Bernie Sanders, Not Joe Biden, Sets the Democratic Party Line

By Justin Charity, The Ringer

14 September 19

Biden may be popular among Democratic voters, but he becomes a marginal figure in the company of his presidential primary rivals

n his opening remarks at the third Democratic presidential primary debate, Joe Biden struck a lonesome defensive in his battle against “Medicare for All.” “My distinguished friend—the senator on my left—has not indicated how she pays for it,” Biden said, “and the senator [on my right] has in fact come forward and said how he’s going to pay for it, but it gets him about halfway there.”

Biden was referring to Massachusetts Senator Elizabeth Warren and Vermont Senator Bernie Sanders, who flanked the former vice president on the debate stage at Texas Southern University in Houston. It was the first debate on network television, and the ABC News moderators asked the 10 candidates far more pointed questions than in the previous debates on CNN and MSNBC. It was also the first time Biden and Warren appeared on the same stage together, which presented a loaded contrast given their decade-old rivalry about bankruptcy reform in the Senate.

But Biden and Warren didn’t duel too aggressively. Biden and Sanders—the two front-runners in the race—haggled over health care reform (in the first hour) and the Iraq War (in the second hour), but they, too, declined to heighten the ideological contrast of their positions. Instead, Biden again confronted his most unlikely critic, Julián Castro, who, like Biden, served in Barack Obama’s administration. Castro, the former secretary of housing and urban development, mocked Biden’s wavering promises about buy-in costs in his “Medicare for choice” proposal. “Are you forgetting already what you said just two minutes ago?”

Castro then ridiculed Biden’s attempt to deflect questions from the Univision anchor, Jorge Ramos, about 3 million deportations—“the most ever in U.S. history,” Castro stressed—recorded under the Obama administration. “Every time something good about Barack Obama comes up, he says, ‘oh, I was there, I was there, I was there, that’s me, too,’ and then every time somebody questions part of the administration that we were both part of, he says, ‘well, that was the president,’” Castro said. “He wants to take credit for Obama’s work but not have to answer to any questions.”

Biden didn’t quite lose to Castro, whose remarks verged on arrogance and cruelty. But Castro’s pointed attacks on Biden’s record as vice president underscored a persistent riddle in these debates. Obama remains highly popular among Democratic voters, and Biden wastes little opportunity to tout that administration’s record. How might the party’s major presidential contenders glamorize Obama’s legacy even as they jockey to supersede the signature achievement of his presidency? On Thursday, the 10 Democrats on stage acknowledged only two partisan forebears: Barack Obama and Bernie Sanders.

Biden’s rivals paid homage to Obama’s efforts to overhaul the health care system. They asserted Obama’s singular responsibility for Obama’s legacy, for better or worse. They denied Biden credit for, well, anything. Meanwhile, they regarded Sanders with measures of deference that elude Biden. “I want to give credit, first, to Barack Obama for really bringing us this far. We would not be here if he hadn’t the courage, the talent, or the will to see us this far,” California Senator Kamala Harris said. At the end of July, Harris withdrew her support for “Medicare for All,” if only to launch her own proposal which would permit private insurance. “I want to give credit to Bernie. Take credit, Bernie! You brought us this far on ‘Medicare for All,’” Harris continued. In these debates, “Medicare for All” has proved as influential in theory as Obamacare has proved in practice. Sanders has proved more vital than Biden in determining what the candidates even bother to discuss. Biden has proved inessential in most policy discussions, though he remains indispensable, in purely practical terms, as a bulwark against Sanders at the polls.

But Biden struggles to deny Sanders’s influence within Obama’s party, a point reinforced by Castro in the debate. “I also want to recognize the work that Bernie has done on this,” he said. “We owe a debt of gratitude to President Barack Obama. Of course, I also worked for President Obama, Vice President Biden, and I know that the problem with your plan is that it leaves 10 million people uncovered.” Minnesota Senator Amy Klobuchar opened the debate with complaints about “off-track” proposals and partisan extremes; she later formalized her opposition to “Medicare for All.” “I don’t think that’s a bold idea. I think it’s a bad idea,” she said. To bolster her criticisms, Klobuchar needed only turn to the party’s alternative figurehead, Obama, in her push for a public option. “What I favor is something that Barack Obama wanted to do from the very beginning,” Klobuchar stressed. She echoed Biden without ever deigning to defend him.

