Exclusive: Here's a spin-free look at how the leading Dems would fix our dysfunctional healthcare system

Exclusive: Here's a spin-free look at how the leading Dems would fix our dysfunctional healthcare system
NBC News

Surveys find that most Americans don’t know what “Medicare for All” would entail. A poll released in June by Navigator research found that “only one in five Americans are very confident they know what ‘Medicare for All’” means. Sixty percent of respondents believed it would give people a choice of buying into the program. According to a Kaiser Family Foundation survey conducted around the same time, 40 percent of the public believed that private companies would continue to “be the primary way Americans” would be covered under the proposal.

To my knowledge, no poll has asked whether Americans know what a “public option” is, or how it might impact the American healthcare system or their own coverage. And it doesn’t have a single meaning--different politicians mean very different things when they say they support a public option.

So far, the Democratic primary debates haven’t done much to help clarify matters. Serious wonks may have been able to follow the fractured, 60-second-at-a-time arguments, but it wasn’t easy. So I summarized what the candidates are proposing in plain English and included brief analyses that are as neutral as possible.

In order to keep to a manageable length, we looked at the proposals of the nine candidates who have qualified for the September debate as of this writing, along with one other, Tulsi Gabbard, who appears to be on the cusp of getting onto the stage. And we skip vague promises like, “will develop new measures to control prescription drug costs.”


South Bend, Indiana Mayor Pete Buttigieg has yet to release or endorse a detailed health care reform plan. In press interviews, on the debate stage and on his issues page, Buttigieg calls for making a “Medicare-type public option” available to all who want it.

On the stump, Buttigieg says that because Medicare has lower administrative costs, it would offer a less expensive product than private insurers and that open competition with the corporate model would eventually lead to everyone switching over to the public insurance program.

Buttigieg also proposes a “national health equity strategy” to address racial disparities in health outcomes. This proposal is light on detail but appears to be centered around making investments in traditionally underserved communities.

This week, he also rolled out a plan to increase access to health care in rural communities. According to Politico, “he aims to beef up the [rural] health workforce through loan forgiveness programs and proposes increasing Medicare reimbursement rates specifically for providers in underserved communities.


Unlike other candidates proposing a “public option,” Buttigieg doesn’t say much about expanding subsidies or otherwise making coverage more affordable. (He mentions more generous subsidies in The Politico piece linked above but doesn’t in the health care policy section of his website.) The current Medicare system offers seniors deeply subsidized coverage; allowing people to buy into a Medicare-like program for the cost of that coverage would not be result in dramatically less expensive coverage than private insurance of equal quality.

Perhaps more significantly, Buttigieg’s approach is the only one among the top five candidates that wouldn’t address the low-income people living in red states who were left uncovered when their state governments refused to expand Medicaid under the Affordable Care Act (ACA). According to the Kaiser Family Foundation, 4.9 non-elderly adults remain uninsured in these states as a result of their decision not to expand Medicaid.

Mayor Pete’s approach is the least ambitious among the top tier candidates but because he hasn’t yet released a detailed policy paper, he has wiggle room to make a more comprehensive proposal moving forward.


Former Vice President Joe Biden’s proposal also revolves around a Medicare-like public option but goes further than Buttigieg’s. He would offer premium-free enrollment for the uninsured in non-expansion states, including automatic enrollment for the approximately two million who earn less than 138% of the federal poverty line. States that did expand Medicaid would have the option of rolling their low-income populations into the new program or continuing to cover them under Medicaid.

Biden also proposes a significant expansion of the premium subsidies that are currently only available to the 11 million people who purchase insurance through the ACA exchanges. These would become available to all Americans who choose to buy into his new public insurance program. While subsidies currently help those who earn less than 400 percent of the federal poverty line (around $100,000 for a family of four), Biden would remove that cap and offer assistance to households with higher incomes. Finally, his plan would increase the generosity of the subsidies by calculating them based on the cost of a “gold” insurance plan rather than the current “silver” plan. Gold plans feature lower deductibles and smaller co-pays.


