Former Vice President Joe Biden is the overwhelming favorite to win the Democratic nomination for President following outsize victories in primaries across multiple states. And with the coronavirus crisis—a public health and financial catastrophe the likes of which many of us have never seen—on everyone’s mind, health care will loom large this election season. Hospitals are already being overwhelmed. Nearly 10 million people have filed for unemployment benefits in the past two weeks alone, and with many health plans tied to employment, this could put lots of people in danger of losing their insurance.
As Biden and his sole remaining opponent, Sen. Bernie Sanders, along with other Democrats sparred over the course of this campaign, Medicare for All became a clarion call for establishing candidates’ progressive bona fides. Some, such as Sanders, advocated for far-reaching proposals that would go beyond even what European nations like the U.K. have in place with single-payer systems.
The Sanders plan would wipe out pretty much all of the U.S. private health insurance industry, with a few exceptions, replacing it with a public health program even more generous than Medicare and Medicaid.
While both Sanders’ and Biden’s plans have plenty of details that need to be filled in, Biden’s proposal is a lot more nuanced.
Coronavirus and the health care debate
Sanders has argued that the staggering costs that someone with COVID-19 may have to face in America underscores the importance of a single-payer system with zero premiums, deductibles, and out-of-pocket costs. Biden has retorted that countries such as Italy, which have seen considerable numbers of deaths, haven’t been able to contain the situation despite a nationalized health system.
Biden doubled down on his position Monday. “The thing that is needed is, for example, we have a whole number of hospitals that are being stretched, including rural hospitals; they are going to need more financing. That doesn’t come from a single-payer system,” he said during an interview on MSNBC.
It all depends on your perspective. “The testing debacle and the holes in coverage and care on COVID-19 are arguments for Medicare for All,” wrote Drew Altman, CEO of the nonpartisan Kaiser Family Foundation (KFF), in a tweet last month. “The poor performance of the federal gov’t and superior performance of states are arguments against. You can make the case you prefer.”
What complicates the issue is that universal coverage and access to health care isn’t quite the same thing as financing for the medical providers who would guarantee such coverage. Sanders would argue that a fully public system that allows a government entity to negotiate prices on behalf of patients would lower everyone’s medical bills, including all the associated costs of coronavirus testing. Biden might say the tradeoff is the financial hit hospitals may face in a time when the health system is already overburdened, understaffed, and suffering from a dearth of tests and medical equipment.
Biden and Sanders have both proposed nixing out-of-pocket costs for patients with coronavirus. “Under the Biden plan, in terms of coronavirus specifically, he’s said no one should face out-of-pocket expenses for getting tested or getting treated,” Larry Levitt, executive vice president of KFF, told Fortune. “Biden’s plan would make [it] clear people wouldn’t face those costs for treatment whether or not they’re insured or uninsured or underinsured.”
The mechanics of how a bill to cover coronavirus health care expenses would work, and if (and when) such a bill would sunset, isn’t clear—and it would have to get congressional approval.
Last week, President Donald Trump signed a historic $2 trillion stimulus bill meant to address COVID-19, including $100 billion in emergency funds for hospitals and health providers grappling with the financial domino effect of the coronavirus. The bill doesn’t address patient costs, but several health insurance companies have said they’ll waive bills for coronavirus-related medical care.
Amid the current economic crisis, many will also turn their attention to current available options for health care, as loss of employment could count as a qualifying event to purchase health insurance through the Obamacare exchange.
What’s in Biden’s broader health care plan?
Coronavirus is one gigantic health care issue. An overhaul of the entire U.S. health system is titanic.
Biden and Sanders have tussled over Medicare for All and whether or not it’s the correct approach to wrangling the fragmented U.S. health system. It’s been a central component of the debates between Biden and Sanders, head-to-head notably held without a live audience because of social distancing measures necessitated by the coronavirus pandemic.
Unlike Sanders’ plan, which would essentially end almost all private health insurance in America, Biden has taken a more incremental approach.
The cornerstone of Biden’s health care proposal is building on the Affordable Care Act (ACA), or Obamacare, which was signed into law a decade ago and is still facing challenges in the Supreme Court by the Trump administration and GOP lawmakers.
A so-called public option would be the largest change under Biden’s plan.
The vast majority of working Americans have health insurance through their employers. The ACA built an interface for people, such as those who don’t receive insurance through their employers or a public program such as Medicare or Medicaid, to connect with the individual insurance market. Biden wants to build on that by adding a federally funded public option to the ACA’s marketplaces.
Biden’s public option is envisioned as a Medicare-like alternative for those who buy private, individual health plans through the Obamacare marketplaces. Unlike private health plans, a public option would be funded by the government.
