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The 45,000 or so residents of Dunn County live off on the western side of Wisconsin, not far from central Minnesota, but not close to much of anything. Like other rural counties, it leans heavily Republican, going by double digits to Donald Trump in 2020. This year, Sen. Ron Johnson, R-Wis., notched a 14-point margin there, and Tim Michels beat the incumbent Democratic Gov. Tony Evers by 9 percentage points.
But when it came to health care, Dunn County voters said they would support a national health insurance program. The overwhelmingly Republican residents of this farming community approved a ballot measure that affirms their support for a single-payer public health insurance program. The idea, which passed 51-49, ran 11 points ahead of Evers, who was reelected statewide, and 16 points ahead of Senate candidate Mandela Barnes.
The largely unnoticed rural election result affirmed support for nationalizing and expanding health insurance, a program popularly known as Medicare for All. While the national media discourse about the election largely ignored health care issues beyond abortion rights, voters across the country registered support for progressive reforms focused on improving health care access and reining in the for-profit industries that dominate the medical system.
In Arizona and South Dakota, like in Dunn County, progressive health care initiatives outpaced Democratic Party candidates by a wide margin. Arizona voters passed Proposition 209, a measure that reduces the allowable interest rate for medical debt and expands exemptions for what can be garnished by medical debt collectors, with a landslide 72 percent in favor. South Dakota became the 40th state to expand Medicaid coverage, making an additional 40,000 residents eligible.
Oregon passed Measure 111, making it the first state to enshrine a right to “cost-effective, clinically appropriate affordable health care” for every resident in the state constitution. In Massachusetts, voters enacted Question 2, which forces dental insurance companies to spend at least 83 percent of premiums on actual dental care, rather than administrative costs and profits.
Medicare for All has become associated with the Bernie Sanders wing of the Democratic Party — not a large population in Dunn County. National party operatives consider it an albatross around the neck of Democrats, and the Democratic Congressional Campaign Committee has warned candidates to stay away from it, and to focus instead on lowering prescription drug prices, which everyone who doesn’t work for the pharmaceutical industry supports instantly.
“The wording of the question sold it to them, because we avoided using words like Medicare for All and single payer,” said John Calabrese, a Dunn County board supervisor who works for Our Wisconsin Revolution, an offshoot of Sanders’s 2016 campaign for president. Taking the issue out of a partisan lens allowed for conversations that, he believed, wouldn’t have otherwise been possible.
In a divided Congress, there is little prospect for a sweeping reform such as single-payer health care. But lawmakers, a growing number of whom support Medicare for All, are likely to face growing pressure to take action on rising costs — and the industry is mobilizing accordingly.
A post-election report by the Healthcare Leadership Council, a trade group that represents the bulk of the private health care system — hospitals, drugmakers, medical device companies, insurers, and electronic records firms — flagged the state ballot measures and scored incoming lawmakers. The update featured polling that showed among voters who prioritized health care issues, apart from Covid-19, there is sweeping support for the need to tackle “high health care and drug costs/prices.”
The group was formed in the early ’90s as part of industry push to defeat progressive provisions of the health reform overhaul announced by President Bill Clinton, and now works to prevent policies that may reduce the ability for investors to make profit from the current system.
The council maintains a team that carefully screens candidates for Congress on health care issues in an attempt to inform industry lobbyists and help foster relationships for influencing legislation. HLC alerted its members about a wave of incoming Democrats who are not considered a “Healthcare Champion” — in other words, candidates who do not favor corporate positions on health policy.
Ohio Republican J.D. Vance and Pennsylvania Democrat John Fetterman are listed prominently as potential critics of the industry. Vance, HLC noted, “has staked out healthcare positions that break from traditional Republican orthodoxy, including support for government involvement in Medicare drug pricing and advocacy for prescription drug importation.” Fetterman, the document explains, adds to the “Bernie Sanders wing of the Democratic Party” and supports “lowering of the Medicare eligibility age to 60 and advocating even tighter government controls on prescription drugs.”
A slew of newly elected House Democrats also support Medicare for All, HLC’s report noted, including Sydney Kamlager, Kevin Mullin, and Robert Garcia in California; Yadira Caraveo in Colorado; Summer Lee in Pennsylvania; and Hillary Scholten, who defeated a Republican opponent in a Michigan swing race. Rep. Peter Welch, D-Vt., who succeeds retiring Sen. Pat Leahy, D-Vt., also backs single-payer health insurance. Subject Matter, a lobbying firm that represents UnitedHealth Group and the Federation of American Hospitals, in a similar note to clients, lists Becca Balint, D-Vt.; Maxwell Frost, D-Fla.; Jonathan Jackson, D-Ill.; Shri Thanedar, D-Mich.; and Glenn Ivey, D-Md., as other candidates who voiced support for Medicare for All.
In addition, many new House Democrats have voiced support for lowering the Medicare eligibility age. The document circulated by Subject Matter observed that Gabriel Vasquez, a New Mexico Democrat who unseated Rep. Yvette Herrell, R-N.M., supports expanding Medicare eligibility, as does Chris Deluzio, who succeeded moderate Rep. Conor Lamb, D-Pa.
The support for an expanded public support for health care across the country gives the administration a mandate as it drafts rules implementing key provisions of the Inflation Reduction Act, which allows Medicare to negotiate prices on the costliest prescription drugs covered by the program.
That sets the stage for the next confrontation. Industry lobbyists have fought bitterly against allowing Medicare to negotiate for lower prices. HLC President Mary Grealy previously denounced the proposal as “heavy-handed government regulation” that imposes “the dangerous precedent of importing the price control policies of foreign governments.”
