Paige W. Cunningham on Healthcare and the 2020 Election

CHRISTIANE AMANPOUR:

Now when it comes to the November election in the United States, healthcare is the number one issue for voters in both parties. Paige Winfield Cunningham is a national reporter at the Washington post and she focuses specifically on healthcare policy and despite the healthcare Wars within the democratic party and also between Democrats and the GOP, Cunningham tells our Hari Sreenivasan and that neither party will make major changes to insurance policies.

SREENIVASAN:
Since we’re thinking about Iowa tonight, does someone in say Dubuque have the same access to healthcare as someone in DC?

PAIGE W. CUNNINGHAM:
It’s been almost 10 years since the affordable care act was passed that landmark health care reform law. But there have been some things along the way which is which have actually hindered the law and so we haven’t reached the uninsured rate that we had hoped or that the insured rate that we had hoped for when Congress was passing the law. Um, and so it sort of varies by state. Some States accepted the laws, Medicaid expansion. And so we have a lot of wide variation in terms of health insurance, public health insurance programs that are available for people state by state. Um, certainly the issue has a, uh, is a, is a really important one for Iowa voters. I think it ranks above even removing Trump from office, um, or climate change in terms of what Iowa voters are worried about. Um, and you really have seen that in a lot of the conversations on the campaign trail that the candidates are having,

SREENIVASAN:
That healthcare, healthcare, healthcare, it’s still matters to them. Um, is there, you know, there’s also been a number of stories including from the Washington post on how rural hospitals are suffering in a, in a different way that there’s basically, obviously geography is a problem for if you’re in rural Kansas or rural Iowa, you have to drive farther. But then now if those few hospitals start to close down, you’re really going pretty far if you’re not going across state lines. And that could actually just affect something as simple as an ambulance getting to you.

PAIGE W. CUNNINGHAM:
Absolutely. So that question of healthcare access has really come to the forefront as the candidates have talked about Medicare for all. Yeah, because you’re right, right now in a lot of rural communities, we do have provider shortages. That’s been a problem we’ve had for a long time. Um, but you’ve really seen hospitals mobilize with a lot of other providers against this idea of Medicare for all. And what they’re saying is that because Medicare pays at so much of a lower rate than what the private insurers reimburse for, that if you go to a single payer system where all of a sudden all of their patients are covered under a single government plan, they’re going to be facing big payment cuts. I mean, I think studies have shown Medicare often pays only 50% or even less than what private plans do for inpatient and outpatient procedures. Um, so, but then at the same time, um, our reporters have looked at healthcare systems in other countries that do have more of a single payer type of a system and found that they don’t have those shortages necessarily. If you go to Canada, um, they have a much more expansive system where people have a basic coverage and then they can buy private coverage for supplemental things. Uh, prescription drug coverage and dental, but they sort of have this basic guaranteed coverage. Um, and you know, those reimbursement rates are certainly lower for providers and yet we don’t see those shortages necessarily.

SREENIVASAN:
But where do the candidates now the, the, this at least the top tier candidates stand on this because early on in the campaigns it seemed like everyone was for Medicare for all. Now Bernie Sanders seems to be the only ones still sticking to it because he’s been talking about it for a long, long time.

PAIGE W. CUNNINGHAM:
Right. It was so buzzy last year. I mean, even as a health policy reporter even, I was surprised at how excited and the candidate seemed to be about it. I think a big reason though was because, you know, it was early on in their, in their campaigns, they hadn’t really taken the time to look closely at what do they mean by Medicare for all. So, you know, on one hand, yes you have Bernie, he’s been thinking about this for a really long time. He had initially proposed his Medicare for all bill several years ago and then came out with a second edition, additional version of it. And he’s really spent the time to think about, you know, what services should be covered. You know, should we have copays or deductibles? He’s come out proposing a very, very generous plan. Um, and I think that Democrats really liked his plan initially because it kind of goes to that idea they all embrace, which is universal coverage, bringing the country to a place where everybody has covered. You know, we’re still kind of stuck in this place where 27 million Americans still lack health insurance even after the affordable care act. Right? So how do you get there? And you know, the thing that all these DMS share in common is the idea that everybody should have coverage. But what you saw last year is as the candidates start thinking about what it would look like as they started looking at how the issue pulls among voters and the tough questions that really come up when you talk about a single payer system, a lot of them kind of started softening their approach. Kind of walking it back a little bit, um, to where you’re right now, I think Sanders would be the only candidate who is still really promising that this is something he would try to really accomplish immediately upon becoming president.

SREENIVASAN:
And was what happened to Elizabeth Warren, kind of a cautionary tale for them to say, okay, well here she is. She’s for this idea. Now when she’s pressed on it, she’s not as stridently in support of it as she used to be.

