I spoke with Senator Bernie Sanders late last week about the issue of the moment nationally: reforming the health care system. Sanders spoke about his views on the prospects for a strong public plan to survive the legislative process, discussed the prospects of meaningful reform against an often too – conservative Democratic caucus and without hitting the private insurance industry head on, the stakes for the nation and the state, and what Vermonters can do to help the process.

My recording rig was decidedly low tech, so there are some gaps where the conversation could not be cleanly transcribed, but 98% of the conversation remains, I think.

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odum: You’re obviously a proponent of single payer health care. You’ve suggested in the past that it might be more workable at the state level…I understand you’ve tried to include that option in the health care bill – and you’ve also introduced the American Health Security Act of 2009 (which would introduce single payer at the national level), so its easy to infer that you’re just going at the issue from every way you can. But of those two approaches, the state level or the federal level – which do you really feel is more practical and attainable?

Sanders: Well at this particular moment, neither is going to be attained. This country is facing a major, major health care crisis, and I think most Vermonters know the dimensions of that crisis. It’s 46 million without any insurance, more are underinsured. John, its very important not to forget that a lot of folks who count for having insurance end up with $10,000 deductibles and very weak insurance programs that really don’t address their health care needs. We have 60 million Americans who do not have access to a doctor on a regular basis, and that can end up in the emergency room or in the hospital at great personal suffering and great expense to the system. In the midst of all that we end up spending twice as much per person on healthcare than almost any other country on Earth.

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So we have a system clearly which is dysfunctional, which is not working, which results, by the way, in some 18,000 people dying every year because they don’t get to the doctor when they should.

So in my mind, if you are serious about doing the following three things; number one, providing comprehensive – that means coverage for all basic health care needs to all Americans, and if you want to do that in a cost effective way – the only solution is to end the dominance of the private insurance companies, and the 1300 private insurance companies and the thousands of different programs which end up, just in terms of administrative and bureaucratic costs, wasting about 400 billion dollars a year. That’s the only approach – and I say that not from an ideological approach, just from a basic economic point of view –  that you can save 400 billion a year through administrative costs, and that’s why I’m for single payer.

Now, you’re asking me which way is going to be more practical – I’ve introduced in the health committee the state option for single payer. I got 4 votes. Out of 23 members. No Republicans and 4 out of 13 Democrats.  I think, you know, there is the potential to do better, but right now – for a variety of reasons having to do, among other things, with the fact that the insurance companies and the drug companies are spending hundreds of millions of dollars in lobbyists, in campaign contributions, single payer is not going to prevail at this particular point. We have more and more people in Vermont, more and more people in America, that  support that concept, but that grassroots strength has not manifested in the congress right now.

odum: Do you think universal coverage is attainable and sustainable without actually eliminating the private insurance industry or is leaving multiple payers on the table – even in a sort of Medicare-for-all scenario – limit the ability to capture savings from inefficiency too much?

Sanders: That’s a very good question. What my fear is, you know, you can put a lot of money into the system, you can expand Medicaid which will cover perhaps 20 million more people if you take it up to 150% of poverty – you can put heavy subsidies and help people, low and moderate income people to find private insurance or a public insurance program – but the question you’re asking is a good question. Because it suggests that if you put that much money – more money – into an already wasteful system, at what point does the federal government just say, you know what, we just can’t afford to keep throwing money at a wasteful system, we’re going to cut back.

So theoretically, yes, you can have universal insurance simply by throwing more money into a dysfunctional system. There is, given the fact that we have an $11 trillion national debt right now, what would probably happen is that at some point people would say, you know what, we’re going to have to cut back.

odum: Now talking about the plan that’s being bandied about and the so-called ‘public option.’ Opponents say it will be too competitive with private insurers and will lead to single payer from everybody opting into it. Proponents generally say no it won’t, but during the campaign, there was at least one Presidential candidate who was openly saying that such an approach might do just that, and was trying to make it a selling point. What do you think? Could this help grease the skids to single payer?

Sanders: Well, what it does do, if you – what the polls seem to indicate, in fairly overwhelming numbers, over 70% in a New York Times poll – is people would like the option of being able to choose a Medicare type program in competition with the private insurance companies. I think, on a level playing field offering the same set of benefits, the public proposal wins out but the administrative costs would be substantially less, and in general people feel better about a Medicare type program than they would private insurance. So I think you will see significant numbers of people coming into a private program.

Would that mean that after a certain period of time, with the existence of an expanded Medicaid, Medicare, and a public program that brings more and more people into it, that if that program performs well, you’ll be left with private insurance companies left with private insurance companies having relatively small numbers of people… perhaps, but there are other scenarios … where that would not take place, but it is a possibility.

odum: Will you vote for a bill that doesn’t include a public option?

Sanders: I don’t want to – the answer is, I have been probably – you know, my view is that there should be a single payer – at the very, very least there has got to be, not just a public option, but a strong public option, and let’s leave it at that. That is what my view is, and I don’t want to be talking about what I will do and what I won’t do, but I think at the very very least there has got to be a strong public option.

Now in the bill – the bill that passed has, I don’t know how many pages it has, but many many many hundreds of pages, so a lot of good things in this bill. While it is not single payer, and while even the public option is not as strong as I would like, there are a number of things in it that have not gotten a lot of publicity which are very important.

