Q&A: Why Bernie Sanders says his ‘Medicare for All’ dream must wait

After railing at the injustices of U.S. health care for decades, Sen. Bernie Sanders in January became the new chairman of the Senate Health, Education, Labor & Pensions Committee. The job gives the health care industry's biggest Washington nemesis an unprecedented opportunity to shape health care reform in Congress. But the sort of radical changes he seeks could prove elusive. Even Sanders concedes there are limits to the powers of his position.

President Joe Biden's State of the Union address Tuesday night showed how much of Sanders' platform has moved into the mainstream of the Democratic Party, with Biden at times sounding like his former Democratic primary foe, lashing out at Big Pharma and its "record profits." Biden bragged about measures taken to lower drug prices and halt surprise bills during his term thus far, and he urged Congress to pass a federal expansion of Medicaid.

Still, the radical changes Sanders seeks could prove elusive. During an interview with KHN at his Senate office recently, the independent from Vermont spoke about the prospects for lowering drug prices, expanding access to primary care, and his ultimate goal of "Medicare for All."

The interview has been edited for length and clarity.

Q: What do you hope to achieve as chair of the HELP Committee — in terms of legislation, but also messaging and investigations?

A: What I ultimately would like to accomplish is not going to happen right now. We have Republicans controlling the House. And many of the views that I hold, including Medicare for All — I think if we had a vote tomorrow, we'd get 15 to 20 votes in the Senate and would not win in the House. I realize that. But I happen to believe our current health care system is dysfunctional.

We spend twice as much per capita on health care as other countries and 85 million people have no insurance or are underinsured. It is a dysfunctional system that to my mind needs to be fundamentally changed to a Medicare for All system — but we ain't gonna get it.

Q: What can you actually accomplish?

A: (From) a poll a couple of months ago just among Republicans. Top concern? High cost of prescription drugs. We're long overdue to take on, in a very bold way, the greed and outrageous behavior of the pharmaceutical industry.

Q: There are so many parts of the system that are messed up — patents, 340B, pharmacy benefit managers, insurance issues with formularies …

A: Right, there are a million parts to this problem.

Q: So short of a complete overhaul, what are the parts that you think you can change?

A: Every year the U.S. government through (the National Institutes of Health) spends tens of billions of dollars on research. The Moderna vaccine was co-developed between Moderna and NIH and received billions of dollars in assistance, guaranteed sales, and you know what's happened in the last couple of years. The CEO of Moderna is now worth $6 billion. All their top executives are worth billions. And now they are threatening to quadruple prices. This is a company that was highly supported by taxpayers of this country. And that's one example of many.

What is the responsibility of a drug company that receives very significant support — financial support, intellectual support for research and development — to the consumers of this country? Right now, it is zero. "Thank you very much for your support. I will charge you any price I choose." We have to end that.

That's the starting point.

Q: But what's the mechanism? "March-in" rights, whereby the government could force a company to share its license for a drug that was developed with federal investment, allowing others to produce it?

A: That is one approach. Threatened by people in George W. Bush's administration, by the way. March-in is one option.

Reasonable pricing is another area. I have made two trips to Canada: once as a congressman from Vermont, took a bunch of working-class women across the border to buy a breast cancer drug; once as a presidential candidate, took people from the Midwest, and we bought insulin. The price was one-tenth of the U.S. cost in both cases.

Another area is primary health care. I have worked hard with other members through the Affordable Care Act and American Rescue Plan (Act) to significantly expand community health centers. FQHCs (federally qualified health centers) provide primary care, dental care, mental health counseling, and low-cost prescription drugs. About one-third of [people in Vermont] get primary care through community health centers.

Q: I was at a meeting of FDA and patent office people, hearing from biosimilars companies, patients, etc., and a lot of what they were saying is that the U.S. Patent and Trademark Office can't do that much about patent thickets, and it'd be good if Congress did something.

A: That is one of the disgraceful tools that pharma utilizes to make sure we pay high prices and don't get generics. Yes, it's certainly something that we should be looking at.

Q: Other priorities?

A: The crisis in the health care workforce. We don't have enough doctors, nurses, dentists, mental health counselors, pharmacists. The nursing crisis is enormous. We have a hospital in Burlington, moderate size by national standards, largest by far in Vermont. They told me they are going to spend $125 million on traveling nurses this year. One moderate-sized hospital! Meanwhile we have young people who want to become nurses, and we can't educate them. We don't have enough nurse educators. I think we get bipartisan support for that issue.

Another thing I want to look at is dental care. Not enough dentists, too expensive, whole regions don't have them.

Q: Did you agree with President Biden's decision to end the public health emergency in May?

A: (Frowns.) I have some concerns. (Sanders appeared to be the only member of Congress wearing a mask during Biden's speech on Tuesday.) It's going to dump a lot more people into the uninsured again.

Q: And things like vaccines would not be covered anymore.

A: They'd go on the market. Our friends at Pfizer and Moderna want to quadruple the prices. So if you're hesitant now about getting vaccinated, and it's free, what about when it costs you $125?

Q: As you say, drug prices are a big concern for everyone. But among Republicans there seems to be more inclination to push on pharmacy benefit managers, or PBMs, as opposed to drug companies. Is that an area where there could be legislation?

A: You've got the insurance companies, the PBMs, and pharma. Everyone wants to blame the other guy. And yet they're all culpable. And we're going to take a hard look at it.

Q: Is Dr. Robert Califf, the FDA commissioner, a good interlocutor for you?

A: A lot of work has to be done with FDA. Let's just say I think it's important that we take a hard look at what they're doing. They have some responsibility for pricing. It's part of that mission that they haven't exercised.

Q: What about the 340B issue? Accusations that hospitals are gaming the system.

A: Yes, it is something. One of the first things [I did] when I was mayor of Burlington from 1981-89 was take away the tax-exempt status of the hospital. Because I did not believe they were fulfilling their responsibility to serve the poor and working families. We had a lot of discussions, and the situation improved. Right now the criteria to receive tax-exempt status is extremely nebulous. That's an issue somewhere down the road I want to look at. If you're not going to pay taxes, what are you, in fact, doing?

Q: Do you have particular allies in either party?

A: I talked today with a conservative GOP senator who will work with me on issue X, but not issue Y. It depends on the issue. If we're going to be successful, we're going to need bipartisan support. And there is that level of support. I've talked to now four out of the 10 or 11 Republicans on the committee, and I'll talk to the rest.

Q: Do you have a policy for dealing with the lobbyists?

A: I don't have lobbyists flooding through my door. These lobbyists are effective, well paid, and they help shape the culture of where you're going. My culture is shaped by going out and talking to ordinary people. I've talked to too many elderly people who cut their prescription drugs in half.

I'm not worried about the lobbyists. Worry about the people who are dying because they can't afford prescription drugs.

I don't have to have some guy who makes seven figures a year telling me about problems of the drug companies. They have to explain to American people why they made $80 billion last year and people can't afford medicine.

Q: Are you going to bring in pharma executives for hearings?

A: We're looking at all options.

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(KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.)