The Difference Between a ‘Public Option’ and ‘Medicare for All’? Let’s Define Our Terms

Various proposals are floating around, each of which would change the health care system in distinct ways. Some, like one from Senator Bernie Sanders, would do away with all private health insurance. Some would make small expansions in existing public programs. Some would try to cover all Americans through a mix of different insurance types.

It can be mystifying when people call all of these ideas “Medicare for all,” as some in the debate have been doing.

.. Private plans handle Medicare drug coverage, and you can choose among options. You pay premiums each year, and you pay deductibles and co-payments when you use medical services.

Because the program’s out-of-pocket spending has no limits, most Medicare beneficiaries also buy private supplemental insurance to limit those costs. That insurance doesn’t cover medical services outside the Medicare system, but it helps pay the patient’s share of the bill when a person goes to the doctor or hospital.

.. Mr. Sanders, who prominently featured such a plan in his 2016 presidential platform and just announced he has joined the 2020 race, uses this term a lot. His plan would both expand traditional Medicare to cover all Americans, and change the structure of the program, to cover more services and eliminate most deductibles and co-payments. So the Medicare everyone would be getting would differ in crucial ways from the Medicare older people get now.

Trump’s Attacks on Health Care Will Backfire

The administration’s chaotic reversals on Obamacare could deprive millions of coverage.

Meanwhile, the administration’s latest budget, released in mid-March, stands behind legislation known as “Graham-Cassidy,” which was pushed by Republicans in 2017 but never won enough support to be brought to a vote.

The Trojan horse of health care reform, the proposal provides for relatively small initial cuts in federal funding and then huge reductions starting in 2027.

According to a Brookings Institution reportGraham-Cassidy would cost 32 million Americans their health insurance by 2027, just as full repeal would. That’s Donald Trump’s idea of a “beautiful,” “terrific” and “unbelievable” health care plan.

.. The administration’s recent decision to submit a brief in a Texas case asking the court to declare all of Obamacare unconstitutional was well publicized.

Slipping by almost unnoticed was Mr. Trump’s instruction last June to the Justice Department, which was defending the A.C.A., to argue instead that certain key provisions — notably, the requirement that Americans with pre-existing conditions be treated equally — be declared unconstitutional.

A win by Mr. Trump in this case could mean that nearly 20 million Americans would lose insuranceaccording to the Urban Institute.

The Individual Mandate Is Here to Stay

The basic economics of U.S. health care makes that easier said than done. Before the ACA, the U.S. stood out from the international pack on health care in two very unpleasant ways. First, it spent a far larger share of gross domestic product on health care. Second, it was the only advanced industrial nation that left vast swaths of its population uninsured. These two doleful facts remain true, although the fraction of Americans without health insurance fell from 13.3% in 2013 to 8.8% in 2017, according to Commerce Department data.

There are several ways to get more people covered. One is to adopt a system in which the government provides or pays for universal coverage—the British or Canadian model. This won’t happen soon in the U.S., not even as Medicare for All.

A second route, advocated unsuccessfully by President Clinton in 1993, is to mandate that every employer provide health insurance to its workers. This approach might seem natural in the U.S. context because so many workers already receive health insurance that way. But the employer mandate has fatal flaws. It wouldn’t cover the nonworking population, and it would impose heavy burdens on small businesses.

For these and other reasons, many economists in the Clinton administration—including me—favored an individual mandate. But that idea was dead in the water in 1993 because it had been advocated by the Heritage Foundation starting in 1989. It was therefore a “right wing” idea.

There are problems with an individual mandate, too. For one, the high cost of U.S. health insurance means that many low- and moderate-income families cannot afford to buy policies on their own. For another, if for-profit insurance companies are made to lose money by covering people with pre-existing conditions, the government must also force young healthy people, who tend to have limited medical expenses, into the insurance pool.

Fortunately, both problems are easily solved—conceptually, that is, not politically—by mandating that everyone buy a policy and providing subsidies to the needy. Massachusetts legislators understood this in 2006. They also knew they were not writing on a blank slate; many citizens received health insurance through their jobs and didn’t want to lose it. Hence the hybrid system that became known as RomneyCare.

If this short description reminds you of the ACA, it should. The two plans are not identical twins, but there is a family resemblance. In 2010 Democrats didn’t follow in the footsteps of Romney Republicans to make them look good; they designed their plan that way because under the constraints of precedent, the underlying logic practically forces you there.

Keep that in mind: If there ever is a TrumpCare, an unlikely proposition, it’s bound to resemble RomneyCare and ObamaCare—no matter what the president claims.

Trump surprises Republicans — and pleases Democrats — with push to revive health-care battle

A surprise move by the Trump administration aimed at striking down the Affordable Care Act thrust the partisan battle over health care into the middle of the 2020 campaign on Tuesday, handing Democrats a potential political gift on an issue that damaged Republicans badly in last year’s midterm elections.

In a new court filing, the Justice Department argued that the ACA, also known as Obamacare, should be thrown out in its entirety, including provisions protecting millions of Americans with preexisting health conditions and allowing young adults to stay on their parents’ health-care plans.

President Trump praised the move during a lunch with Senate Republicans, and suggested the GOP should embrace a new congressional battle over health-care policy ahead of the 2020 elections.

“Let me tell you exactly what my message is: The Republican Party will soon be known as the party of health care,” he told reporters before the lunch. “You watch.”

.. Trump spent much of his time at the Senate lunch talking about health care, according to several senators present.

If there’s a message to be learned from 2018 on policy, it’s health care,” Sen. Lindsey O. Graham (R-S.C.) told reporters after the lunch Tuesday. “Let’s become the party of health care.”

“He thinks that that’s the one area where we’ve fallen short and he wants to see us address it,” said Sen. John Neely Kennedy (R-La.). “He made that very clear.”

“If you’re a Republican thinking about 2020 right now, you want to be on offense on health care, not defense,” she said. “And the only way to do that is to make the focus on what Democrats want to do — on Medicare-for-all — rather than making it on what the president and the White House are suggesting.”

.. A federal judge in Texas ruled in December that the law’s individual mandate “can no longer be sustained as an exercise of Congress’s tax power” and further found that the remaining portions of the law are void. He based his judgment on changes to the nation’s tax laws made by congressional Republicans in 2017.

.. “It is highly unusual for the Department of Justice not to defend duly enacted laws, which the Affordable Care Act certainly was,” Collins said. “This decision to even go more broadly in failing to defend the law is very disappointing.”

.. “I think Obamacare should be gone,” he said. “We’ve got to cover people with preexisting conditions apart from Obamacare, which is what I talked about a lot.”

.. There would be ripple effects throughout the health-care industry and insurance landscape as well. Those with workplace plans could be affected, as employers would be allowed to scale back certain medical benefits, and people with preexisting conditions buying coverage on their own would no longer be guaranteed access to coverage at no extra cost.