Biden may be popular among Democratic voters, but he becomes a marginal figure in the company of his Democratic rivals. In a quaint moment for an otherwise slick participant, South Bend Mayor Pete Buttigieg fretted about Castro’s hostility toward Biden. “This is why presidential debates are becoming unwatchable,” Buttigieg interjected. “This reminds everybody of what they cannot stand about Washington: scoring points against each other, poking at each other.” Castro relished the irony in Buttigieg’s seizing a debate stage to rail against the very existence of disagreement: “It’s an election,” Castro responded. Viewers might have struggled to discern which candidate’s example proved more Obama-esque: Buttigieg’s post-partisan posturing or Castro’s irreverent challenge to a front-runner on the defensive. They might struggle to accept Sanders’s vision for U.S. health care. But Biden offered viewers little reason to believe he might dominate the Democratic imagination as Obama once did—and how Sanders now does.

How Greedy Hospitals Fleece the Poor

By Libby Watson, The New Republic

14 September 19

The most vulnerable Americans are being dunned into destitution through surprise fees and fraudulent practices.

he pundit class collapsed back in its chair last week, exhausted and spent, from a furious wonk-off session over Bernie Sanders’s rhetoric on medical bankruptcies. The Washington Post’s in-house political fact-checking apparatus assigned a devastating three Pinnocchios to Sanders for saying 500,000 people a year go bankrupt from medical bills. The Sanders camp complained, and the Post’s Grand Factmaster Glenn Kessler pushed back. Wonks stranded on the periphery of the action, like Megan McArdle, joined the fray, arguing that medical bankruptcies are actually much less common than Sanders asserts, because how can you tell whether medical debt was the precipitating event in a bankruptcy if sometimes people get unnecessary cosmetic dermatology? Checkmate. 

The episode was a good reminder of the dangers of Wonk Brain, which leads sufferers to fight viciously over questionable methodology and imprecise rhetoric while ignoring the bleeding obvious and the obvious bleeding. Americans face rapidly ballooning health-care costs; get pursued into financial ruin for the crime of getting sick; and get sicker and die because the price of health care is too high to pursue it at all. The precise number of people who go bankrupt because of a medical bill matters far less than the fact that medical bankruptcy is a real danger in the United States in a way that it simply isn’t in other developed countries. You don’t have to have a degree in economics to figure that out; you just have to have ever looked at a hospital bill.

Or read the newspaper, because lately, they are filled with tales of chicanery from those same hospitals. On Monday, a Kaiser Health News report detailed the University of Virginia hospital system’s heartless pursuit of poor patients who owe them money. The hospital has sued its patients 36,000 times over six years, for as little as $13.91, with devastating consequences. The hospital has garnished wages and put liens on houses, levying high interest on delinquent patients. It sued its own employees for unpaid bills around 100 times a year.

It’s not just happening at UVA, though they are particularly aggressive. Last week, The New York Times reported on Carlsbad Medical Center in New Mexico, which has sued many more of its patients for unpaid medical bills than nearby hospitals; even the county judge who hears the cases was sued. In June, ProPublica published a story on Methodist Le Bonheur Healthcare Hospital in Memphis, which filed 8,300 lawsuits against patients in five years. 

These hospitals are outliers in their communities, pursuing cases more aggressively than other hospitals do; some don’t file lawsuits against patients at all. These particularly aggressive hospitals are only known about because reporters have highlighted their practices. How many more of the 6,210 American hospitals are suing their patients? And, in turn, how many Americans have been sued by their hospitals? We don’t know, but it’s at least thousands. 

We are, however, learning some of the stomach-churning details about these hospitals’ practices. The primary case documented in the UVA article involved Heather Waldron, who was sued over a $164,000 bill she received for emergency intestinal surgery. The article notes that figure is “more than twice what a commercial insurer would have paid for her care.” What relationship, then, does that charge have to what it actually cost UVA to provide Waldron’s care? We don’t know. The hospital probably doesn’t even know. It doesn’t have to tell anyone anything about how they came to this dollar amount in order to pursue her to the point where she has to sell her house and go on food stamps. 

