DES MOINES — Health care likely will be the foremost issue to voters in selecting a Democratic presidential nominee, and it’s an issue — as Iowans saw up close this past week — that’s dividing some of the candidates as well.
The wide-ranging debate taking place within the Democratic Party includes whether the federal government should enact modest expansions to the Affordable Care Act, take bigger steps to put the system on the path to a government-run, Medicare-for-all program, or take the giant and essentially immediate leap now to Medicare-for-all.
“I think what you see is sort of a group of candidates that are more focused on building the Affordable Care Act, filling in the gaps, strengthening some of the programs and the subsidies, and addressing some of the problems,” said Jennifer Tolbert, director of state health reform with the nonprofit, non-partisan Kaiser Family Foundation. “(And a group) moving a little bit further from the ACA through creating a new public option that would be available in the marketplace, or perhaps even more broadly to employers. ...
“And then you have those who are supporting Medicare-for-all, which would fundamentally transform our health care system.”
Vermont Sen. Bernie Sanders’ proposal is the most dramatic: to move to a “Medicare-for-all” system, one completely operated by the government. Such a system would eliminate private insurance, leaving those companies to sell only supplemental plans.
It would, as Tolbert said, fundamentally transform the U.S. health care system.
That’s exactly what Sanders is going for.
“Let me be very honest and tell you that, in my view, the current debate over Medicare-for-all really has nothing to do with health care. It has everything to do with greed and the desire of the health care industry to maintain a system which fails the average American, but which makes the industry tens and tens of billions of dollars every year in profit,” Sanders said last week in a speech.
Sanders said his plan is to move the nation to a publicly funded health care program over four years by gradually lowering the Medicare eligibility age.
Sanders asserts his plan would reduce overall health care spending while eliminating the un- and underinsured; premiums, deductibles and co-payments; and provider networks, allowing anyone to see any doctor any time. He said it would save the average middle-class family $3,000 per year.
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“We have a health care crisis in this country. Every day, Americans die because they cannot afford the health care they desperately need, while the CEOs of insurance and drug companies get rich off their suffering,” Sanders said in a statement issued by his campaign. “We cannot continue to tinker around the edges while 80 million Americans lack health insurance or are underinsured with high premiums, copays, and deductibles.”
Massachusetts Sen. Elizabeth Warren also supports a Medicare-for-all system, her campaign said, and she makes many of the same arguments: health care is too expensive even for families with insurance and costs continue to increase while private insurance companies are making billions of dollars in profits.
So, too, does California Sen. Kamala Harris. Her campaign said she supports expanding the ACA, but also a Medicare-for-all program that would eliminate premiums and copays and cover most procedures, and include dental, vision and hearing care.
“There will eventually not be a need for private insurance,” Harris said during a forum in Davenport sponsored by the AARP and the Des Moines Register.
Some of the Democratic presidential candidates, though, are pushing back at Medicare-for-all, going so far as to say it is a losing issue in the election.
Former Maryland Rep. John Delaney, for example, said if the Democratic nominee campaigns on Medicare-for-all, Republican President Donald Trump will win reelection.
“If we run on taking health insurance plans away from 150 million Americans, we will lose,” Delaney said in a campaign video. “Health care is the number one issue for voters and they won’t trust us that the new government health care will be as good as the health insurance they like. Donald Trump will be reelected and we’ll spend another four years wondering how we managed to lose again.”
Delaney’s health care proposal, which he has dubbed BetterCare, would automatically enroll every American in a free, government-run health care program. But it would allow them to opt out and provide a tax credit to be put toward their private insurance.
Other candidates have suggested a middle ground between the Affordable Care Act and Medicare-for-all: the introduction of an optional government-funded and operated health insurance program, commonly called a public option.
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While the potential versions would vary, a public option would simply compete with private insurance and the ACA marketplace plans.
A public option is one of the centerpieces of former Vice President Joe Biden’s health care plan. Biden, who also opposes a Medicare-for-all system, has described his public option as similar to Medicare. But it would only be an option: individuals would be able to keep their insurance.
“I believe we have to protect and build on Obamacare. That’s why I proposed adding the public option to Obamacare as the best way to lower costs and cover everybody,” Biden said in a campaign video, using the Affordable Care Act’s common nickname. “I understand the appeal of Medicare-for-all. But folks supporting it should be clear that it means getting rid of Obamacare. And I’m not for that. ... Starting over makes no sense to me at all.”
Biden issued an even more stark warning during an AARP/Register forum in Des Moines. He suggested the addition of so many Americans onto Medicare would fundamentally alter the system, not for the better.
“Medicare goes away as you know it,” Biden said. “It’s gone.”
Some other candidates, including Minnesota Sen. Amy Klobuchar and former Colorado Gov. John Hickenlooper, also favor a system with a public option.
Klobuchar said a public option gives Americans a choice that doesn’t involve private insurance but also does not completely overhaul the health care system. She said she would be concerned with forcing millions of Americans off their insurance plans.
Hickenlooper said if operated properly, a public option would give individuals another choice.
“It would be an evolution, not a revolution,” Hickenlooper said.
Some candidates are proposing incremental steps as a way to eventually get to Medicare for all — but just not as quickly as Sanders.
South Bend, Ind., Mayor Pete Buttigieg has proposed putting a program similar to Medicare on the ACA’s marketplace, then allowing people to opt into it. He has called this approach, “Medicare for all who want it.”
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New Jersey Sen. Cory Booker said he supports Medicaid for all, but said there are logistical and political reasons that it may not be likely to happen. He said it would be difficult, even if Democrats win the White House and majorities in both halls of Congress, to immediately approve legislation enacting such “massive transition.”
Meantime, Booker said he supports “a robust public option.”
Sanders’ campaign pushed back at public option plans, with his campaign manager calling the plans “a policy and moral failure.” The campaign claimed a public option approach would be “destined to fail” because insurers would reject the sickest and highest-need individuals, causing the public option to be populated mostly by individuals who are most costly to treat.
“We cannot settle for a middle-ground proposal that would leave in place the corporate greed that robs our health care system,” Sanders’ campaign manager, Faiz Shakir, said in a statement.
Navigating the field
Democratic caucusgoers and primary voters have an overwhelming amount of candidates from which to choose. And while the candidates’ health care policies vary greatly in some cases, many also sound similar.
Tolbert, the Kaiser Family Foundation health care expert, said voters who want to parse the candidates’ health care plans can do so by asking pointed questions.
“I think what may be helpful for voters in trying to get at the differences and nuances among the candidates and their proposals is to focus on the issue that they are facing,” Tolbert said. “The question should not be, ‘What are you doing about health care,’ but, ‘What are you doing about rising premiums? I can’t afford my premiums.’ Or, ‘What are you doing to address rising deductibles? People can’t afford to access the care they need.’”
Tolbert said voters could ask similar questions about access to doctors and continuity of care, and what impact candidates’ proposals would have on Medicare and Medicaid.
“Consumers can get maybe a better understanding of what a candidate’s plan looks like by asking these very targeted questions,” she said.