Health care remains the nation’s top voting issue ahead of the 2020 elections, just as it was during the 2018 midterms. Surveys show voters remain frustrated with high drug prices, growing out-of-pocket expenses, and skimpy health-insurance benefits.
The leading candidates have publicly promised to fix these problems, but all are omitting certain details about their health care plans. To help voters make informed decisions next November, this article looks at what politicians on all sides – left, middle, and right – are not telling you about their health care promises.
Health care took center stage during both rounds of the 2020 Democrat debates so far. There, progressive candidates like Bernie Sanders and Elizabeth Warren touted slightly different versions of Medicare for all, which remains a popular reform plan despite the fact that few voters understand the details.
Here are the two most important things these candidates are omitting from their health care promises:
1. The math doesn’t add up
It’s a well-known fact that Medicare is a government-funded program for seniors. It’s a little-known fact that the program underpays doctors and hospitals (currently only 90% of the fully allocated costs) to treat Medicare’s 60 million enrollees. Doctors and hospitals offset these underpayments by charging private insurers 120% to 130% of the actual cost to treat America’s 155 million covered employees and dependents. In other words, the Medicare math works now because private insurers (and, thereby, U.S. businesses) are footing much of the bill. So, what would happen if Medicare for all became law and private insurance went away? Option one: The government will continue underpaying health care providers, which would bankrupt hundreds of community hospitals. Option two: the government will reimburse providers for the full cost of care. Combine that added cost with the number of newly insured Americans (28 to 44 million of them), and total health care spending would go up by an estimated $3 trillion over the next ten years — an expense that would no doubt raise taxes.
2. It’s not happening
Most election maps project Democrats to fall short of taking the Senate in 2020, and way short of the 60-vote “supermajority” needed to pass Medicare for all without a filibuster. Republicans have made clear they would vote unanimously against the bill (and they’d likely get some help from centrist Democrats who’ve expressed strong doubts). Ultimately, voters in favor of Medicare for all care less about policy specifics and more about scrapping the old, ineffective system and starting anew. Unfortunately, there isn’t a conceivable 2020 election outcome that’d allow that to happen.
Although the loudest voices in politics have always come from the margins, polls show that 38% to 46% of Americans identify as “independents.” Some 2020 candidates are hoping to woo independent “swing voters” with health care plans that uphold private insurance, at least at first.
Here’s what they’re not telling you:
1. “Medicare for some” is Medicare for all in slow motion
When asked if they favored eliminating private health insurance, just four of the 20 Democratic candidates raised their hands during the first round of debates. Mayor Pete Buttigieg and Sen. Cory Booker kept their hands at their sides. Their respective plans can best be described as “Medicare for Some,” which would expand the availability of Medicare while allowing individuals the option to keep their private insurance. In the short term, this plan relieves the anxiety of voters who fear losing their private coverage. Less discussed is the long-term plan. Booker said, “Medicare for all is the right way to go, but I’m also realistic …” while Buttigieg said his plan will be “a very natural glide path to a single-payer environment.” By granting more people access to Medicare, these candidates know that private insurers will get hit with ever-more cost-shifting. As commercial health insurance prices go up, more patients will gravitate toward the public option and, eventually, the private pool will dry up. Buttigieg and Booker won’t trumpet the fact, but “Medicare for Some” is just a slower means to the same end: Medicare for all.
2. If you like your doctor, you might not like this plan
In a post on Medium, Sen. Kamala Harris spelled out her plan: a 10-year nationwide transition to a “Medicare Advantage” program, run by private insurers like Humana and UnitedHealthcare (not the government). Patients today enjoy the generous benefits of Medicare Advantage (like dental, vision, and fitness) and the low cap on out-of-pocket payments. That’s why a third of all covered seniors are now enrolled in this alternative to traditional Medicare. However, not all Medicare Advantage plans are created equal. When tied to large, multispecialty medical groups, patients receive high-quality care and sufficient choice in providers. But narrower versions of Medicare Advantage restrict access to doctors and hospitals. Harris promised to “give everyone access to comprehensive health care.” What she hasn’t said is that this plan will likely disappoint voters who expect unlimited choice in doctors and hospitals.
