Ignored in the furor is what might be the most incredible assertion in the health-care debate: the claim by the centrists that they can provide health care to everyone for less money than Medicare-for-all by cobbling a public option onto our current system. Americans, they claim, can have their choice between private insurance or a public system like Medicare.
It doesn’t take much reflection to realize that this is a real stretch. Adding a public option on top of our current system would continue the staggering administrative waste of the private insurance system. About 30 percent of every health-care dollar is squandered on administrative overhead — largely the paperwork, the pre-approvals, denials and appeals that are inherent in a system of for-profit private insurance companies. That’s about $1 trillion a year. Medicare-for-all can cut that trillion dollars in half by eliminating that bureaucratic waste. To continue to pay for that waste, a public option system will either end up as Medicare for All Who Can Afford It — rationed by cost, with tens of millions deprived of adequate health care — or it will cost far more than Medicare-for-all.
The argument by Biden and Buttigieg that Medicare-for-all is “elitist” because it takes choice away from people is also disingenuous. The choice most Americans care about is the choice of doctors and hospitals. Private insurers restrict that choice through authorized networks to maximize profits, and they restrict access to health care by cost — with deductibles, co-pays and other out-of-pocket costs that many can’t afford. Rising costs force employers to search constantly for different plans, with different in-network doctors and hospitals, even as they seek to charge more costs to employees.
Even good employer-based plans exact a price in personal freedom. As Rep. Pramila Jayapal (D-Wash.), the architect of the House bill on Medicare-for-all notes, “I have so many people who write to me with these unbelievable stories about how they have these dreams and they were lost, because they have to work for a company that they totally don’t believe in because they need the health care. … People who have gotten divorced because that’s the only way to get care.”
And the assumption that employer-based insurance provides adequate care is facile. A recent report from the authoritative Kaiser Family Foundation reveals that employees are facing soaring premiums, deductibles and out-of-pocket costs. From 2008 to 2018, premiums rose 55 percent, twice as fast as workers’ earnings (up 26 percent). Over the same period, deductibles rose on average over 212 percent, nearly 10 times as fast as wages. So it’s no surprise that 4 in 10 insured Americans report that their family has faced problems in paying medical bills. About half say someone in their household skipped or postponed some type of medical care or prescribed drugs in the past year because of cost. Nor is it a surprise that the No. 1 reason families go into bankruptcy remains health-care costs. As Warren notes, three-fourths of those who declare bankruptcy after an illness had health insurance. Half of people not on Medicare either have no insurance or are underinsured. For literally tens of millions, employer-based health care works well as long as they don’t get sick.
Democratic voters focused on getting rid of Trump have every good reason to be nervous about taking on the deep-pocketed insurance and pharmaceutical companies that will spend billions to defend their lucrative arrangements. As Sanders has said, the question isn’t a budget issue about how to pay for Medicare-for-all, the question is a political one: Do we have the courage and the capacity to take on these entrenched interests and create a system that can actually make health care a right, not a privilege accorded to those who can afford it?
Health care will remain a central issue for televised debates, town hall meetings and candidate gatherings. Warren and Sanders have laid out how they would pay for Medicare-for-all. For voters to be clear about the choice, those assailing Medicare-for-all should be asked to describe how we can afford a plan that will provide comprehensive coverage to all — including those underinsured by employers — while adding a public option onto our employer-based private insurance system.
As Jayapal puts it, “It is absolutely absurd to subject Medicare for All to a different standard of scrutiny. Instead of saying, ‘Wow, Medicare for All costs too much, how are you going to pay for it,’ the question to every candidate should be, ‘What is your plan to bring down health care costs over the next ten years? And what is your plan to universally cover everybody, because none of the other plans do that.’”
The plans for Medicare-for-all have been and should be scrutinized. But those calling for more of the same plus a public option shouldn’t get a pass. It’s important to unpack their assumptions about cost and coverage so that voters can get a clear sense of the choice before them.