How Democratic presidential candidates want to change your health care

Feb. 8--WASHINGTON -- Since her daughter Gabbie was born 16 years ago, Sarah May has had to balance work against caring for a daughter with disorders that cause seizures and force her to use a wheelchair.

It hasn't been easy. But May, a 37-year-old bartender in White Lake, sees the two of them as lucky.

They have Medicaid, which has covered what she estimates would have been hundreds of thousands of dollars in medical bills and could have meant financial ruin. "I've never once had to sit and just be, 'Oh my God, this is the fourth doctor's appointment in two weeks -- how am I going to afford this?' " she said.

Others may not be as fortunate, which is why May, a Democrat in what traditionally has been a mostly Republican part of Michigan, is supporting what is known as single-payer: a government-run health care plan, paid for by taxes, covering all Americans.

"Linking your entire family's health and well-being to a job where a boss can do anything to you because you're afraid to lose your health care, that's wrong," said May, referring to the 157 million Americans who have coverage through their jobs.

While many -- if not most -- Democrats agree with May's sentiment, support for the remedy is far from universal, however.

Among the Democratic candidates running for president, there is a split between those like Bernie Sanders and Elizabeth Warren, who want a government plan for everyone, and others, including Joe Biden, Pete Buttigieg and Mike Bloomberg, who aren't ready to embrace proposals to take private plans and employer-provided coverage away from people who want to keep them.

Ahead of the state's March 10 primary, it's a question splitting Michiganders as well.

A recent survey of 600 Michigan voters done by the Glengariff Group of Lansing for the Detroit Regional Chamber of Commerce found just one in five supported single-payer, which has also come to be known as Medicare for All -- though it has nothing to do with Medicare, the popular government plan covering 44 million older Americans.

That's compared with 36% who prefer a more widely available Medicare-like option that would leave private insurance and other plans available under the federal Affordable Care Act, otherwise known as Obamacare, in place. Biden, Buttigieg and others are promoting that type of plan.

There are major differences between the two.

A single-payer plan would totally revamp the whole health care system and how it's paid for, guaranteeing coverage but upending long-standing practices and shifting costs in ways that might seem beneficial to some and not to others.

A public-option seems more modest. But it represents a major shift as well, with government, tax resources and the power of the law behind it, becoming a direct competitor with commercial insurers for customers. Some see it as a backdoor to a single-payer plan over time.

And both could cost plenty.

More than 30% of the Michiganders polled for the survey believe nothing should be done or only modest tweaks be made to the ACA.

But it's the debate between Medicare for All and Medicare for those who want it that is central to the Democratic primary fight and the area where candidates have the sharpest differences on a topic that voters routinely say is one of their top concerns..

Among those polled who identified as leaning Democratic, support for the Medicare-like option beat that for a single-payer plan, 46%-27%. Among those Michiganders who consider themselves staunch Democrats, meanwhile, 51% said they favor the option compared with 23% who favor the one government plan.

"Once voters understand that going to a Medicare for All system means they would lose the plans they have now that they are by and large happy with, their support goes away pretty quickly," said Brad Williams, vice president of governmental affairs for the Detroit Regional Chamber.

But that hasn't stopped many self-described Democrats, like May, from supporting a single government plan, believing that maybe, if everyone had the same, comprehensive coverage, she wouldn't have to worry that every time an official-looking letter comes that someone is going to make her justify her daughter's coverage and make her recite again her list of disabilities.

"Sometimes I'm so nervous to open an envelope from the state of Michigan, I let it sit for weeks before I do," she said, becoming emotional. "You have to say everything that is wrong with your kid. You spend so much time fighting for them to be (recognized) for the good things about them. ... You try to teach people she can't help her disabilities, that it's not her fault, but then the paperwork comes and you have to write down every single thing that's wrong with her."

Voices like hers are among the loudest in the Democratic primary fight.

There has been sniping among the Democratic candidates on the issue for months, especially between the front-runners -- particularly Sanders and Biden -- with the former complaining a public option isn't a drastic enough change to substantially improve access to coverage and stop profit-gouging and the latter saying a single-payer plan is a political pipe dream, going too far for people who are happy with their coverage and costing too much money.

