Coverage of health care in the context of the 2020 Democratic presidential campaign amounts to asking a yes-or-no question about support for Medicare-for-all and then pointing out that Democrats are “divided.” (A rift! A split in the party!). The Medicare-for-all crowd accuses the others of being incrementalists (horror!) and the Medicare-for-all critics say this is pie-in-the-sky stuff that won’t work. That’s it. That’s the “health-care debate” as it has generally been covered.
What’s missing is any deep analysis of the costs and feasibility of Medicare-for-all and, more important, what some of the alternatives might look like.
A few candidates have listed some ways of building on the Affordable Care Act (e.g., extending Medicare down to age 50, allowing interstate and international drug purchases to lower costs). It is incumbent on Democrats to spell these out, explain how they will be funded, and indicate how they’ll get past a filibuster in the Senate by Republicans who wanted to repeal the ACA, not fix it.
They might also take a look at two alternatives to Medicare-for-all. These, at least, help frame the debate and suggest some of the holes that need to be plugged in the Affordable Care Act (as it has been crippled by the Trump administration and GOP-led Congress).
One plan comes from the moderate Third Way group, described in an op-ed on Wednesday in The Post. That plan would leave the ACA in place and add caps on “premiums, deductibles, and other out-of-pocket costs for everyone based on income” and provide automatic enrollment for everyone to achieve universal coverage. In this plan, out-of-pocket expenses would be capped regardless of whether insurance came from Medicare, Medicaid or private employer-provided plans. How do we pay for all that? They aim to wring some costs out of the system by eliminating pay-for-fee services and increasing taxes “on the wealthy.”
There are plenty of questions. What is the definition of “wealthy”? What taxes will be needed? How exactly does it constrain costs? (“Reduce complexity” and banning “surprise bills” don’t sound all that concrete while moving away from fee-for-service raises its own questions.) How did the authors arrive at the $2.8 trillion price tag over 10 years? (They argue, “That is still less than one-tenth the cost of the most prominent single-payer legislation, and much of the cost of our plan will be offset through aggressive measures we propose to tame the medical-industrial complex.”) Still, it is perhaps the least disruptive (and least expensive) approach to expanding coverage; private insurance doesn’t go away.
Drew Altman of the Kaiser Family Foundation tells me, “The emphasis in the plan on capping out-of-pocket costs would be a strong selling point and is directly responsive to what the public and voters care about most — their out-of-pocket costs.” He adds, “I do think voters will retreat to familiar corners (progressives for Medicare for All, moderates for building on the ACA, republicans against anything democrats are for) unless candidates can get beyond talking points and connect their plans to these pocketbook concerns.” He notes that any plan with have tradeoffs and “landmines.”
There is also a plan put out last year by the Center for American Progress called “Medicare Extra for All.” That would beef up existing Medicare (”an out-of-pocket limit, coverage of dental care and hearing aids, and integrated drug benefits") and then become "available to all Americans, regardless of income, health status, age, or insurance status.” This plan would also aim to cap costs based on income, keep employer-provided coverage and be paid for, in part, by tax increases. (“One option would be a surtax on adjusted gross income — including capital gains — on very high-income individuals. . . . One option would be to eliminate this stepped-up basis so that large accumulations of wealth cannot avoid capital gains tax.”)
This plan raises its own questions including how quality and availability of care is maintained when “payment rates for medical providers would reference current Medicare rates — and importantly, employer plans would be able to take advantage of these savings.” There is also a question as to how private plans could compete with a Medicare Extra plan that is funded by taxpayers.
It is worth noting that while voters tell pollsters they want Medicare-for-all, support drops when they learn private insurance would disappear. As the Kaiser Family Foundation finds, “Larger majorities of the public favor more incremental changes to the health care system such as a Medicare buy-in plan for adults between the ages of 50 and 64 (77 percent), a Medicaid buy-in plan for individuals who don’t receive health coverage through their employer (75 percent), and an optional program similar to Medicare for those who want it (74 percent). Both the Medicare buy-in plan and Medicaid buy-in plan also garner majority support from Republicans (69 percent and 64 percent).”
We don’t aim here to give anything close to a complete analysis of alternatives to Medicare-for-all, but it would behoove candidates and the media to start looking at the substance of various alternatives. One benefit of this would be to reacquaint voters and politicians with a simple proposition: More health care costs more, and we have to decide how to pay for it. Another benefit would be teasing out whether candidates actually disagree on the substance of their health-care approaches or just on the terminology.
Voters keep saying they are willing to tax the rich and want to lower health-care costs. They deserve a meaningful, serious debate on what that would look like.