in its February 2016 poll, which was widely cited in the press. Respondents were asked to pick one of four possible directions for the future of U.S. healthcare. Among the choices were "The U.S. should establish guaranteed universal coverage through a single government plan" and "Lawmakers should build on the existing health care law to improve affordability and access to care." Thirty-three percent of Democrats chose the single-payer option, while fifty-four percent chose the incremental option. The questions were clearly intended as stand-ins for the Sanders and Clinton healthcare proposals, but note that the single-payer option is a policy, whereas the incremental option mentions no actual policies, but asks respondents whether they support the (universally desirable) outcomes of improving affordability and access.
What would happen if the media lifted the curtain on Clinton's healthcare platform and introduced any level of scrutiny to her proposed improvements on the Affordable Care Act? They would find two categories of Clinton proposals: some that are so vague they're difficult to evaluate, and other more concrete plans that follow in the footsteps of one of Congress's most practiced healthcare incrementalists: Senator Bernie Sanders.
For example, one of Clinton's clearest incremental proposals is to repeal the Affordable Care Act's poorly named "cadillac tax" on health plans with high premiums. She announced this proposal on September 29, drawing the ire of White House spokespeople. The move, however, followed in the footsteps of a Senate bill to repeal the Cadillac tax introduced by Bernie Sanders and seven Democratic Senators just a few days previously on September 24. Clinton's position was correctly seen by reporters as necessary if she didn't want to lose labor union support to Sanders.
"Because Clinton's healthcare platform has received zero public scrutiny, she has had the luxury of floating other policy ideas in broad outlines, too vague to evaluate."Many of Clinton's well-defined healthcare proposals are rolled into a package of prescription drug reforms, which she released on September 22, 2015. They bear a striking resemblance to the Sanders prescription drug plan announced on September 1, filed as legislation on September 10. Both would legalize importation of prescription drugs from Canada, where costs for identical drugs are much lower due to Canada's single-payer healthcare system. Sanders was a pioneer of importation, and in 1999 started driving busloads of American patients who couldn't afford breast cancer drugs across the Canadian border. Both candidates call for empowering Medicare to negotiate drug prices - even Donald Trump jumped on board in January. Both would ban "pay-for-delay" deals between brand-name and generic drug makers, and increase prescription drug rebates for Medicaid and/or Medicare.
Because Clinton's healthcare platform has received zero public scrutiny, she has had the luxury of floating other policy ideas in broad outlines, too vague to evaluate. Take the proposal to expand the use of Accountable Care Organizations. How? According to Clinton's December policy brief: "In the coming months, [Clinton] will provide full detail on her plans for delivery system reforms that drive down costs." With the primaries drawing to a close, no such details have been released. The same could be said of another proposal to "create a fallback process" to review insurance premium rate hikes in states that don't already review rates. There has been no explanation of how such a plan would work, or whether it would require new legislation.
This is the double standard at work in almost all national coverage of Clinton and Sanders on healthcare reform: Clinton has been taken at her word that her incremental plans will be politically feasible, succeed in improving affordability and access to care, and are not shared by her opponent. Sanders on the other hand received intense public pressure to release details of his single-payer healthcare proposal, and when he did the proposal was subject to an avalanche of public analysis and scrutiny.
This double standard is all the more remarkable because single-payer healthcare is an established policy, practiced in one form or another in almost every developed nation in the world. Incremental reforms that work within the market-based healthcare system of the U.S. are far more uncertain, and deserve greater scrutiny. They are easier to enact but dramatically more likely to fall short of their goals. This is because incremental reforms in the United States usually focus on expanding access to care, without significant cost controls, in order to avoid opposition from the healthcare industry. The resulting policies are often unsustainable; make little headway against national trends of rising costs and eroding access; or simply move costs around (e.g. from premiums to deductibles and co-payments, or vice versa).
Previous national trends in incremental healthcare reform - from managed care through pharmacy benefit management, chronic disease management, narrow networks, and beyond - have often created lucrative new industries, but had dubious impacts on underlying healthcare costs or access to care. Most of Clinton's healthcare platform falls exactly into these danger zones, and should be received with a critical eye.
The national discussion of single-payer healthcare reform is long overdue. However, when the full range of national media outlets force one candidate to run on real policies, while allowing another to run on values and aspirations, we aren't having a real discussion of systemic vs. incremental reform, we are merely aiding the corrosion of informed democracy.