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Sen. Bernie Sanders (I-VT), former Vice President Joe Biden, and Sen. Elizabeth Warren (D-MA) on stage during the Democratic presidential debate on September 12, 2019, in Houston, Texas. | Win McNamee/Getty Images

The three Democratic frontrunners finally got the chance to throw down on health care.

The leading Democratic presidential candidates finally got the chance to all jostle together over Medicare-for-all, the biggest issue so far in the Democratic primary, during the third Democratic presidential debate on Thursday night.

Former Vice President Joe Biden, Sen. Bernie Sanders and Sen. Elizabeth Warren — the three Democrats on top of the 2020 polls — finally shared the debate stage at the same time. Sanders and Warren both support single-payer Medicare-for-all, which replaces private insurance with a national government health plan. Biden has instead endorsed a public option that allows people buy into government plan but leaves much of the current health care system in place.

At the debate, Biden knocked the progressives, Sanders bemoaned the inadequacy of the center-left’s agenda, and Warren sought to assure voters she knew how the plan, Medicare-for-all, would work. It was typical of the campaign between these three frontrunners so far.

The former vice president attacked single-payer health care as too expensive and too disruptive. Sanders parried by accusing Biden of advocating for half measures that would leave millions of Americans still uninsured. Warren, splitting the difference, attempted to fact-check some of the arguments Biden applied against Medicare-for-all, but didn’t attack his plan as directly.

The odds that a Democratic president will be able to pass a health care bill in 2021 are long; Republicans are favored to keep the Senate and there is a lot of division among Democrats on Capitol Hill.

But Democratic voters care about health care, and it has been the marquee issue of the primary so far. It is also a useful proxy for the different kind of campaigns Biden, Sanders and Warren are trying to occupy in the 2020 field.

Joe Biden: Medicare-for-all is too much too fast, pass a public option instead

Biden led off the debate embracing the Affordable Care Act — he reminds voters about his relationship with Barack Obama as often as he can — and then said he wants to introduce a Medicare buy-in that lets people pay to join a government plan but doesn’t overhaul the full system, as single-payer would.

He then pivoted to attacking Sanders and Warren directly on the projected cost of Medicare-for-all: $3.2 trillion per year, or $32 trillion over 10 years. That’s roughly what expert projections expect a national health insurance program that covers everybody with minimal cost-sharing to cost. (There is a fierce and wonky debate about whether that would actually represent savings from the existing system.)

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Democratic presidential hopefuls Sen. Bernie Sanders (I-VT) and Former Vice President Joe Biden speak during the third Democratic primary debate.

“How are we going to pay for it? I want to hear that tonight,” Biden said. “My distinguished friend, the senator on my left [Warren], has not indicated how she pays for it and the senator on my right [Sanders] has, in fact, come forward and said how he’s going to pay for it, but it only gets him halfway there.”

Later, he said that “the middle-class person” would pay $5,000 more in federal taxes to cover the cost of a Medicare-for-all program. It is true taxes would increase — though he left out, and Warren quickly noted, that taxes would largely replace the private insurance premiums they pay now.

“They’re going to pay 4% more on their income tax. That’s a reality,” Biden said. “That’s not a bad idea if you like it. I don’t like it.”

Biden emphasized that his plan, which would make the government plan available to both people who buy their own insurance and people who get coverage through work, had a price tag of $740 billion, a fraction of the cost of single payer. He touted that for the 150 million people who have employer-sponsored insurance, they would be able to maintain that coverage.

“Of the 160 million people who like their health care now, they can keep it,” Biden said. “If they don’t like it, they can leave.”

However, as his opponents would soon point out, it would also fall short of universal coverage.

Bernie Sanders: Medicare-for-all is the only option, and Biden’s plan falls short

Medicare-for-all has been Sanders’s hallmark issue since his 2016 presidential campaign, and he boasted on Thursday night that he “wrote the damn bill.”

He aggressively rebutted Biden’s attacks on single payer, hanging his counterargument on two points: the current health care system is already really expensive, and Biden’s plan would still leave millions of Americans vulnerable to financial ruin if they have a medical emergency.