Last year, The Wall Street Journal reported on the case of a Wisconsin hospital that had actually attempted to determine the real cost of a knee surgery at its facility, for which the list price was more than $50,000. It turned out the answer was $10,500. The hospital had set the price nearly five times higher “using a combination of educated guesswork and a canny assessment of market opportunity,” according to the Journal. 

Mere days after that report, Kaiser Health News reported on the case of Drew Calver, an Austin, Texas, man whose heart attack resulted in a bill of $164,941, which the billing experts at WellRithms told the reporter should have only cost around $26,985. No one is stopping this—except for Kaiser Health News reporters, whose efforts got Calver’s bill lowered to $332. 

Though Medicare and Medicaid will only reimburse a set amount for each procedure, a hospital can charge private insurance—and patients—whatever it can get away with. The Congressional Budget Office found in 2017 that private insurance paid hospitals an average of 200 percent of what Medicare would pay, which is why the hospital lobby is so desperate to prevent any expansion of government-provided health insurance. 

The Affordable Care Act protected more patients from this desperate situation insofar as it increased the number of people with insurance, and mandated coverage for preexisting conditions. But people with insurance routinely end up with massive medical bills, most horribly through the practice of “surprise billing,” where a patient goes to an in-network facility but sees an out-of-network doctor. (The expectation that patients in the middle of medical emergencies are supposed to diligently look up whether the emergency room is in-network is absurd enough, but there is almost nothing a patient can do to prevent an out-of-network doctor from treating them when they arrive.) Hospital groups are currently fighting legislation that would end this practice.

Because of this system, where hospitals set a potentially bogus list price and then negotiate from there with each insurance provider they accept, uninsured patients or those who get surprise bills get screwed. Those without insurance are expected to pay a lot more than their insurance would if they were insured, or if their insurance covered it. Patients are mere pawns in the games that hospitals play with insurance. (UVA offers a 20 percent discount for uninsured patients, but clearly prices can be inflated by much more than that discount would provide.) If a hospital has to pretend that a knee surgery costs five times what it does to get insurance to pay twice what it actually does, who cares if the odd patient gets sued into financial oblivion? 

If you’re a poor patient who lied about having a preexisting condition when you signed up for your short-term health insurance plan—which, because short-term plans are not covered by the Affordable Care Act’s rules about what particular means of price-gouging insurance companies can engage in, is allowed to discriminate and charge more on the basis of preexisting conditions—you could be charged with fraud. Would UVA ever be charged with fraud for telling Heather Waldron she owed them $164,000 when the hospital would have accepted half that from insurance? Would anyone in the legal system that allowed them to garnish thousands of paychecks and seize people’s tax refunds ask them to prove that the charges themselves were not fraudulent? 

We can keep letting hospitals use the state to immiserate its own citizens. But it will not stop uninsured people from needing care; American livers and lungs will keep resolutely ignoring their owners’ financial shortcomings. And when you have uninsured people seeking care, you will have to spend a lot of time and money figuring out how to pay for it. 

A much simpler way would be to have the government pay for all health care—a “single payer” that covered everyone. That would help hospitals that don’t benefit from having large numbers of privately insured patients, like rural hospitals. But hospital CEOs who currently make a lot of money (even those at nonprofits; many large nonprofit hospital executives make multimillion dollar salaries) would not be helped. They would make a lot less money.

In America, corporations are warmly encouraged to put their foot in the state’s boot to stand on the neck of the poor, whenever that might be profitable. Landlords get judges to sign off on the civil arrest of tenants in pursuit of unpaid rent, plus that juicy lawyer’s fee and accumulated interest (for whatever reason interest must always accumulate). Stores like Walmart pursue shoppers who they have falsely accused of shoplifting for the value of the goods they didn’t steal. Debt collectors trick people into reviving their old debts that have fallen out of the statute of limitations, then sue them again.

There is a thread connecting stories like this with UVA’s outrageous pursuit of its indebted patients. Any arm of the state—the law, courts, Congress, the police—can act as a tool of any corporation organized and rich enough to use them. One patient in the UVA story, Zann Nelson, had entered the hospital “bleeding and in pain” with “newly diagnosed uterine cancer,” according to the story. She lost her court battle against UVA over its pursuit of her $23,849 bill, when a judge ruled that she had “the ability to decline the surgery.” What chance does the average person have against a system like this?