Biden’s plan is surprisingly ambitious given that he’s running as a “safe,” moderate antidote to Trump, and shows how far toward the progressive side the Democratic healthcare debate has shifted in recent years. With a relatively modest price tag of $750 billion over ten years, according to the campaign, it would be a major expansion of public health coverage that would attract the support of center-left and centrist Dems and the pundit class.

According to the campaign’s own estimate, it would leave 3 percent of the population uninsured. That would be a significant reduction—Gallup says that around 14% have no coverage at present—but nonetheless fails the test of universality.

One quirk of his proposal that’s worth noting is that states that didn’t expand their Medicaid programs under the ACA would not be required to contribute to the cost of covering their low-income populations, but expansion states would. This effectively rewards red states for their hostility toward public insurance.


Vermont Sen. Bernie Sanders has made Medicare for All his signature policy.

Sanders’ plan would significantly expand Medicare’s benefits, eliminating out-of-pocket costs and covering everything other than voluntary cosmetic surgery. He would roll all existing public health programs into Medicare, with the exception of Veterans Administration care, the Indian Health Service and Medicaid’s long-term coverage. Everyone in the country would be automatically enrolled in the new program; the law would forbid private insurance from offering the same coverage.

There would be a four-year transition period, during which everyone under 18 would be covered immediately and the current age for Medicare eligibility would drop each year until everyone is covered in the fourth year.

The program is estimated to cost around $30 trillion over ten years but that number is misleading because the federal government already spends around $2 trillion per year on healthcare and most of that money would be repurposed for Medicare-for-All. Similarly, private premiums would be eliminated, and replaced with a 7.5 percent payroll tax (small businesses with payrolls under $2 million would be exempt).

Additional revenues would come from increases in income and capital gains taxes, the estate tax, and the establishment of a wealth tax--and by closing various corporate loopholes.


Sanders’ proposal for Medicare for All is significantly more generous than other countries’ single-payer systems. It would bring a great deal of economic security to American households.

In political terms, it is also the most difficult to enact. While it would reduce system-wide costs overall, the political reality is that its high price tag probably makes it a non-starter for center-left and centrist Democrats to support. Polls also consistently find that by significant margins, the public prefers to have an option to buy into Medicare over proposals for a mandatory shift.

Ultimately, it’s hard to imagine there being 218 House votes for this iteration of Medicare for All in the foreseeable future, but the campaign should get credit for moving the entire Democratic debate over healthcare to the left.


Massachusetts Sen. Elizabeth Warren is a co-sponsor of Sanders’ Medicare for All bill. Given the opportunity in last month’s debate to chart a more moderate approach that would retain a role for private insurance, she demurred.


In the past, she has also said that she might be open to an approach that maintains a reduced role for private insurers. Given that she has not made Medicare for All the centerpiece of her campaign, as Sanders has, she could probably pivot in the general election to a proposal like Sen. Kamala Harris’s (see below) without taking too much flack.


California Sen. Kamala Harris is proposing a ten-year transition period to get to a Medicare for All system modeled on the current Medicare program, which allows private insurers to sell highly regulated Medicare-compliant plans. She would also add some additional benefits to the program.

During the transition period, Harris proposes offering everyone an option to buy into Medicare, but unlike Biden and Buttigieg’s plans, hers would automatically enroll all newborns and the entire uninsured population into the transitional plan. Anyone could go to a healthcare provider for treatment, and if they didn’t already have other coverage, they’d be instantly enrolled. Their premiums, calculated on a sliding scale, would then be added to their tax bill, and those who don’t pay federal taxes wouldn’t be charged.

At the end of the ten-year period, Harris’s new Medicare program would cover a basket of essential services, including “hearing aids, vision, dental, mental health and substance use disorder treatment, and comprehensive reproductive health care services.” Individuals would have the choice of a public Medicare policy or a Medicare-compliant policy from a private insurer. Businesses would still be able to offer their employees coverage as a benefit, giving them a choice of either a private or public Medicare policy, and would also be able to offer them private supplemental coverage.