That would, theoretically, cut premiums and out-of-pocket costs compared to the private insurance available via the ACA—though not necessarily eliminate them completely. The thinking is that a public plan would be able to have more negotiating power with hospitals, drugmakers, and other sectors of the health industry, and a far wider pool of plan holders that could drive down costs.
Nearly half of all Americans receive insurance through their employers. Currently, if employers offer a minimum standard of coverage, its employees are not eligible for a plan on the Obamacare marketplaces that offer private insurance plans.
Biden would do away with that provision, giving workers the option of transitioning to an ACA plan or—if his full proposal passes—a public option on the ACA marketplace if their employers’ offerings don’t fit their needs.
“One of the most significant elements of Biden’s plan is that workers could choose a public option rather than what their employers offer them,” said Levitt.
Workers’ ability to transition from their employer-sponsored health care to an Obamacare marketplace that offers a public option could, in theory, significantly cut out-of-pocket health costs for low-income workers who may not receive sterling medical benefits.
But Biden’s plan is more of a guidance than a step-by-step explanation of what might happen on an individual basis. The steak still needs to match the sizzle.
“The public option Biden has proposed is quite far-reaching by historical standards,” said Levitt. “It’s a fair assumption a public option would give people a broader choice pool, but there are a lot of details in Biden’s plan about how the public option would work that still need to be worked out.”
Former President Barack Obama supported a public option in the initial debate over the ACA but gave it up as a concession once it was clear that no comprehensive health care bill including a public option would pass even with a Congress dominated by Democrats between 2009 and 2010.
Wide swaths of the health care industry aren’t interested in any sort of expansive federal involvement in health care price negotiations that may eat into their bottom lines—including both Sanders’ Medicare-for-All proposal or Biden’s public option. The Partnership for America’s Health Care Future (PAHCF), which includes major trade associations such as American Medical Association (AMA), the Pharmaceutical Research & Manufacturers of America (PhRMA), the Federation of American Hospitals (FAH), and others have released statements slamming these ideas, warning they would limit patients’ access to hospitals under financial duress.
“Unfortunately, Vice President Biden’s proposal for a new government insurance system through a ‘public option’ would undermine the progress our nation has made and ultimately lead our nation down the path of a one-size-fits-all health care system run by Washington,” said Lauren Crawford Shaver, executive director of PAHCF, in a statement last year.
Then there’s the issue of the Obamacare marketplace plans themselves. Currently, only people who make anywhere from 100% to 400% of the Federal Poverty Level (FPL) qualify for subsidies to help pay their health insurance premiums on the exchanges. In 2020, FPL stands at $12,760 in annual income for individuals and $26,200 for a family of four.
Biden’s plan would enhance those premium subsidies significantly by lifting the cap and calculating how much a household might have to pay for insurance on a more generous basis—it would set a ceiling of 8.5% of income on purchasing health insurance.
On the Medicare and Medicaid fronts, Biden would significantly expand Medicare’s ability to negotiate prescription drug prices (a proposal that has been embraced by Democratic and Republican politicians alike but yet to be enacted) in an effort to lower costs.
As for Medicaid, the program that provides insurance to some of the poorest people in the country, Biden would seek to extend coverage via an interesting workaround.
The ACA significantly expanded Medicaid coverage by offering much more federal funding for states, which increased the pool of residents who qualified for the program to all households at 138% of the Federal Poverty Level. That was, originally, a mandatory requirement—but the Supreme Court struck down the original provision and made it an optional expansion by states.
Medicaid is a state and federal partnership program, so qualifications differ significantly based on where someone lives. For instance, in states such as Texas and Alabama, which chose not to expand Medicaid under the ACA, individual, nondisabled adults without children wouldn’t qualify for the program at all; even parents in a family of three would have to make about $3,700 or less per year to qualify.
Most states took the money and expanded Medicaid. But 14 still have not, according to the Kaiser Family Foundation, and some 4.5 million impoverished Americans would be able to receive health insurance at little to no cost were those states to expand their programs.
Biden’s plan would rely on the Obamacare marketplaces to extend coverage to those who have fallen through the cracks by allowing these people to buy into a public option that covers a wider array of benefits than certain private health plans.
These series of proposals would not ensure universal coverage, according to KFF’s Levitt, and though they may significantly lower out-of-pocket medical costs for many, a significant chunk of people would still struggle financially in the health system, depending on the specific plans which people seek.
There are multiple other elements to Biden’s plan, including ending the practice of “surprise billing,” wherein patients may be left with a massive hospital bill because they were treated by an out-of-network doctor at a facility that was in-network for their health plan.
Women’s health care has also become a major issue amid the pandemic as some states attempt to further enact restrictions on abortion. Biden has proposed repealing the Hyde Amendment, which largely prohibits the federal funding of abortion services, and using the Justice Department to fight back against state laws which make it difficult to get an abortion—including mandatory waiting periods and ultrasound requirements.
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