South Carolina Senate Hopeful Runs on Health Care Populism

The media’s opinion leaders are always looking for the next big thing in election trends. Data centers and AI have exploded as midterm issues, and now they’re being lapped by Flock cameras. Compared to these, focusing on health care sounds practically antiquated. But with $1 trillion in Medicaid cuts and the expiration of Obamacare tax credits leading to spiking insurance premium prices and struggling hospitals, health care costs are in fact a top-tier concern, even if it seems boring to some to report about.

The Republican scheme to delay Medicaid cuts until after the election to avoid this reckoning was always doomed to fail. Health systems must plan for the future, and that future is coming in a matter of months. Hospitals are predictably cutting services or closing in advance, and the Obamacare subsidy cuts have been in place for close to a year. It was obvious this would be an anchor for Republicans, and that is playing out across the country.

In fact, health care may be just the thing to spur what would be one of the biggest upsets in November.

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Dr. Annie Andrews, a pediatrician and mother of three, is making the U.S. Senate race in South Carolina competitive. The seat was once held by the late Sen. Lindsey Graham and is now held by his sister, Darline Graham, and Democrats have not held it since Strom Thurmond switched parties over 60 years ago. (Democrat Fritz Hollings held the other Senate seat until he retired in 2004; Republicans have captured that one ever since.) But national prognosticators have downgraded the advantage for Graham, multiple pollsters have shown the race as a toss-up (including Republican pollsters), Donald Trump is insulting Andrews with anti-transgender slurs, and this week saw the biggest signal of a real race: The Senate Leadership Fund, the main super PAC for Senate Republicans, is putting $5 million into South Carolina to save Graham.

Democratic groups are also spending here, attacking Graham for “kick[ing] millions of Americans off their health care, including families with seniors and children.” Andrews herself has spent over $6 million on television advertising, much of it health care–focused. There are two right-wing minor-party candidates on the ballot here, which could help Andrews.

On the stump, Andrews centers her experience as a doctor and what she repeatedly characterizes as a broken health care system: caring for kids whose families had to choose between medical care and the rent, dealing with red tape instead of helping patients. She has said that health care is a right and not a privilege, and while as someone trying to win statewide in South Carolina she has not gone full out for Medicare for All (though she does support a public insurance option), what she has proposed in a new policy platform is unusually detailed and perceptive about the problems in health care, particularly those created by consolidation and market power.

In it, Andrews includes normal Democratic priorities like reversing the Medicaid cuts and restoring the enhanced Obamacare tax credits. She wants South Carolina, one of ten states to not accept the Medicaid expansion in Obamacare, to change its mind, though a senator would have no formal ability to affect that. She wants to increase prescription drug price negotiation under Medicare. All of this is important, if expected. But the rest of the platform goes much further.

For instance, Andrews highlights the medical loss ratio (MLR), which requires insurance companies to use a large percentage (80 to 85 percent) of premium revenue for medical care. But she cites the loophole: Higher premiums that increase the denominator translate to higher profits. She calls for an MLR based on profits per enrollee to foreclose that option.

A separate way insurance companies game this system is through vertical integration. UnitedHealth is the largest employer of doctors in the U.S., and there’s evidence that it gives its own doctors higher reimbursements, fulfilling the MLR by just moving money from one pocket to another. The answer to that would be structural separation, prohibiting insurance companies from employing doctors.

Andrews doesn’t quite go there, but she supports banning private equity firms from owning hospitals, including preventing on-paper “ownership” from doctors who have no formal control. (Oregon recently passed a law to ban these strawman doctor shell games, and Oregon’s federal lawmakers have introduced a version on the federal level.) She also would increase oversight of hospital mergers and stop UnitedHealth and others from “gaming” Medicare Advantage through upcoding, which costs the government $76 billion a year in overpayments. So there’s a real understanding that concentrations of power are a significant factor in the failures of the health care system.

Another example of this is Andrews’s support for ending prior authorization for routine and emergency treatment, which she says has “become an impediment that can delay, or even block, necessary care.” (She doesn’t fully define “routine” in the platform.) She is strong on patent abuse by pharmaceutical companies, seeking to ban “pay for delay” payments to generic manufacturers to withhold competition and other exploitation of the patent system. And she wants stronger reforms of pharmacy benefit managers, the middlemen that make drug prices higher; she would have all insurance plans adopt new Medicare rules preventing PBMs from “steering patients to higher cost drugs.”

Perhaps the most striking passage in the entire platform is this siren call for accountability: “We send drug dealers to prison—unless those drug dealers are billionaire opioid company executives that misled the public about the dangers and addiction risks of their products for profit. We should pass legislation to create criminal liability for the wealthy executives who caused the opioid crisis.”

I appreciate that Andrews is clear that, as the Prospect has reported, the reform of so-called surprise billing has not worked. Andrews’s reforms are more along the lines of preventing health care companies from using tricks to bill patients anyway, rather than the bigger problem of a runaway arbitration system raising health care costs broadly. But recognizing that something’s wrong is a start, and she does want to extend surprise billing restrictions to ambulance rides, which are currently exempt.

There are many more proposals in the document, some of them technical: capping out-of-pocket costs on insulin in private insurance, requiring human customer service agents at insurance companies, price transparency for hospitals with real price caps on highest-cost procedures, so-called site-neutral payments that ensure procedures cost the same in clinics or hospitals, and a ban on the use of AI to make decisions on treatment in Medicare. There are entire sections on rural hospitals (with a focus on attracting doctors and improving reimbursements) and veterans care (with vows to fight funding cuts).

It’s not the platform that I would write, because I’m not trying to win a Senate seat in South Carolina. But it’s much closer to prescriptions to break up Big Medicine than I’ve seen out of practically any Senate candidate this year. And that life experience of seeing doctors burned out by endless paperwork and demands from investor owners, while seeing patients struggle to afford necessary care, surely informs it.

Andrews has taken this platform on the road in several campaign events this week. “Too many families across South Carolina are running into a health care system that is expensive, difficult to navigate, and puts bureaucracy ahead of patient care,” Andrews said at the first stop on this campaign tour. It does not appear to be a white paper that will collect dust on a shelf.

Outside groups have picked up on this. Fresh Start PAC, a Democratic-aligned organization, has put health care in the forefront of its $2.5 million campaign backing Andrews. Its most recent ad, released Wednesday, hits Graham for being “bankrolled by big insurance companies, and she’s helping them rip you off.” The ad also cites several of the provisions in Andrews’s health care platform.

A lot would have to go right for Andrews to win in November. But she is leveraging the historical Democratic advantage on health care, while adding tangible topics that put her on the side of patients and doctors over corporate interests. It could prove a winning formula.