“We need a health care system that guarantees health care to all people as every other major country does,” Sanders said, “not a system which provides $100 billion a year in profit for the drug companies and the insurance companies.”

 Robyn Beck/AFP/Getty Images
Democratic presidential hopefuls Vermont Sen. Bernie Sanders (I-VTP) and Former Vice President Joe Biden speak during the third Democratic primary debate.

“Let us be clear, Joe, in the United States of America, we have spending twice as much per capita on health care as the Canadians or any other major country on Earth,” Sanders said later.

“This is America,” Biden retorted.

“Yeah, but Americans don’t want to pay twice as much as other countries,” Sanders said.

The vice president raised a separate but substantively interesting question: right now, health insurance is part of the compensation workers receive from their employer. Biden asked Sanders whether he really thought companies would take the money they saved on health insurance under Medicare-for-all and give it to their employees in the form of higher wages.

Sanders said he thought they would. Biden scoffed: “For a socialist, you have a lot more confidence in corporate America than I do.”

So the Vermont senator went back on the offensive, trying to pin the troubles of American health care as it exists today on Biden’s way of thinking.

“You’ve got to defend the fact that today, not only do we have 87 million people uninsured and underinsured, you have to defend the fact that 500,000 Americans are going bankrupt,” Sanders said. “You know why they’re going bankrupt? Because they suffered a terrible disease, cancer, or heart disease.”

Elizabeth Warren: Here’s why I think Medicare-for-all makes sense

Sanders knows what he wants to say about Medicare-for-all — he’s been saying it for a long time — and he seemed intent on turning the spotlight back on Biden and associate him with the status quo.

Warren, on the other hand, absorbed some of Biden’s attacks and then tried to make the policy case for single payer. Earlier in the campaign, the Massachusetts senator sounded like she had reservations about Medicare-for-all. But on Thursday night, she made a forceful argument for it.

 Robyn Beck/AFP/Getty Images
Democratic presidential hopefuls Former Vice President Joe Biden and Sen. Elizabeth Warren (D-MA) on the debate stage.

She had earlier in the campaign waffled on whether Medicare-for-all was the right path forward, but Warren has discarded those reservations in recent weeks and wholeheartedly embraced Sanders’s Medicare-for-all proposal. She has try to leave little space between the two progressive frontrunners.

At the debate Thursday, Warren was the one who was trying to make an affirmative argument for Medicare-for-all, whereas Sanders focused on Biden and the shortcomings of his more incremental plan. The moderators sought to ask her point blank whether people in the middle class would pay more money under Medicare-for-all. Warren responded:

What families have to deal with is cost, total cost. That’s what they have to deal with. And understand, families are paying for their health care today. Families pay, every time an insurance company says, sorry, you can’t see that specialist. Every time an insurance company says, sorry, that doctor is out of network, sorry, we are not covering that prescription. Families are paying every time they don’t get a prescription filled because they can’t pay for it. They don’t have a lump checked out because they can’t afford the copay.

What we’re talking about here is what’s going to happen in families’ pockets, what’s going to happen in their budgets. And the answer is Medicare for all. Costs are going to go up for wealthier individuals and costs are going to go up for giant corporations. But for hard-working families across this country, costs are going to go down and that’s how it should work under medicare for all in our health care system.

Warren laughed off Biden’s “if people like their plan, they can keep their plan” line by quipping: “I‘ve actually never met anybody who likes their health insurance company.”

When Sen. Amy Klobuchar raised the prospect of half of Americans losing their current insurance plan under single payer, Warren argued Medicare-for-all’s virtue would be cutting private insurance out of people’s lives.

“We just need to be clear about what Medicare for all is all about. Instead of paying premiums into insurance companies and then having insurance companies build their profits by saying no to coverage, we’re going to do this by saying, everyone is covered by Medicare for all, every health care provider is covered,” Warren said. “And the only question here in terms of difference is where to send the bill.”

Author: Dylan Scott

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