3. It will take more than minor tweaks to Obamacare to rein-in spending
Economists agree that the cost of American health care is unsustainable. So, bringing down the 10-year projected rate of health care inflation (from 5% to 6%) to the rate of overall inflation (generally 2% to 3%) will require bold legislative change. That’s unlikely to happen under former Vice President Biden’s plan, which seeks to “protect” and “build on” the Affordable Care Act, President Obama’s signature legislation. Biden hopes to build in a public option and expand access to Medicaid, actions that would no-doubt benefit recipients. But he hasn’t acknowledged the elephant in the exam room: If all the government does is increase coverage, be it through Medicaid or a public option, the health care inflation rate will continue its upward climb.
With no Republican willing to challenge Donald Trump’s reelection bid until now, the president has felt little pressure to get specific about his future health care plans. That doesn’t mean the GOP is standing still. Conservative AGs and governors are challenging the constitutionality of Obamacare while the current head of the Centers for Medicare and Medicaid Services (CMS) confirmed the Trump administration is “actively engaged in conversations” to repeal and replace the Affordable Care Act. Replace it with what? That’s not entirely clear, but the administration has, in the past, advocated for greater patient choice and fewer government regulations.
Here’s what the Trump administration isn’t saying about its health care ambitions and achievements:
1. The cheapest insurance plans don’t cover much
Through the ACA, President Obama mandated that all insurance products offer broad and comprehensive coverage. President Trump, for his part, supports insurance options that give beneficiaries more freedom to choose cheaper plans (see: association health plans and so-called “short term insurance”). What his administration isn’t saying is this watered-down coverage (a) comes with extremely high deductibles, (b) excludes people with pre-existing conditions and (c) sidesteps ACA requirements to cover maternity care. The promise of cheaper insurance may seem attractive to voters — until they need to use it.
2. Promises don’t mean much
Candidates almost never spotlight their lack of accomplishments, and President Trump is no different. But if his presidency ends in 2020, he’ll have a very modest health care legacy to look back on. Drug prices continue to soar despite promises to clamp down on pharmacy middlemen and overhaul federal Rx purchasing. The ACA is still law even though Trump promised its repeal in 2016, 2017, 2018 and 2019. Opioid deaths are down for the first time in three decades, but scientists worry this short-term development says more about Trump’s enforcement efforts than it does about the addiction and mental health reforms needed to sustain the trend. Even known wins, like getting drug list prices on TV and bolstering the transparency of hospital bills, pale in comparison to the notable losses.
What needs to be said
With rare exception, the health care-policy debate has centered solely on questions of health insurance: Who pays for it? Who gets it? What does it cover?
These are important questions. But the answers, no matter how well-articulated, will not fix the health care system’s biggest problem. As a nation, the U.S. spends much more than other countries on health care with clinical outcomes that lag behind all industrialized nations.
That’s not a health insurance problem. That’s a health care delivery problem — one that the 2020 candidates haven’t been willing to address.
U.S. lawmakers have the power to curb egregious drug pricing and set tighter limits on Rx patents. They can punish the doctors and hospitals responsible for wasting $440 billion each year on unnecessary and harmful medical care. They can reform the reimbursement system so that health care providers are rewarded for the quality, not quantity, of care they offer patients. They just haven’t.
When elected officials promise radical change, voters deserve to know what they’ll be getting. Until the conversation changes and politicians focus on what really matters, the real problem will only get worse. At some point, the day of reckoning will arrive. Voters will ask, “Why didn’t you tell us?” The only truthful reply will be, “If I had, you wouldn’t have voted for me.”
Robert Pearl is a physician and CEO, Permanente Medical Groups. He is the author of Mistreated: Why We Think We’re Getting Good Health Care–And Why We’re Usually Wrong and can be reached on Twitter @RobertPearlMD. This article originally appeared in Forbes.
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