The conventional wisdom on
Senator Bernie Sanders of Vermont is that he’s a charming if impractical
dreamer, a pie-in-the-sky socialist who’s good at inspiring young
people and aging hippies, but hopeless at the knife fighting that
real-life politics requires.
Despite the inherent limitations of a self-described democratic
socialist who eschews the norms of Beltway fundraising, the Democratic
presidential candidate from Vermont has won legislative victory after
victory on an issue that has been dear to him since his days as
Burlington’s mayor.
That issue is the simultaneously benign and revolutionary expansion of federally qualified community health clinics.
Over the years, Sanders has tucked away funding for health centers in
appropriation bills signed by George W. Bush, into Barack Obama’s
stimulus program, and through the earmarking process. But his biggest
achievement came in 2010 through the Affordable Care Act. In a series of
high-stakes legislative maneuvers, Sanders struck a deal to include $11
billion for health clinics in the law.
The result has made an indelible mark on American health care,
extending the number of people served by clinics from 18 million before
the ACA to an expected 28 million next year.
As one would expect, the program was
largely met with plaudits from patients and public health experts, but
it has also won praise from even the biggest Obamacare critics on
Capitol Hill. In letters I obtained through multiple record requests,
dozens of Republican lawmakers, including members of the House and
Senate leadership, have privately praised the ACA clinic funding,
calling health centers a vital provider in both rural and urban
communities.
To Sanders, the clinics have served as an alternative to his
preferred single-payer system. Community health centers accept anyone
regardless of health, insurance status or ability to pay. They are
founded and managed by a board composed of patients and local residents,
so each center is customized to fit the needs of a community. No two
health centers are alike.
In rural North Carolina, ACA-backed health centers now provide dental
and nutrition services, while in San Francisco, the clinics provide
translation services and outreach for immigrant families. In other
areas, they provide mental health counseling, low-cost prescription
drugs, and serve as the primary care doctors for entire counties. They
have also served as a platform for innovation, introducing electronic
medical record systems and paving the way with new methods for tracking
those most susceptible for heart disease and diabetes.
Author John Dittmer, in
The Good Doctors, traces the history
of the modern health center to the civil rights activists who ventured
into the South during the early 1960s. The activists were seen as
outside agitators, and local doctors refused to treat them. As a
solution, volunteer bands of physicians were organized by a group called
the Medical Committee for Human Rights.
Beyond treating the civil rights workers, the MCHR physicians were
struck by the stark disparity in health services, encountering many
African-Americans who had never seen a doctor before in their lives. The
activist physicians returned to the South after the “Freedom Rides” to
found a small clinic in Mound Bayou, Mississippi, in the heart of the
Mississippi Delta, and by doing so, began a movement to launch health
clinics across the country in underserved areas. Winning support from
President Lyndon Johnson’s Office of Economic Opportunity, the clinics
became part of Johnson’s “War on Poverty.”
Over the years, health centers have gained support on a bipartisan
basis. Health centers secured critical funding from the efforts of the
late Sen. Ted Kennedy, D-Mass., and both George W. Bush and John McCain
campaigned on pledges to expand them.
Sanders’s place in health clinic history
will be remembered for his forceful role in the winter of the health
reform debate. In December 2009, tensions ran high as Congress inched
closer to a final health reform deal. Sen. Harry Reid, D-Nev.,
tapped Sanders to help win support from liberals who thought the bill
was too weak as well as from Democrats from rural states who were facing
mounting pressure. More funding for community health centers, Sanders
argued, was a win-win solution for both camps, since the program would
ensure access to health care for even the most remote areas of the
country while also helping those without insurance. Sen. Ben Nelson,
D-Neb., among others, held out to the very last moment.
Two days before the Senate voted to break a Republican filibuster of
the bill, Reid called on Sanders to make his case on the Senate floor.
Sanders, in typical fashion, said the legislation was far from perfect,
but thundered about the common-sense need for health centers, citing the
acute demand for more primary care doctors, the cost-savings from
patients who would otherwise use the emergency room for the common cold,
the patient-centered model of clinics, and so on. Senate Democrats
rallied and overcame the Republican filibuster.
Bernie Sanders on community health centers in the ACA from The Intercept on Vimeo.
