The Democrats Are Fighting for Your Health in 2020

Paths to Coverage

We compare 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)
• Cost: $30-40 trillion over a decade; replaces current private spending; estimates of possible savings-offsets vary

If there’s a leader for this group, it’s Bernie Sanders. As he is fond of reminding people, he “wrote the damn bill” and has supported moving to a single-payer system for decades. His proposal would transfer the whole country to a government plan in four years and would make everything from emergency-room visits to long-term care free for patients.

Sanders frames his plan as a morally and financially necessary response to the inequality and waste of the current system. He may have a point. Nearly 30 million Americans lack health insurance, and plenty that have coverage ration care or medicine because they can’t afford it or end up in debt. A recent paper found that as much as $935 billion, or more than a quarter of the $3.5 trillion spent in the U.S. each year on health care is wasteful. The most significant causes are excessively high prices and administrative complexity, the two things Medicare for All would arguably be best equipped to fix by simplifying the system and using the government’s negotiating power. Those fixes would have side effects: providers would get paid much less, and eliminating private insurance would mean job losses.

While Sanders is the biggest champion of Medicare for All, Elizabeth Warren is the more likely nominee. As she has climbed in the polls, her primary health-care position has been, “I’m with Bernie.” That’s an unusual stance for a candidate who has detailed and highly individual plans on many other issues. It’s worth watching whether Warren, who has supported other approaches in the past, continues to align herself with Sanders or begins to offer a vision of her own.

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 rise
• Proposed legislation: Medicare for America
• Cost: An estimated $2.8 trillion over 10 years for a plan similar to Medicare for America, offset by reduction in total health spending

Think Medicare for All, but with some private insurance and out-of-pocket costs. This is a viable middle path that may offer many of the benefits of a single-payer system without quite as much disruption. California Senator Kamala Harris’s proposal, for example, would move most Americans to a new plan that offers an expanded version of Medicare coverage over a decade, with private insurance still available in the form of strictly regulated Medicare Advantage-type plans. Though deductibles would vanish, patients would face other capped costs for coverage and care. Other details are still scant, so it’s hard to truly weigh the costs and benefits.

Former Texas Congressman Beto O’Rourke’s plan doesn’t have that problem; he supports an actual piece of legislation called Medicare for America. The proposal would move most Americans without employer insurance into a new public plan. The benefits, cost limits, and subsidies detailed by the legislation would make this new plan quite generous, though it falls short of Medicare for All. Private coverage would still exist in something closer to its current form than it would under the Harris plan, but would have to compete with the new government behemoth.

Then, there’s what I would call the vague gang. Entrepreneur Andrew Yang and the other candidates listed above say they support Medicare for All as a goal. They just don’t necessarily agree with that whole getting-rid-of-private-insurance-in-one-fell-swoop thing. None of them have released plans that are detailed enough to give a sense of how much of the current system they’d retain.

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
• Cost (Biden): $750 billion over 10 years
• Cost (Buttigieg): Close to $1.2 trillion 10-year cost projection of a similar plan, offset by around $400 billion in potential savings

These candidates, led by Biden, are much more eager to assail Medicare for All as too costly and politically infeasible. They argue that an element of choice should be retained, and prefer to add a more limited, less generous, and mostly optional public plan to the market, which would then compete with private options.

Biden and South Bend, Indiana Mayor Pete Buttigieg’s public-option plans are very similar in many ways. Both candidates want to create a new government-run plan that auto-enrolls low-income Americans in states that didn’t accept Obama’s Medicaid expansion. Both would boost subsidies for people who wish to buy into the program by capping premiums at 8.5% of income. People with employer coverage they don’t like would be able to drop it for the new public option, and some would be eligible for subsidies.

Buttigieg’s plan has extras that make it much more impactful. He wants to cap hospital and provider prices at 200% of what Medicare pays. That would go a long way toward controlling costs for both his public option and private plans, potentially helping a broad swath of America. His plan would also add an out-of-pocket cost cap to Medicare. Biden may feel pressure to step up his proposal.

There are more limited public option plans offering fewer benefits and stricter enrollment limits. That may be where Minnesota Senator Amy Klobuchar ends up, as she has previously supported constrained Medicare and Medicaid buy-in plans. Billionaire Tom Steyer is likely to come down on the more ambitious side. He envisions a federal program that’s cheap and comprehensive enough to prompt people to leave private insurance in droves.