2020 Democratic presidential candidates Amy Klobuchar, Pete Buttigieg and Bernie Sanders at the July 30 debate in Detroit. (Anthony Lanzilote/Bloomberg)
Opinion writer

With the announcement that Sen. Amy Klobuchar (D-Minn.) has qualified for the September debate, we now are guaranteed a critical mass of center-left candidates who advocate building on Obamacare rather than scrapping it for a single-payer plan. In addition to Klobuchar, Beto O’Rourke, South Bend, Ind., Mayor Pete Buttigieg and former vice president Joe Biden favor a public option while Sen. Cory Booker (D-N.J.) seems to want to split the difference by aiming for Medicare-for-all — starting with a public option.

This group would do well to make several points:

  • The goal is universal coverage and affordable health care. The dispute is about the means to getting there. The threat is President Trump’s vow to dismantle Obamacare root and branch. There is no virtue in sticking with a plan so unattainable that it delays implementation of available solutions or, worse, is so unpopular that it increases the risk Trump will win reelection.
  • Obamacare didn’t cover everyone in large part for three reasons: Medicaid expansion was left up to the states, some Americans still found health care on the exchanges too expensive, and employer-provided insurance also became more costly. Obamacare also did not cover illegal immigrants. (Giving illegal immigrants full Obamacare insurance coverage is a political nightmare; expanding free clinics and other means of accessing health care is another matter.)
  • A public option to buy into Medicare (that may be expanded to cover dental care and hearing aids) at an affordable rate should address the main Obamacare defects if it is coupled with a plan to address prescription drug costs. The Center for American Progress’s plan (Medicare Extra for All), for example, would give everyone (even those getting health care from employers) the option to enroll in Medicare. Someone not covered by any plan would be automatically enrolled in Medicare. People at or below 150 percent of the federal poverty line would have no deductible.
  • Expanding coverage would come at a cost but be vastly less expensive than a single-payer system. Candidates nevertheless should explain how they would pay for higher costs for new services (e.g., dental) and keep premiums low and for new out-of-pocket limits.
  • People get a choice to keep existing plans if they like them. Employers no longer get to dictate coverage (employees can choose a public option) and the main concern for voters — cost — would be addressed.

Advocates of Medicare-for-all need to explain the following:

  • Exactly how will they pay for the trillions of dollars in added cost? They need to explain how much money is needed and who gets taxed. If the wealthy avoid a new “wealth tax,” where does the money come from? If a middle- or working-class person likes his plan, what’s the justification for forcing him to pay higher taxes to support a single-payer system that will make health-care coverage cheaper for much wealthier people?
  • Are they really going to give completely free insurance coverage to anyone who can cross the border? Won’t this incentivize illegal immigration?
  • How will they ever get this through Congress if every Republican and a good number of Democrats object to a single-payer plan? Do these advocates imagine whatever they put in a white paper is going to sail through Congress?
  • What’s the benefit of outlawing private insurance entirely if people have the option to choose a public option that controls costs?
  • How do they address people who want to stay in generous union benefit plans?
  • What happens to providers such as rural hospitals that cannot make ends meet on Medicare reimbursement rates? (As the Manhattan Institute’s Brian Riedl explained last year, “Cutting all hospital and medical providers to Medicare rates — without the ability to recover those losses by charging higher insurance rates to others — would bankrupt many health providers. While some efficiencies can always be found, an immediate 40 percent reduction is not even remotely plausible. That is why the Urban Institute’s analysis of the Sanders 2016 single-payer plan insisted on more realistic payment rates — and concluded that the plan would raise national health spending by $6 trillion over the decade.”)

There can be a rational discussion of health care, but not until moderate Democrats do a better job explaining what is at stake and why their plan is better policy and better politics. Medicare-for-all advocates shouldn’t be able to flick away legitimate questions with ad hominem attacks on public-option advocates. Most importantly, the debate should reaffirm that Obamacare or any improvement on Obamacare would be vastly better than Trump’s goal of no Obamacare.

Read more:

Paul Waldman: Medicare-for-all faces its moment of truth

The Post’s View: No matter which health-care plan you support, Democrats have a leg up on Trump

Charles Gaba: Despite what Sanders says, Harris may have the best claim to Medicare-for-all

Pramila Jayapal: It’s time for Democrats to get their facts right on Medicare-for-all

Paul Waldman: Democrats are making Republican arguments about health care. Why?