Another turning point came several weeks later, when Massachusetts
Republican Scott Brown won a special election in an upset victory,
ending the Democrats’ filibuster-proof majority. Brown’s
election brought Democrats close to despair, because lawmakers could
only use a procedure called reconciliation to pass the law. Such a move
would keep chances for passage alive while foreclosing any chance of
enacting the much stronger legislation that originated in the House of
Representatives through a conference committee. For progressives, it was
a painful blow that not only sealed the defeat of the Public Option
insurance program but also removed many robust provisions they had
worked hard to include. Again called upon to work out a solution with
House liberals, with whom Sanders enjoys a strong working relationship,
the Vermont senator forged a deal to build support for the bill by
focusing on health clinics.
Daniel Hawkins, vice president of the National Association of
Community Health Centers, recalls that in the end Sanders was able to
negotiate with Rep. Jim Clyburn, D-S.C., to increase health clinic
funding through a special technical amendment that could modify the
reconciliation Senate bill through a simple majority vote. The technical
amendment passed, with $9.5 billion targeted for health center
operations and $1.5 billion for construction and renovation
projects. The House passed the final Senate bill, and President Obama
signed the legislation with $11 billion in health clinic funding into
law on March 23, 2010.
“There was no one who played a more important role than Senator
Sanders,” Hawkins says, remembering Sanders’s constant lobbying of other
lawmakers to support the funding.
Although the
health reform has transformed the funding of local health clinics, few
patients even realize that the changes have occurred as a result of the
law, because few aspects of the health reform are explicitly branded as
being part of the ACA.
That relative invisibility has shielded health clinic funding from
the hyper-partisan attacks faced by other provisions of the law. But it
has also allowed Republican opponents of Obamacare to play a two-faced
game. Every single congressional Republican has voted to repeal the
entire bill, health center funding included. But many have taken credit
for popular local health clinic programs funded by the ACA, without
disclosing the source of the funds. Others have written letters
expressing their support for the money.
As I reported
previously for
The Nation,
Rep. Paul Ryan, R-Wis., among other Republicans, authored letters to
the Obama administration to recommend ACA funding for local health
clinics. Now, a new batch of letters, obtained through a Freedom of
Information Act request, shows other requests by GOP leaders.
Rep. Steve Scalise, R-La., the House Republican whip, for instance,
signed onto a letter with other members of the Louisiana congressional
delegation to ask the Obama administration for health center funding in
New Orleans. The proposed clinic, the letter noted, would build a
graduate medical training program, a proposal that “will attract not
only more citizens back to our community but provide critical training
opportunities for our region’s future healthcare workforce.”
Sen. John Cornyn, R-Texas, the number two leader in the Senate, wrote
at least 17 letters to the administration asking for funding, in cities
such as Lubbock and Houston, for a wide range of programs,
including clinics devoted to low-income rural residents and
Asian-Americans in Texas. Senators Mark Kirk, R-Ill., Kelly Ayotte,
R-N.H., David Vitter, R-La., Rob Portman, R-Ohio, and Pat Toomey, R-Pa.,
made similar requests.
It’s no wonder that politicians from rural states such as Texas would
seek community health centers to better serve their constituents. A
recent report from the Texas A&M School of Public Health found that
only 9 percent of physicians practice in rural areas. Many rural Texans
live in areas that are more than 30 minutes from the nearest hospital,
which dramatically raises mortality rates in cases of medical
emergencies.
Still, press releases from GOP officials have lashed out at the Affordable Care Act’s health center funding as some sort of “
slush fund.”
Regardless of the politics, the success
of health centers has been particularly satisfying for Sanders, who can
simply point to his own state as a reminder of its impact. One in four
Vermonters are now served by more than 50 health centers throughout the
state, according to the senator’s office. Just last month, a new
federally qualified health clinic opened in Shoreham, Vermont, to
provide dental care, physicals and medication for common diseases.
Though his own role in securing the funds for the ACA is barely
mentioned on his Senate website, the image gallery is adorned with
pictures of Sanders beaming a smile as he breaks ground and cuts ribbons
for various health clinic openings in Vermont.
Photo: Bernie Sanders, during a news conference on June 25, 2015. (Bill Clark/CQ Roll Call/AP)
