'Medicare For All' Has Real Trade-Offs. So Does The Public Option.

A user's guide to the debate dividing the Democratic Party's presidential field.

Health care is high on the list of voter concerns for 2020, as last week’s Democratic candidate debate made clear once again. It’s no mystery why. About 28 million Americans don’t have health insurance, while tens of millions with coverage still struggle to pay their medical bills

Things would be a lot worse without the Affordable Care Act, which Republicans have repeatedly tried to repeal. Whatever the law’s shortcomings, Obamacare has improved access to care, prevented financial hardship from medical bills and reduced mortality, according to the best available research. 

For Democrats, the question is what to do next.

Some of the 2020 candidates are proposing “Medicare for All.” Some are proposing a “public option.” And it’s not clear how many voters actually understand the two concepts, the differences between them or the trade-offs they entail.

Here’s a quick guide:

Q: What exactly are the 2020 Democrats proposing?

A: The most ambitious proposal is Medicare for All, and its biggest champion is Sen. Bernie Sanders (I-Vt.). 

Medicare for All would basically wipe away existing insurance arrangements, public and private, and replace them with a new government-run insurance plan. The benefits would be comprehensive and more generous than anything you see today, even compared to traditional Medicare: It’d cover all medically necessary care, and there would be no out-of-pocket costs except for some token copayments on certain name-brand prescription drugs. 

Sen. Bernie Sanders (I-Vt.) speaks at a Dec. 16 rally in Rancho Mirage, California. Sanders's signature issue in the Democrat
Sen. Bernie Sanders (I-Vt.) speaks at a Dec. 16 rally in Rancho Mirage, California. Sanders's signature issue in the Democratic presidential primary has been Medicare for All.

Since the federal government would control what the new program pays the to providers of health care, it could set limits and reduce overall spending on health care. To pay for the new program, the government would have to raise existing taxes or create new ones.

Q: Is anybody besides Sanders supporting it?

A: Sen. Elizabeth Warren (D-Mass.) is a co-sponsor of the bill Sanders has introduced in the Senate but has said she would attain Medicare for All through a two-step process as president.

Warren’s plan would use executive authority to drive down drug prices and push Congress to pass a narrower piece of legislation, one that improved the financial assistance available through the Affordable Care Act and created a government plan open to anybody who wanted to join it. 

This “public option” would be essentially free to many lower- and even some middle-income people and offer better benefits than most private plans. But Warren would let employers continue to offer coverage to employees, at least at first. She’d also leave the existing Medicare and Medicaid programs as they are, though she’d improve Medicare benefits for seniors.  

Elizabeth Warren rally on 16 September 2019, Washington Square Park, Manhattan, New York, USA (Photo credit should read Joel
Elizabeth Warren rally on 16 September 2019, Washington Square Park, Manhattan, New York, USA (Photo credit should read Joel Sheakoski / Barcroft Media via Getty Images)

Warren has said that in her third year in office, she would ask Congress to pass legislation moving all the way over to the version of Medicare for All in the Sanders bill. 

Whether these differences between Warren and Sanders are more about strategy or substance, or maybe a little of both, is a matter about which even like-minded progressives can disagree. The same goes for how much these differences really matter.

Q: What about the other top candidates?

A: Former Vice President Joe Biden and former South Bend, Indiana, Mayor Pete Buttigieg have different plans, but they take a similar approach.

Both would create a public option open to all people, give government new power to negotiate directly with the pharmaceutical industry over the price of prescription drugs, limit “surprise billing” from doctors and hospitals, and improve the financial assistance available to people buying coverage on their own through HealthCare.gov or one of the state-based exchanges, including Covered California

It’s more building on the Affordable Care Act than replacing it.

Other candidates, including Sen. Amy Klobuchar (D-Minn.), have also endorsed the public option approach.

Q: What’s the best argument for Medicare for All?

A: It’s the surest way to make sure everybody has insurance, since the government just signs up everybody ― and anybody who might miss out gets insured the moment they interact with the health care system, whether it’s at the emergency room or a pharmacy. The benefits are so comprehensive that nobody would struggle with medical bills. 

It’d be a lot simpler than the existing system ― no more billing hassles, no more dealing with pre-authorization from insurance companies, no more worrying about whether a doctor is in-network. The government could really limit national health spending, in the way most other countries do. 

Q: So what’s not to like?

A: Conservative-leaning critics would say all that government control is bound to stifle innovation, that the free market allocates resources better than the federal government, and that this approach could potentially lead to shortages and rationing. 

Former Vice President Joe Biden takes questions at a Dec. 30 campaign town hall in Derry, New Hampshire. Biden favors a publi
Former Vice President Joe Biden takes questions at a Dec. 30 campaign town hall in Derry, New Hampshire. Biden favors a public option for health coverage.

Supporters would argue that the track record of such systems abroad suggests that the government can allocate resources as well, if not better than, the private market. A well-funded single-payer system could even mean better care, more choices of provider or shorter waits for appointments. It all depends on the details.

Still, even many progressives would concede that the transition to Medicare for All would be difficult. If you want most people to end up better off financially, taking into account what they pay today (as premiums and out-of-pocket expenses) versus what they’d pay for the new system (in taxes), then, according to most projections, the government would have to squeeze the health care industry’s income.

Q: That’s why Sanders and Warren and the rest talk about going after insurers and drugmakers. What’s wrong with that?

