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A Project of The Annenberg Public Policy Center

Clinton’s Attack on Sanders’ Health Plan

The Clinton campaign has made a series of misleading attacks on Sen. Bernie Sanders’ health care plan, saying he wants to “dismantle Medicare” and private insurance and that he would turn over “your and my health insurance to governors.” Not exactly.

Sanders calls for replacing the current health insurance system with a new “single-payer” system in which everyone has insurance paid through taxes. And a federal board would approve individual states’ universal insurance plans, with the power to take over if a state refused to participate or didn’t meet certain standards.

The Clinton camp is free to question Sanders’ plan and its structure — and whether it’s a good idea or politically or practically feasible. But comments by both Hillary Clinton and her daughter, Chelsea, suggest people would lose health insurance under Sanders’ single-payer plan — when such a plan is designed to cover everyone, going beyond what the Affordable Care Act is expected to do. The ACA is expected to leave 27 million uninsured in coming years, according to Congressional Budget Office estimates.

On Jan. 12, Chelsea Clinton said in a stump speech in New Hampshire: “Sen. Sanders wants to dismantle Obamacare, dismantle the CHIP program, dismantle Medicare, dismantle private insurance. … I worry that if we give Republicans Democratic permission to do that, we’ll go back to an era — before we had the Affordable Care Act — that will strip millions and millions and millions of people of their health insurance.”

That “dismantle” claim reminds us of Democrats’ past “end Medicare” claims directed at Republicans. Just as Republicans didn’t call for an “end” to Medicare altogether — they called for replacing the current system with a new insurance program for future seniors — Sanders hasn’t called for dismantling all forms of insurance without a replacement plan.

The day before, on Jan. 11, Hillary Clinton said at a campaign stop in Iowa that Sanders’ plan would “take Medicare and Medicaid and the Children’s Health Insurance Program and the Affordable Care Act health-care insurance and private employer health insurance and he would take that all together and send health insurance to the states, turning over your and my health insurance to governors.” Sanders has proposed having the states implement the single-payer plan, but Clinton gives the impression that governors would be free to do whatever they wanted. That’s not the case.

For his part, Sanders has glossed over the fact that his plan would replace all forms of current insurance with a new system — one he calls “Medicare-for-all,” but would actually be a new insurance system administered largely, if not entirely, by the states. The Washington Post Fact Checker gave Sanders two Pinocchios in November for saying: “I helped write the Affordable Care Act. So I don’t want somebody suggesting I’m trying to dismantle legislation that I helped write.”

But the ACA would no longer exist under what Sanders has proposed.

Sanders’ Plan

Sanders has not released a formal plan as a presidential candidate. But he has introduced single-payer legislation, most recently the American Health Security Act of 2013, and his campaign points to that legislation in responding to the Clinton camp attacks.

The bill, which was referred to committee and never came to a vote, calls for a single-payer, universal coverage system that would be administered by the states and regulated by an American Health Security Standards Board. Medicare, Medicaid and other government health programs, as well as the current private insurance system, would in fact be eliminated, because everyone would get the same health insurance, paid for with tax money, rather than individually through premiums. The bill calls for tax credits and premium subsidies that would have gone to state residents under the ACA instead going to a new trust fund.

The Health Security Standards Board would be charged with overseeing implementation of the law, including setting benefit levels and state/federal funding levels.

Each state would submit a proposal to the board for a “health security program” that would cover all residents, and states would be allowed to join together to create regional plans. The board could approve or reject the plans. And if a state refused to participate, the bill says, the board “shall develop a plan for a State health security program in such State.”

The Clinton camp’s implication that Sanders’ plan would turn over health insurance to the states to do whatever they wished is wrong. There are mechanisms in the law to control the state plans, and take over for a state that doesn’t develop such a plan, or develops one that’s considered subpar by the board.

The legislation spells out “consequences of failure to comply” saying that if a state plan doesn’t meet the board’s requirements “the Board shall provide notice to the State of such failure and that unless corrective action is taken within a period specified by the Board, the Board shall place the State health security program (or specific portions of such program) in receivership under the jurisdiction of the Board.”

Chelsea Clinton worried that “millions and millions and millions” would lose their health insurance. But Sanders’ bill includes provisions to stop that from happening.

How well that would work is of course an open question. Under the ACA, the federal government has stepped in to run most of what were supposed to be state-based insurance marketplaces, and 19 states haven’t expanded Medicaid under the law. But Sanders’ plan is different — a governor’s actions wouldn’t affect some of the states’ residents; they would affect all of them.

“Ultimately it’s hard to imagine governors undermining insurance – for everyone — literally from CEOs to janitors,” Larry Levitt, senior vice president of the Kaiser Family Foundation, told us in a phone interview.

What would be more likely is that governors would allow the federal government to administer their programs, he said. But there are plenty of unknowns about how a single-payer system would be implemented.

“A single-payer plan has never come very close to passing,” Levitt said, “so a lot of the details about how it would actually work have never been worked out.”

It would be a major change from the current insurance system in the country. “It would change everyone’s coverage from what they have today to a new state-sponsored insurance plan. And it would shift the financing dramatically from the premiums that individuals and employers pay today to a tax-based system,” Levitt said.

When we contacted the Clinton camp, the campaign raised the question of what states’ refusal to participate would do to the financing mechanisms or level of taxation of Sanders’ plan. The 2013 bill calls for a federal contribution for all states of 86 percent on a weighted-average, and for that federal contribution to be no less than 81 percent and no more than 91 percent.

If a state failed to participate — or didn’t develop an adequate plan — the federal government would have to make up the funding difference in some way. We asked the Sanders campaign how such a potential shortfall would be covered under his plan, and we did not receive a response.

In her Iowa campaign stop, Hillary Clinton called Sanders’ plan a “risky deal,” saying, “I don’t believe number one we should be starting over. We had enough of a fight to get to the Affordable Care Act. So I don’t want to rip it up and start over.”

She is entitled to that opinion. But her campaign has given misleading statements on what exactly Sanders has proposed, leaving the impression that he would cede control to governors and “dismantle” insurance coverage altogether.