Out-of-pocket expenses would be capped at $200 per year. Medicaid and the Children’s Health Insurance Plan (CHIP) would be rolled into the new system.

As yet, we don’t have a cost estimate for this approach, but based on those of structurally similar plans, it would be somewhere between $2.5-5 trillion over ten years.


Harris’s proposal is probably the most progressive after the Sanders plan. Automatic enrollment of the uninsured population meets the test of universality. The system-wide cost savings would be somewhat more modest than with Sanders’ plan, but at a fraction of the cost, this approach, which polls well, would be a somewhat easier lift politically.

If Dems win big in 2020, they will have to coalesce around a healthcare reform scheme that can get progressive, liberal and centrist support, and Harris’s proposal, or something like it, may represent that sweet spot. 


Texas Rep. Beto O’Rourke’s plan is light on details but appears to be similar to Kamala Harris’s proposal.

He has repeatedly praised The Medicare for America Act, a bill introduced in The House by Rep. Rosa DeLauro (D-CT), which differs from Harris’s plan in that private insurers would be allowed to sell plans outside the Medicare system. The bill also expands subsidies to defray the cost of insurance premiums.


Like Buttigieg, Booker has not released or endorsed a comprehensive health care policy. On his website, he promises to “fight for Medicare for all” but has also said he envisions a role for private insurance.

He has issued a detailed proposal for long-term care. Presently, seniors can qualify for Medicaid’s long-term care program only if they meet strict limits for income and assets. This forces many people to spend down their life savings on care before they can receive public assistance. Booker wants to significantly raise those caps, and then offer the ability to buy into Medicaid’s long-term care program to anyone who doesn’t meet the new eligibility limits, with subsidies determined according to income.


In the Senate, Minnesota’s Amy Klobuchar has co-sponsored the State Public Option Act, which would give states the option of allowing citizens to buy into their Medicaid programs, and the Medicare-X Choice Act, which would add a public insurance option to the ACA exchanges. She also proposes establishing a reinsurance program to reduce premiums and would expand subsidies in the ACA exchanges. Like all other Democratic candidates, she favors repealing a law that bars Medicare from negotiating lower prices for pharmaceuticals and would allow individuals to import them from Canada.


If Buttigieg’s plan is the most moderate among the top-tier candidates, Klobuchar’s approach is the least ambitious among the ten we’re looking at here. Unlike other proposals for a public option, the bill Klobuchar supported would only be available for people who are currently eligible to purchase insurance on the ACA’s exchanges. That is currently around 11 million people.

A few years ago, strengthening the Affordable Care Act, bringing down premiums with a reinsurance scheme and adding a public option to the exchanges might have become the consensus among moderate Democrats but in 2019, a policy approach significantly to the right of Joe Biden’s seems like a non-starter.


Tech entrepreneur Andrew Yang endorses Medicare for All, presumably along the lines proposed by Bernie Sanders. He also calls for “providing holistic healthcare to all our citizens,” which he claims would “drastically increase the average quality of life, extend life expectancy, and treat issues that often go untreated.”

As explained on his website,

…we can look to the Southcentral Foundation for another important shift necessary in the way we treat patients: holistic approaches. At this treatment center for native Alaskans, mental and physical problems are both investigated, and, unsurprisingly, the two are often linked. By referring patients to psychologists during routine physicals, doctors are able to treat, for example, both the symptoms of obesity and the underlying mental health issue that often is related to the issue. The referral also leads people with issues they may otherwise try to bury – sexual abuse, addictions, or domestic violence issues – to bring them up with a doctor so that they can be addressed.


Hawaii Rep. Tulsi Gabbard has said that “all Americans should have access to affordable healthcare through Medicare or a public option,” but she now advocates Medicare for All. In the last Congress, she was one of over 100 co-sponsors of H.R. 646, the House’s version of Sanders’ Medicare for All proposal.

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