PAIGE W. CUNNINGHAM:
Yeah, I would say I think the candidate that was the more, the most forward thinking or the most, um, foresightful on this was probably, um, mayor P Buddha judge. Um, you know, he had said things very much in favor of Medicare for all, just as mayor before he ever launched his presidential candidacy. But then, you know, last spring you could almost see the wheels turning and he kind of realized that it wasn’t going to be a very tenable position to be in favor of eliminating most people’s coverage. And so he came out with this Medicare for all who wanted option, which is sort of a very clever way of saying let’s have a government plan available to everybody, but the voter gets to choose what they want. Um, Elizabeth Warren has gone a similar direction but in a little bit of a different way and a way that I think is actually you could argue was politically smart where you know, she says she still wants Medicare for all as envisioned by Sanders. This very generous plan. That’s her ultimate goal. But she kind of walked, softened her position a little bit last fall by saying, I’m not going to push for this right out of the gate. What I’m going to try to do initially is just make Medicare available for more people. So people down to age 50 actually, and then introduce a public option plan that people could also buy into. And then once I hit the third year of my presidency, then I’m going to try to go for Medicare for all. So I think she’s, she’s kind of trying to like walk both sides of that, but by positioning herself as not quite as revolutionary as someone like Sanders, but also someone who’s progressive enough that this is where she wants to ultimately go.

HARI SREENIVASAN:
You can promise anything you want when you’re on the campaign trail, but if you don’t have, well if you don’t run the board, if you don’t take the white house, you don’t take the hold the house and you don’t take the Senate, what is the likelihood even of a president Sanders getting this through a Republican controlled Senate?

PAIGE W. CUNNINGHAM:
Yeah. Well, you know, I’ve been covering all of the battles over the affordable care act now for almost a decade and 10 years out. We are, Congress is still not at a point where it can even agree enough to fix things in the ACA or improve the ACA. Of course, it’s looking like Republicans are going to retain control of the Senate and if they do that, I’m a democratic president. Whether it’s Sanders or Biden, um, is probably going to be largely stuck with trying to undo a lot of the policies that the Trump administration has rolled out in terms of Medicaid and different rules around the affordable care act. Um, democratic administration could also work on drug pricing and tried to advance some of those things, but I don’t ultimately see a situation where you have any kind of seismic shift in the insurance programs that are available to Americans or any big shift didn’t really who’s insured or how many people are insured or where their insurance comes from. No, Congress did try to take on a surprise medical billing, drug pricing. What happened to that? Oh, that is a real story. I think of industry influence. Um, you know, last year there was a lot of optimism at the beginning of the year that we were, that was sort of one area of bipartisanship and you saw leaders in both the house and Senate saying, we want to make this happen. We saw a big, you know, a bipartisan, um, drug pricing bill out of the finance committee. We’ve seen a lot of bipartisan work on the surprise billing issue in house committees and there was a lot of talk that some of these provisions would get tacked onto the year end spending bill in December. But there was a huge, huge opposition of course from pharma, which everyone expected to the drug pricing measures. But what was really surprising is on the surprise medical billing issue, um, which everyone thought was going to happen. Um, you saw a lot of these doctors groups, uh, a lot of hospitals actually kind of take sides with insurers over how you would fix this problem and they’re sort of different ways to um, calculate how surprise medical bills would be paid. And the doctors and the hospitals were afraid they were going to get the short end of the stick and the insurers were afraid they were going to get the short end of the stick. And so at the end of the day when the lawmakers were trying to sort of hammer out these specific approaches, there was so much advertising and so much pressure from the industry groups that it all seemed to kind of collapse at the end of the year.

SREENIVASAN:
One of the images that struck me in the past year and a half for the busloads of people going across to Canada to get their medications just because the prices were so different. Right. And that was one of the things that the president said he was going to do is make it possible for you to buy drugs from Canada. Where, where’s that at now?

PAIGE W. CUNNINGHAM:
Yeah. So, um, this is become a real sore point for health and human services. Secretary Alex ASR, he had really wanted to sort of put his Mark on the drug pricing issue, um, and they have just kind of run up against wall after wall. Um, and you know, they came out with several policy proposals that were considered very aggressive, especially for a Republican administration. Um, they were going to try to crack down on these, um, drug rebates that are paid, that sort of convolute the whole system and push list prices up. Uh, they issued a rule requiring drug makers to display the list prices of drugs and television ads. Um, in December, they proposed a rule to allow the importation of some cheaper drugs from Canada. Um, but in many of the cases, not the Canada case, but in many of the other cases, they either had to walk back because of sort of side effects or industry pressures.
They’ve seen some of the things blocked by the courts. And then some other, uh, policies that they had promised haven’t actually come to fruition yet. And so now we’re at a point where, you know, there’s been reports recently that Trump has been really frustrated about the state of affairs and he spent a lot of the last two years promising that drug prices would go down promising to make his Mark on this. And now he’s going into this election year with honestly not very much to show for it. And we saw a lot of drug makers hike prices once again this year. Something they typically do at the beginning of the year. We saw the house Democrats pass a drug pricing bill in December. Uh, but they only got the support of two Republicans for that. And that would have been pretty revolutionary. And allowing the federal government to start directly negotiating prices, much like what happens in other countries. Um, but of course that’s a nonstarter in the Republican led Senate. So it’s a little bit difficult at this point to see where we go from here.

