Now that he’s the presumptive Democratic nominee for president, Joe Biden has to make an overture toward disappointed Bernie Sanders supporters, only 80 percent of whom say they’re ready to back him in the general election. It’s not just that Biden needs their votes (though he does). It’s that the party’s younger, left-leaning members deserve to be treated like equal partners in a coalition rather than as a nuisance that ought to keep quiet and get in line at the polls. The former vice president won’t win over everybody (to state the obvious), but he should still make a good-faith effort.
At the same time, Biden isn’t going to suddenly stop being a moderate and adopt Medicare for All. That’s obvious. While he’s finding ways to move left at the margins—he’s come out in favor of lowering the Medicare age to 60 and forgiving a large chunk of student debt, for instance—he hasn’t come up with a marquee peace offering. So what should he do?
I have a suggestion. It’s a way Biden could reach out to the Sanders wing while updating his health care vision for life after the coronavirus crisis—which has made the failings of our current system even more apparent, and given him an obvious reason to go bolder. It would grow naturally from his own current platform, as well as Sanders’ underappreciated work as a legislator. Plus, it would give Biden a catchy, signature proposal so that he’s not just the guy who wants to beef up the Obama administration’s legacy.
Biden should propose creating an American Health Service, an expansive network of federally funded, locally run primary care providers and hospitals that would offer more affordable treatment and help coordinate public health responses. It would build on the thousands of community health centers that already serve low-income and rural communities, which Sanders played a key role in growing, but cater to middle-class patients, as well. And it would all come wrapped in some stirring patriotic branding.
Why an American Health Service? First, and most important, it would be good idea on the merits that would address some of the glaring shortcomings of our current medical system. Most discussions about health care reform in this country tend to focus on the insurance side of the equation, for the obvious reason that we’re the only advanced country in the world that doesn’t have universal coverage. But many corners of the U.S. suffer from a basic lack of health care services, too. More than 77 million Americans live in federally designated Health Professional Shortage Areas, where providers are in short supply for part or all of the community; the dearth is especially acute in poor and rural areas, which leads people to rely on expensive emergency rooms for essential care.
The U.S. also fares poorly in international measures of health care capacity. Despite spending a bigger share of our economy on health care than anyone else, we have far fewer doctors, hospitals, and hospital beds per capita than many of our peer nations. Meanwhile, we’ve got a rural hospital closure crisis that’s threatening to make these issues worse. We overspend, yet we’re under-resourced. And while it’s too hard for many Americans find a doctor even in normal times, now we’re fighting a plague that has left us all worried about literally running out of hospital rooms.
One straightforward way to address these shortages would be to publicly fund more providers, the tried and true method used across much of the globe. In the U.S., public hospitals provide just 15 percent of beds, according to the Commonwealth Fund. In Australia and France, by contrast, they provide about two-thirds; in Germany they provide almost half; and in even in heavily privatized Japan, they provide more than 20 percent. I’m not exactly suggesting that we try to replicate the United Kingdom’s National Health Service, which directly employs most of the country’s doctors and cares for the vast majority of patients. But if we want hospitals to survive in, say, rural Oklahoma, it seems like we should take a cue from our international peers and just pay for hospitals in rural Oklahoma.
We also already have a successful model to work from: Community Health Centers, which provide primary care and services like mental health, dental, and drug treatment to around 29 million patients across the country. For that, we can largely thank Sanders, who convinced Democratic leaders to ramp up federal health center funding during the negotiations to pass Obamacare. These clinics receive federal grants, along with state and local dollars, to treat residents in underserved communities and charge on a sliding scale based on income (people in poverty pay little or nothing). Almost half their patients use Medicaid, while another 23 percent are uninsured, according to the National Association of Community Health Centers. These are not, for the most part, government-run operations—the vast majority are private nonprofits. But they have to abide by strict operating and reporting rules, including a requirement that patient representatives make up the majority of their governing boards, which keeps them focused on their public mission. And research suggests that they are very successful at providing high-quality care to patients while also lowering costs.
Sanders is widely seen as the patron saint of the Community Health Center program, and he has proposed boosting its funding as part of a wide-ranging effort to increase access to primary care in the U.S. But the centers are now widely popular within the Democratic Party; Hillary Clinton wanted to expand them in 2016. Joe Biden is currently calling to double their funding, which reached $5.6 billion in 2019.
But why not go bigger? An American Health Service could include the more than 1,300 Community Health Center organizations that already exist, which ran 11,744 care sites in 2018. Biden could triple or quadruple their funding over time, with the goal of expanding the number and size of clinics, while providing subsidized services to more middle-class patients. He could then take the basic health center grant model and apply a version of it to hospitals in underserved areas. Last July, Sanders proposed a large bailout fund to help states and counties buy distressed local hospitals. Biden could do him one better by a creating a continuous source of funding, with strings requiring hospitals that participate to keep charges affordable and serve needy populations. Nonprofit and public hospitals could both apply. And there could be additional funding for states to build new hospitals (or reopen old ones) in areas that currently lack enough beds.
Again, this wouldn’t be a strictly government-run system, like the Veterans Health Administration or Britain’s NHS. Instead, the American Health Service would be an umbrella agency overseeing a vast array of public and closely monitored nonprofit organizations operated from within the communities they serve. If we wanted a greater level of federal on-the-ground involvement, we could deploy members of the U.S. Public Health Service to work at the clinics and hospitals overseeing community health initiatives.
Aside from being good policy, creating an American Health Service would probably be a popular idea that would fit with Joe Biden’s moderate image. Americans don’t love being told to give up their private insurance. But they do like public (or quasi-public) services. The Community Health Center program in particular enjoys overwhelming support from Democrats, as well as significant backing from Republicans, who understand that it’s a crucial source of care for their rural constituents. When its funding lapsed in 2018, 105 House GOP members signed a letter to then-Speaker Paul Ryan urging him to reauthorize it. Slapping a catchy name on the program and supersizing it to include more clinics and hospitals is an idea that moderate Democrats should be able to get behind. It would also cost a fraction of other ambitious health policy ideas. Again, the current Community Health Center program costs about $5.6 billion per year. You could go an order of magnitude higher and it’d still look modest compared to the policy ideas that have been kicked around this campaign cycle; plus, it could save money for programs like Medicaid by reducing patient costs.
An American Health Service would be a complement to, not a substitute for, an ambitious agenda to reform health insurance in this country. (I’d personally like to see another Medicaid expansion, a strong public option, and more generous exchange than Biden has proposed, but let’s not digress.) It would make sure that the newly insured actually have a place to get care when they need it, and that if anybody somehow falls through the insurance system’s cracks, they still have a way to see a doctor. But while it isn’t a one-shot cure for what ails the health care system, it’s a project that could bring the centrist and left wings of the party together while giving Biden an opportunity to work directly with Sanders. Medicare for All might be the Vermont senator’s marquee policy proposal. But his biggest accomplishments as a member of Congress have been the Community Health Center expansion and the bipartisan deal he struck with Sen. John McCain to reform the VA health system. There is arguably nobody on Capitol Hill better qualified to help craft a large expansion of the federal government’s role in directly funding the provision of health care service, and Biden could promise that, if elected president, he’d make Sanders the point man on crafting legislation to create the American Health Service, or possibly put him in charge of administering it once it is passed into law. If Biden wants to win over Sanders voters, he can give their candidate a real role shaping the future of American health care.