Few things are less enlightening during a debate than to ask candidates to raise their hands to give a yes-or-no answer to a question, but since the TV networks seem incapable of running these events without at least some measure of idiocy, that’s what we got in both of the Democratic debates that took place this week.

The topic was one of the most complex policy challenges we face — health-care reform — so I guess dumbing it down as much as possible seemed like the right approach to somebody at NBC. Predictably, at least one candidate is trying to clarify what she did and didn’t mean with her raised hand:

Sen. Kamala D. Harris (D-Calif.) said Friday that she does not support abolishing private health insurance in the United States, saying she misheard a question from NBC’s moderators about Medicare-for-all during the presidential debate.
Thursday night, Harris alone joined Sen. Bernie Sanders (I-Vt.) in raising her hand when all of the candidates were asked if they would outlaw private health insurance in favor of a government single-payer plan.
But appearing on “Morning Joe” on Friday, Harris suggested she had incorrectly heard the question as being about whether she personally would be willing to use a government plan instead of a private one. NBC’s Lester Holt had asked: “Many people watching at home have health insurance through their employer. Who here would abolish their private health insurance in favor of a government-run plan?”

So Harris now says she would allow supplemental private insurance even if everyone is covered by Medicare.

But the truth is that whether we actually “abolish” private insurance under various health reform schemes, though not irrelevant, is not the most important question. What happens to private insurance is. So let’s break it down.

First, moving significant numbers of people into public insurance — Medicare, Medicaid or some new program that resembles one or the other — is the centerpiece of what every Democratic candidate wants to do. The most important reasons for this are that the government insurance would be more secure, would cover everyone and would likely be less expensive than private insurance.

The candidates differ on how many Americans they want to move onto a government plan. On one end, you have Sen. Bernie Sanders (I-Vt.), who would move everyone — including those without insurance, those who buy on the individual market and those who have employer-provided coverage — into a government plan within a few years. Then you have “public option” advocates such as Sen. Amy Klobuchar (Minn.) or South Bend, Ind., Mayor Pete Buttigieg, who want to allow anyone to join a government plan — but only if they choose to.

But while Sanders says that, in his scheme, private insurance would only remain for voluntary procedures such as plastic surgery because the government would cover everything else, it’s important to understand that in every universal health-care system in the world, there’s at least some role for private insurers. They are regulated much more strictly than ours, and their functions vary from country to country, but they’re still there.

For instance, in some countries, such as Germany, everyone is required to get insurance from private nonprofit “sickness funds” that are closely regulated. In France, everyone is covered by a basic government plan, but most people also buy private supplemental insurance to fill in gaps in the public plan. Even in Britain, with the most socialized system, supplemental insurance exists for people who want an extra level of benefits.

But in all those places — where everyone is covered at a far lower cost than what we pay — private insurance still has some role. That’s even true of our own Medicare, in which a third of people are enrolled in Medicare Advantage plans administered by private insurers.

Part of the challenge is that there are multiple plans right now being called “Medicare-for-all,” and they would each have a different role for private insurers. But while there are a number of reasonable policy choices you could make, it’s the political challenge that might make it all moot.

In particular, the reason candidates such as Harris are struggling in how they talk about this issue is that everyone knows that there’s a whole lot of Republican “death panels” demagoguery on the way. This is a political problem for which no one has a good answer. Even if you’re sure that moving from a private plan to a government plan would be better in the end for the vast majority of people, you’ll struggle against loss aversion — the tendency we all have to fear losing what we have.

Even if your current insurance is driving you crazy, you may be reluctant to give up whatever security it offers for the prospect of something in the future that you don’t quite understand and worry might be worse.

In the Medicare-for-all advocates’ telling, that’s what’s at the heart of surveys showing that most people are satisfied with their employer-sponsored coverage: It’s preferable to the alternative of not being covered and, in any case, they may be thinking more about their doctors than their insurers when they answer the question. But that doesn’t mean they wouldn’t be happier with something cheaper and more comprehensive.

So those advocates put the focus on the insurance companies, as Sen. Elizabeth Warren (Mass.) did during the first debate:

Look at the business model of an insurance company. It’s to bring in as many dollars as they can in premiums and to pay out as few dollars as possible for your health care. That leaves families with rising premiums, rising co-pays, and fighting with insurance companies to try to get the health care that their doctors say that they and their children need. Medicare-for-all solves that problem.

True enough. You can solve the problem by regulating them more tightly, or by relegating them to some strictly defined and less central role in how we fund health care. If you can get the public to agree to it.

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