HARI SREENIVASAN:
When we talk about healthcare reformers really kind of seems like two fronts. One is the expansion to cover more people than have it today. And then the other is to really fix the problems with the system that hundreds of millions of people are on. Right. I mean, what’s the administration up to, uh, in terms of either expanding the roles or perhaps even doing the opposite.

PAIGE W. CUNNINGHAM:
Yeah. So, um, what the administration has done and of course they, you know, it should be noted, they very much wanted the affordable care act to be repealed and replaced. Back in 2017 the president had, had talked about promises and even exactly, and even hammered on it last year, even though Congress had really moved on past that and Republicans had indicated they were tired of that effort. Um, so, you know, I, I think the administration has tried to carve out a niche for itself on expanding alternate forms of coverage. So one of their arguments against the affordable care act has been okay, more people have health coverage but it’s not affordable coverage, which there is some truth to that certainly. And so what they’ve done is they have issued regulations expanding access to some of these short term limited duration plans. Um, and also, um, association health plans. Um, Democrats have sort of taken that and run with them and kind of pointed the, pointed the finger and tried to argue that the administration is trying to expand junk plans and all this. So sort of turned into a political issue. But you see president Trump out there sort of making these big bold claims saying that we’ve suddenly fixed Obamacare and made insurance so much more affordable.

PAIGE W. CUNNINGHAM:
And it’s important to keep in mind that while they have made sort of these minor changes, they haven’t made any major changes to sort of the insurance coverage offerings available to people and the cost of that insurance.

HARI SREENIVASAN:
What about the efforts to tie work requirements into Medicaid? That happened kind of on a state by state level in a couple of different places. Where’s the administration on that?

PAIGE W. CUNNINGHAM:
So that’s another big way that the administration is kind of looking to put a more conservative Mark on health insurance. You know, Republicans have been frustrated by the Medicaid program for a long time. They’ve always argued that this is way too expensive for States. And so Sima Varma who’s the head of the centers for Medicare Medicaid services, she actually comes from Indiana where she worked a lot on their program. So two years ago she extended a letter to States inviting them to apply. So the States have to go to the federal government and say, Hey, could we have permission to implement these work requirements? About 10 States have done. So CMS has given permission to all of them to go forward with this. Um, but at this point it’s really turned into a big legal battle because courts have blocked these work requirements in almost every state. You know that the heart of the question here is whether, um, what are the key objectives of the Medicaid program? Um, the obviously the, the fundamental point of Medicaid is to make sure that people who are low income have access to health insurance. What SEMA Verna likes to argue is it should also have the purpose of incentivizing people to find work to get job training to volunteer in their communities. Exactly. So it, she, she sees it as a program that is supposed to help give people a hand up. And so this is so, so this is sort of the fundamental dispute about what is the nature of the Medicaid program and that’s what the courts are considering right now.

HARI SREENIVASAN:
So how does president Trump deal with healthcare on the campaign trail going forward this year? Considering that there are a couple of key things that he promised that he hasn’t been able to do. And there were a couple of things that he kind of has underway.

PAIGE W. CUNNINGHAM:
I can’t overstate how tricky this is for him. Um, you know, when you look back at his campaign in 2016, um, he was writing off of those wins of Obamacare repeal and, and, and this was an issue that voters still believed Republicans would repeal, replace Obamacare and it played really well for Republicans at the time. Now four years later, obviously he hasn’t been able to do that and he hasn’t been able to implement any big changes on drug pricing so far.

PAIGE W. CUNNINGHAM:
And his parties tired of that fight and his party. Yeah. And so Democrats really probably had the upper hand on healthcare issues back in 2018 because they talked about this issue of preexisting condition protections and this lawsuit against the affordable care act. And so the challenge for Trump is going to be to try to flip that script and make sure that he’s not one the one on the defense about healthcare the whole time. So far, I haven’t really seen what his line is gonna be or how he is going to be talking about that. That’s probably partly because the democratic candidates have mostly been going after each other at this point, talking about and arguing about their differences over public auction versus Medicare for all. But I think once we have a democratic nominee, then those, those discussions between him and whoever the nominee is, uh, will probably become clearer and he’ll really have to figure out what is his healthcare message going to be.

HARI SREENIVASAN:
Paige Winfield Cunningham, thanks so much.

PAIGE W. CUNNINGHAM:
Thank you.