A: There’s lots of evidence that health care prices are higher than they need to be. But that applies to the entire industry, including doctors and hospitals. And cutting revenue to any of these sectors too dramatically, indiscriminately or quickly carries its own risks. You could reduce incentives for the development of new treatments, force the shuttering of struggling but vital hospitals, and so on.

It would depend on the policy details, and even then there’d be room for debate about exactly how real or serious the effects would be. But the industry would do its best to scare people, which brings us to the other problem with Medicare for All: Politically, it’d run into massive opposition from the health care sector. And few industries wield as much political power.

Q: So it’s mostly a matter of overcoming special interests. Isn’t that the whole point of building up a grassroots movement?

A: The energy behind Medicare for All is a credit to Sanders and his allies, some of whom, like Physicians for a National Health Plan, have been at this for decades. 

But it’s not just industry pressure that advocates must overcome. It’s also public anxiety. Most working-age people have private insurance and, though they may not love it, polls suggest they’re wary of giving it up. This is especially true at a time when faith in government is at historic lows.

Q: Would a public option be easier for wary Americans to accept?

That’s the hope. By allowing employers to keep offering coverage and leaving the big programs like Medicare and Medicaid largely in place, you could reassure voters who get skittish about government forcing them into a new plan.

If the public option is as attractive as proponents say it will be, it could eventually win over everyone or nearly everyone, creating something a lot like Medicare for All. Even if it serves only part of the population, it could help tens of millions.  

Former South Bend, Indiana, Mayor Pete Buttigieg speaks during a town hall event Nov. 10 in Walpole, New Hampshire. Buttigieg
Former South Bend, Indiana, Mayor Pete Buttigieg speaks during a town hall event Nov. 10 in Walpole, New Hampshire. Buttigieg has proposed a health care plan that would allow employees to keep coverage provided by their employers.

The public option has come to be seen as the “moderate” proposal, because of all the attention to Medicare for All, but it would represent one of the largest expansions of the social welfare state in modern history. It could even include some aggressive efforts to control prices, although it would depend on the specific design

And yet for the first few years, the program would likely cost the federal government a lot less than Medicare for All would. Less federal spending likely means fewer tax increases and that could be another political advantage.

Q: Sounds appealing. What’s the problem?

A: There are always trade-offs. The public option plans out there envision some people continuing to carry significant out-of-pocket costs or facing substantial premiums. It’d be a marked improvement over the status quo, but you’d still have some people with high medical bills.

Coverage gains would probably be smaller. Ten million fewer people would get coverage under Biden’s plan, according to projections. Buttigieg’s would probably reach more of the uninsured because he envisions some kind of “automatic enrollment” for people who don’t sign up. But that could mean some people facing large retroactive premiums

Patients (who would still be dealing with insurance bureaucracies) wouldn’t see the same gains in simplicity; providers (who would still be dealing with multiple insurers) wouldn’t see the same gains in efficiency. 

These public option alternatives represent less change than Medicare for All ― which you can see as a strength, a weakness, or both.

Q: At least the public option wouldn’t force people to change coverage. Isn’t that a big deal?

A: Here’s where things get really complicated. Under these public option plans, the government wouldn’t force employers to drop coverage. But some employers might decide to do it anyway, figuring the public option offers workers an alternative. 

It’s hard to say how people would feel about this. Employers can already raise copayments or deductibles, alter provider networks, and switch carriers altogether. But people don’t seem to feel as skittish about that possibility as they do about the government forcing them to change.

Q: OK, but at least special interests wouldn’t fight so hard. Or would they?

A: The Partnership for America’s Health Care Future, which represents a consortium of interests including insurers, hospitals, and drugmakers, has attacked the public option just as strongly as it has attacked Medicare for All. It’s possible industry groups might not ultimately fight the public option as relentlessly as they would Medicare for All, but it’s not like they’re going to embrace the idea. 

Q: What would the public option do to federal spending?

A: If people flock to the public option in higher-than-expected numbers, the program’s cost would exceed projections ― although, as with Medicare for All, public spending would largely displace private spending. The precise mix would depend on details we don’t yet have.

Q: I’m getting the impression the details are really important. Why haven’t the candidates been more specific?

A: Some have been more specific than others. Warren provided a detailed financing plan for her proposal, though some experts have questioned whether its assumptions are realistic. Sanders has full legislation that outlines some funding options but doesn’t commit to any. 

The other candidates have been less specific, yet they have not gotten the level of scrutiny that Warren’s plan famously has.

Then again, there’s only so much a candidate can or should say in the context of a campaign. And all the Democrats are offering more details than Republicans typically have. 

In 2016, when Donald Trump was running for president, his plan was a promise of “something terrific” and a few bullet points. It had zero relation to what he and the Republicans tried to accomplish once he got into office.

Q: Oh, yeah. The Republicans. What do they want to do?

A: Their plan, insofar as they have one, remains to repeal Obamacare. And though they don’t have the votes to make that happen right now, the Trump administration is supporting a lawsuit that would wipe away the Affordable Care Act and leave 20 million more Americans uninsured. The administration is also doing what it can to undermine the law via executive action.

The 2020 Democrats have some big disagreements, but if you step back, you’ll see they all support new government-run insurance programs, more government influence over prices and more financial assistance to protect people from crippling medical bills. The common thread is that they all want to move the country in the same direction, toward making health care truly a right.