And the industry are moving to influence the Biden administration to derail the Inflation Reduction Act’s provisions on drug prices. Shortly after the election, Grealy sent a letter to Health and Human Services Secretary Xavier Becerra to ask that the administration provide an opportunity for groups such as HLC to weigh in on the implementation of the drug pricing program.
Wisconsin is one of just 10 states that has yet to accept the Medicaid expansion included in the Affordable Care Act. Calabrese, the Dunn County board member, said that the toll health insurance takes on the county budget helped persuade his fellow board members to allow the referendum to go forward. The county has roughly 350 employees, he said, and insuring them costs roughly a half million dollars every month.
“So when you’re at the end of the year trying to balance the budget button, and we’re cutting $1,000 here and 500 bucks there and having to cut jobs, I mean, half a million dollars a month?” Calabrese, who helped shepherd the referendum through the maze of committees needed to get before the full board, said. “I thought, I bet there’s a way where we can talk about this single-payer system, this national health insurance program at a county level, and talk about the finances — maybe that’s worth putting some volunteer effort into and could really start to shift some conversations.”
On the day of the hearing, residents showed up to tell stories of their nightmare experiences either with insurance companies or without insurance. It also happened that the state had just released its annual health and human services report, and a state official was on hand to walk the county lawmakers through the budget.
“Nobody on that committee said, ‘I think that our health insurance system is great,’’’ said Calabrese. And really, nobody said that to me in going around the county for a month and a half handing out literature, not a single person started a conversation with ‘This is crazy, our health insurance system is great.’ We got some people saying, you know, this sounds like a socialist takeover, or whatever.”
The board’s most conservative member, Larry Bjork, was apoplectic at health care costs the county was accruing for people in its care in jails and other institutions. “Where does the money go?” he asked. “It blows my mind when I look at the financial statement, Chris, and we spend 38 percent of our budget on behavioral health services and health and human services. … I guess my question to you is, in listening to the presentations from the public today about universal health care, do you think there would ever be a universal — can counties get out from underneath that 38 percent going to mental health care by a federal program of any sort?”
The state official told him that if it was implemented, it would indeed resolve it for the county. She noted that before implementation of the Affordable Care Act, the county was spending roughly $100,000 a year to treat uninsured indigent patients at local hospitals, but that number had fallen to around $10,000. “Medicaid expansion to childless adults helped with some of that,” she said, according to audio of the hearing. “In direct answer to your question, if people had affordable health insurance available to them and coverage to get them the care that they needed when it wasn’t a crisis or emergency, it seems hard to not conclude that there would be cost savings to that.”
Calabrese said that Bjork’s approach to the issue, moving away from ideology toward practicality, was common among the board members confronted with the overwhelming cost of health care. Bjork said he was all in, and the referendum was moved to the ballot unanimously.
The measure would ask Dunn County voters, in an obviously nonbinding fashion, “Shall Congress and the president of the United States enact into law the creation of a non profit, publicly financed national health insurance program that would fully cover medical care costs for all Americans?”
Members of Our Wisconsin Revolution and other supporters of the referendum made day trips around the county throughout the fall, leafleting in small villages and hitting every door they could find. Calabrese had run unsuccessfully for state legislature in 2018 and 2020, and had gotten access to Democratic voter data to help with his targeting. He noticed that the county’s trailer parks and many of the apartment buildings weren’t included, as many of the residents there move frequently and/or aren’t registered to vote. “We visited every trailer park in the county,” Calabrese said.
On election night, as the returns came in, he watched as the villages they visited sided with a national public health insurance program. Those same towns had soundly rejected him for state legislative office. “All these little townships started to come in first for the referendum,” Calabrese said, “and what I was noticing was there are the little villages — the village of Elk Mound, village of Boyceville, village of Wheeler, and these little places — and as the names kept coming in, I noticed that those are the places where me and some other volunteers spent entire days doing lit drops and talking to anybody that we could. And so in those places that I know always go Republican, we were winning in these little villages by 10 or 15 votes and I’m like, oh my God, we spent a day in Wheeler, we spent a day there.”
“In the townships, people don’t really trust the government, don’t trust it can do anything good for them,” said Dr. Lorene Vedder, a retired general practitioner and one of the leaders of the referendum. Vedder is active with Physicians for a National Healthcare Program, which supports single payer. She noted that in rural areas they visited, the numbers were good. “Otherwise it was just dismal in the townships,” she said.
In Boyceville, for instance, voters went 239-132 for Ron Johnson over Mandela Barnes, but supported single-payer by 183 to 171. In Wheeler, Johnson won 52 votes to Barnes’s 27, but the referendum carried by 40 to 37. In Elk Mound, Johnson won 190-142, but health insurance won 184 to 124. The county seat of Menomonie delivered the biggest margin for the referendum, where it won by 1,369 votes.
In some parts of the surrounding countryside, the results fell along more partisan lines, but the overperformance in places like Elk Mound meant that even outside the county seat, it only lost by 485 votes, close enough to let Menomonie carry it. Rural townships “[are] much harder to get to, it’s rural country roads and we only had so much time and our resources weren’t as locked in as we hope to be in the future,” he said.
“I don’t want to get too high-minded and idealistic about it, or whatever the word is,” he added, “but I felt, at the end of it all, this real connection to my neighbors, in a time where it seems like if you watch national news, there’s this almost push in some networks and from some politicians who actually further the division and tell people that half the country is irredeemable, these people should just be written off and so to approach every trailer, whether it had big Trump flags or not, was — I just felt like talking about issues that affect everybody, it’s kind of the secret to us getting along better.”