For example, I have pushed very hard on the whole issue of primary health care. Because I think you’re not going to tackle the health care crisis in general, to what it means to the people and the costs, unless you significantly change our approach to primary health care. In this bill, we have basically laid the groundwork for a revolution in primary health care, and that’s something that I pushed. There will be a quadrupling of community health centers in Vermont. In the last six years we’ve gone from 2, to 8, and you know have over 30… federally qualified health care centers which provide on a sliding scale basis primary health care, dental care, mental health counseling and so forth – prescription drugs. We have over 30 satellites treating over 100,000 Vermonters in terms of their primary health care right now. We’re going to increase that number with new health centers in Bennington and Addison Counties over the next couple of years. This legislation quadruples the number of community health centers in America. Quadruples them. Providing them in every underserved area in America. … we’re going to get tens of thousands of new doctors and dentists into primary health care. Is that pretty significant? It is.

This legislation puts a lot more money into disease prevention, so that we can do our best to prevent people from coming down with heart disease, cancer, diabetes, and other chronic diseases, which cost significant sums of money. We have language in there dealing with quality control – (to) deal with the reality that some medical facilities provide higher quality care at lower costs than other facilities do, and to learn from that experience. Is that important? It sure is.

So there are a number of components in this bill that are pretty good. Pretty significant. There are others that are fairly weak, and that’s where we are today.

odum: How committed do you think the Obama administration is to making sure this bill comes out the other end a meaningful bill – it seems like the signals have been sometimes mixed.

Sanders: I think that’s not necessarily the right question. I think they are committed. The problem is – here’s what you’ve got politically. You have the Republicans who essentially don’t want to do anything. So that means the ballgame is completely with the Democrats, and as you know, the Democrats are not a particularly progressive party. So you’ve got a number of conservative Democrats whose views on this issue are not different than the Republicans. They don’t want – forget single payer – they don’t support a strong public plan. You need to expand funding for example – they don’t want to do progressive funding, they would do a tax on health care benefits for example, which is totally anathema to many progressives.

Here in an instant is the heart of the problem; you have a health care system today that is disintegrating, and it ends up being the most wasteful, expensive, bureaucratic, in the entire world. The situation if we don’t do anything will only deteriorate further…

…you have Republicans saying no to anything significant, which leaves only the Democrats to deal with it. You have a number of conservative Democrats who are not prepared to do that for a variety of reasons, you have the insurance companies and the health care industry spending $1.3 million every single day – every single day – on lobbying, drug companies spending huge sums of money.

So the political question you have – is the United States Congress with the Republicans saying no – right wing and not wanting to do anything. With the Democrats not being particularly progressive. Is there the political capability of addressing this crisis? And the answer is, it’s not quite clear. It may well be that there is not. You know, its like saying that there’s is a major fire in a downtown in a small town and you just don’t have the fire department to put it out, and the fire is wreaking havoc. That’s where we are right now. It’s a huge crisis, it is getting worse, we are in worse shape than any other major country on Earth, and we may not have – for a variety of reasons – the political will to stand up to the insurance companies … and that just may be the political reality. I hope it is not, but that may be.

odum: Well, we’re working on those Democrats…

At this point, how are the prospects for keeping the caucus together against a filibuster looking – and that’s been an effort you’ve really been at the forefront in.

Sanders: And I’ve helped kind of raise that issue. In some respects, the election of Al Franken is the best thing that could happen to the Democrats, and in some respects its the worst thing, because what it says now, when the average American says ‘Wait a minute, we’ve given you a Democratic – we had 8 years of the worst administration in the modern history of America, George W Bush, all right? We turned that administration aside and we gave you a Democratic president, we gave you a strong vote in the house, and now we’ve given you a filibuster proof vote in the Senate with Al Franken. You’ve got 60 votes. And the good news is you have the power to do something.’

What I have said is that every Democrat in that caucus – or independent – can say to the Republicans that we’re not going to let you filibuster and filibuster and filibuster and defeat the ability of the American people to address the health care crisis, and that’s wrong. We’re going to vote to stop the Republican filibuster, and the point here that’s underlying that point is that  you do not need 60 votes to pass legislation, you need 60 votes to stop a Republican filibuster. And my view from day one has been that every Democrat has to pledge to stop a Republican – every person in the Democratic caucus – has got to vote to stop a Republican filibuster. And if after that, there are some Democrats who are not prepared to support at the very least a strong public plan, let them vote no. All you need is 50 votes plus the vice president and you’re going to have health care reform with a strong public plan. And that’s been my view.

And running to the Republicans – and Chuck Grassley and others in the conservative group saying ‘oh you need our vote.’ You don’t need their vote. There’s 60 in the Democratic caucus, you can stand together you can defeat the Republican filibuster, then you need 50 of them plus one and you’ve got 50 of them plus one to pass a strong public plan

odum: On the way out, I’d ask if you have any suggestions of what Vermonters can do to help this process, given that, you know, we’ve got a pretty solid delegation in you three guys up there. Is there any other way we can weigh in and try to affect it?

Sanders: The answer is, I think, you have – the message has got to be that every member of the Democratic caucus has got to be prepared. That number one – at the very least, there’s got to be a strong public plan within the legislation. And the Finance committee is not going to report out a strong public plan. The Health Committee did and the House bill has a reasonably strong plan. And number two, that if there are people in th4e Democratic caucus that don’t want to support a strong public plan, that’s fine. Let them vote no. But let the entire caucus stand together against the Republican effort to do nothing, and that we need a national movement – a strong grassroots national effort to do that, and I hope Vermonters will participate in that effort.