Undaunted by skepticism over the political viability of "Medicare for All," Vermont Sen. Bernie Sanders on Wednesday unveiled a new and more sweeping version of his signature health care bill.
Sanders is introducing the revamped proposal in the midst of a charged political moment, as the presidential primary heats up and the Trump administration makes a fresh push to topple Obamacare in the courts. But even as they circle the wagons around the current law, Democrats are eyeing the future -- and the prospects of enacting a single-payer system that would fundamentally re-order American life well beyond doctors' offices and emergency rooms.
The decision to move forward now is also expected to stoke a more pointed debate on the 2020 presidential primary circuit, where top contenders -- including Sens. Kamala Harris, Elizabeth Warren, Kirsten Gillibrand and Cory Booker, who all cosponsored the Medicare for All bill -- are being faced with a high stakes new question over the role of private insurance companies. Sanders, through this legislation, is determined to put the industry out of business. The other four, and a raft more who do not support the bill, have all said the private insurers are either inescapable or, as many moderates argue, vital cogs in America's health care system.
At a Wendesday morning event on Capitol Hill, Sanders cast the movement supporting the legislation in historical terms.
"We are involved in a great struggle not unlike, to be honest with you, the struggles of the labor movement, the struggles of the civil rights movement, the struggles of the women's movement, the struggles of the gay community, the struggles of the environmental movement," Sanders said. "This is what we're about."
Asked earlier if Sanders -- an independent who caucuses with the Democrats and is again seeking their party's nomination -- is priming for a showdown with his 2020 opponents, including the bill's candidate-cosponsors, campaign manager Faiz Shakir laid down a marker.
"Whether it's a fight that he's going to have with them is up to them," Shakir said. "This is a core pillar of why (Sanders) is running for president, a core pillar of what he would do as president. It's up to other people to determine for themselves whether and how much, how core it is for them. I will let other people decide for themselves how they'll go about it."
Much like Sanders has on the stump, Shakir predicted a sharp and expensive fight with private insurance interests to come.
"You aren't going to upend that system easily," he said. "So there's going to be a bunch of lobbying groups out there (spending) hundreds of millions of dollars and you can be damn sure that they're going to decide that an advertising campaign against Bernie Sanders is a worthwhile expenditure for them -- rather than providing health care coverage for people."
At the Wednesday rally in Washington, Gillibrand, the only cosponsor in attendance, said that universal, government-guaranteed coverage needs "to become the next social safety net, to become something that is there for you no matter what."
The New York senator, who has supported single-payer for more than a decade and wrote the Sanders legislation's four-year transition plan, said the path to building support for the bill could be greased by allowing Americans to first buy-in to a government-run public option -- a move, she argued, that would ultimately wipe out the private insurance industry.
"I dare any insurance company to just try to compete. They won't," Gillibrand said. "The insurance industry wants to make money. They are a for-profit industry. Their goals are not aligned with ours."
Booker, who was not at the rally, also discussed the bill -- and the roadblocks facing it in Congress -- during a New York radio interview.
"I think the best way to do (reach full coverage) would be to design a Medicare for All system," he said. "But anybody who says those words, 'Medicare for All,' who's running for president, the next thing out of their mouth should be talking to people about, in a split Congress, what are you going to actually do in your first year to make healthcare more accessible and affordable?"
Sanders, who did not take questions from reporters on Wednesday, has expressed reservations about blowing up the Senate filibuster, which requires at least 60 votes to pass most legislation. He has not discussed in detail his plan for moving it through a Senate in which Democrats lack that 60-vote supermajority. In a divided Congress, the legislation would likely be dead on arrival.
Soon after Sanders' announcement, White House press secretary Sarah Sanders offered another preview of the pushback awaiting Democratic candidates who back Medicare for All.
"Democrats just announced their government takeover of healthcare plan," she tweeted, claiming the plan "confiscates every American's private health insurance."
In addition to Sanders, Gillibrand and the other three presidential hopefuls, the bill's cosponsors also include Sens. Tammy Baldwin, Richard Blumenthal, Patrick Leahy, Mazie Hirono, Ed Markey, Jeff Merkley, Brian Schatz, Tom Udall, Sheldon Whitehouse and Martin Heinrich. A number of them, like the five candidates, have also signed on to less radical bills, some of which would create a Medicare buy-in system or expand previously existing programs.
The 2019 legislation would go further than Sanders' previous plans by covering more long-term care services, bringing it closer in line with a broader House version sponsored by Washington Democratic Rep. Pramila Jayapal. Nursing home and other institutional coverage would still fall to Medicaid under the new bill, as it had before, while long-term care at home and in the community would be expanded.
Apart from its new measures to cover long-term care, much of Sanders' proposal remains the same as what he introduced in 2017. He wants to create a federal universal health insurance program that would cover medically necessary services, prescription drugs, dental and vision services. Premiums, deductibles and co-pays would disappear, except for a potential $200 co-pay for brand-name drugs.
Though many of his rivals have said they would maintain a role for private insurance, Sanders' bill would effectively eliminate the industry. Insurers would only be allowed to provide services not covered by the universal plan, such as cosmetic surgery.
As for how to foot the bill, Sanders describes a litany of ways Americans are already spending billions on health care, particularly because of high administrative costs, executive pay packages and prescription drug prices. He maintains that Medicare for All, despite its cost, would save many people money.
The new legislation also lists several ways to raise additional funds, including levying premiums on workers and employers; boosting income and estate tax rates; and establishing a wealth tax.
The decision to extend coverage for home- and community-based long-term care was predicated on a need to help the elderly and the disabled, while extending care to rural communities, Shakir told CNN.
"It's a really critical part of whether you're going to be able to sustain life (among the elderly)," he said. "Home care means so much to the disability community because it is literally liberty and freedom to be able to still run their own lives and not be committed to institutions or have to travel far distances to get basic care."