The Democratic Party’s Health-Care Battle

Paths to Coverage

Here, we compare the plans with the Affordable Care Act on four measures:

• • How many people will have public health-insurance coverage
• • How drastically the plan will upend current insurance plans and provider rates
• • How much patients will be able to reduce their out-of-pocket medical costs
• • The potential to increase government spending or raise taxes

These are not, however, empirical measures. Rather, each graphic is an abstraction of the tradeoffs and potential impact.

Medicare for All

• Benefit: Everyone has health insurance regardless of their ability to pay; premiums, deductibles and most out-of-pocket costs vanish
• Trade-off: Taxes rise; most private coverage eliminated; provider payments slashed
• Proposed legislation: Medicare for all (Jayapal); Medicare for All (Sanders)

The U.S. pays more for health care than other developed countries, and often gets worse results. Sanders argues that the best remedy is to get everyone on the same plan in four short years and bring the government’s full negotiating power to bear on rising costs. His proposal would transform how we pay for care, swapping insurance premiums and big medical bills for a tax increase. Many Americans would save in this exchange, but it could be costly for others. The plan’s price is a big unknown; people would likely use more care if it’s free. Eliminating insurer overhead and profit would offset some costs, but price controls will be needed. Opponents warn that Sanders’s plan is too much, too fast. They may have a point. Moving half of the country off of private plans and slashing provider payments would shock the system. The idea of Medicare for All polls well, but voters balk at the details. Senator Elizabeth Warren and New York City Mayor Bill de Blasio indicated support for Medicare for All during June’s debates. It’s unclear if they support Sanders’s specific legislation, or if they have a distinct spin.

Medicare for All-ish

• Benefit: Path to universal coverage; many patients get relief with premiums; limited cost sharing
• Trade-off: Opt-outs mean not everyone has the same coverage; taxes increase
• Proposed legislation: Medicare for America

Many candidates want universal coverage, but are wary of eliminating private insurance. Beto O’Rourke supports Medicare for America, a less disruptive alternative. Over time it would auto-enroll many patients in a generous government plan with limited cost sharing that would absorb Medicaid and Medicare. Private employer coverage would exist, but would have to compete with a new behemoth. It isn’t the explicit choice of every candidate in this category. Fence-sitters including Senators Cory Booker and Kirsten Gillibrand have co-sponsored both Medicare for All and limited proposals. Senator Kamala Harris recently released an ambitious plan that makes an expanded version of Medicare universally available, with a role for regulated Medicare Advantage-style private plans, some out-of-pocket costs, and a 10 year transition period. It’s not surprising that candidates cluster here; they want to stay close to Sanders’s catchy phrase, while avoiding some of its controversies and costs.

Public Option

• Benefit: Narrower scope keeps spending down
• Trade-off: Many still need to buy potentially costly insurance, resulting in lower coverage rate
• Proposed legislation: The Choice Act; Choose Medicare Act; Keeping Health Insurance Affordable Act; Medicare X-Choice

Several less ambitious plans are a better fit for candidates who have been more explicitly critical of a shift to a single payer. This family of proposals, which includes frontrunner Joe Biden’s, creates a more limited public-insurance option via the Obamacare individual-market exchanges. They leave existing government programs intact and retain a more significant role for private insurance. A robust public option that allows broad employer buy-in or makes subsidies universally available could cover lots of people. But the status quo may not change much for many Americans and costs could stay high, particularly under narrower proposals. Biden is making the case that a less disruptive approach has the broadest appeal and best chance to beat Donald Trump. His lead in the polls has diminished, but plenty of people still seem to agree with him.

Limited Buy-In

• Benefit: Older people or residents in states that opt in can buy public coverage; smaller increase in government spending
• Trade-off: Many groups excluded
• Proposed legislation: Medicare at 50; Medicare Buy-In and Health Care Stabilization Act; State Public Option

Another subset of plans would enable different populations to buy in to currently existing government programs. But these come with limits. Senator Debbie Stabenow’s proposal would allow people over 50 to purchase Medicare coverage; everyone else is out of luck. Senator Brian Schatz’s State Public Option plan would create a Medicaid buy-in, but it would be up to states to approve and implement it. A significant number of states haven’t enacted the ACA’s more limited Medicaid expansion, and some that have are attempting to limit the program with work requirements. No candidate seems to support these plans as a sufficient option, a sign of how much the health debate has shifted, though some see them as a positive first step toward something more comprehensive. Senator Amy Klobuchar has endorsed them as things that could “work now” as opposed to Medicare for All, which “could be a possibility in the future.” But even she has called for a broader public option.