The truth is both may be right.

The 5 questions to ask about any health care proposal

No one who has dealt with health insurance needs to be told that it's complicated.

Depending on your circumstances, your age, your job, the medical conditions you have or might develop, there are a universe of options, all potentially costing different amounts, with different premiums and deductibles. Medicare is the primary backstop for older Americans; Medicaid, for lower-income citizens, or people with disabilities. Employer-sponsored coverage is widespread but far from ubiquitous and still comes with questions about how much it costs and what it covers, and which doctors you can go to.

Coverage on the individual market -- meaning for those without government or employer-sponsored coverage -- is available through exchanges set up by the ACA, which also requires insurance to cover all pre-existing conditions and sets caps on spending, but also has been targeted for repeal by Republicans and has its own issues with the cost of coverage, subsidies to help lower-income recipients pay their costs, and availability. There are also legal challenges intent on having it overturned.

If you consider health care costs or access a problem to be solved, begin with this: It's a tough nut to crack, no matter how you want to do it.

The ACA, for instance, significantly reduced the number of uninsured people in the U.S., from about 44 million in 2013, the year before it took effect, to about 27 million in 2017. But health care costs are still accelerating -- with total costs expected to grow by more than 5.5% a year over the next decade. Premiums and deductibles are climbing for people covered under ACA and employer-sponsored plans.

A lot of that is because of government spending on Medicaid and Medicare, especially as baby boomers continue to move into retirement. But prescription drug prices, hospital costs and other factors are expected to drive increases as well.

So, how to solve it? Linda Blumberg, a health care expert who has written extensively about the various Democratic proposals for the Urban Institute, a Washington, D.C., research group, proposes that anyone setting out to understand them should start with five questions:

1. Is it available at the same price to everyone regardless of their health condition?

2. How generous are government subsidies to help pay premiums and other costs?

3. Should payments to doctors, hospitals, drugmakers and others be regulated?

4. How important is it that everyone, including undocumented immigrants, be covered?

5. How do you pay for it?

Those factors are incredibly tricky to balance, so in the October 2019 report Blumberg and others at the Urban Institute helped write, they made several assumptions and came up with figures that made headlines.

Working through eight different options ranging from providing more financial help to families on the ACA to various forms of public options all the way to a generous single-payer plan, they found:

-- The most modest changes are the most affordable, costing government perhaps $26 billion more a year, but leaving tens of millions without coverage.

-- Depending how it's structured, a public option could result in just about universal coverage but could cost as much as $162 billion a year -- or more, if undocumented immigrants are included. It could be less, however, if it wasn't made available to those who have employer-sponsored plans.

-- A generous, comprehensive single-payer plan could cost as much as $2.9 trillion a year, though, like the others, it could result in savings for many households while costing others more.

The Democratic candidates are looking at various ways of paying for their plans but they all come down to either shifting costs through payroll and other corporate taxes to be paid by employers and adding taxes designed to mostly hit wealthy people, such as instituting capital gains taxes and increasing income brackets on the highest earners.

Biden, for instance, would increase to 39.6% the top income tax bracket for people making more than $500,000 annually. Warren has proposed a tax equal to 2% on any assets worth more than $50 million and 6% on assets worth above $1 billion.

There are also questions whether those various programs will raise all the money the candidates say they will and the Urban Institute's report is not the only one out there about possible effects, though it is one of the most cited by experts.

But before anyone gets to ultimately deciding how much money is needed, you have to answer Blumberg's questions

And it's hard to do so.

Say you think all Americans should be covered, regardless of age or condition. But you also want health care overall to be no more costly than the current system and you want to keep out-of-pocket costs down, maybe decrease them, for poor and middle-class people.

That means you have to try to increase taxes on wealthy people or spread them out broadly; implement some other sort of cost-sharing for a larger section of the population; limit benefits; or sharply limit payments to health care providers. Or some mix of those three. But each is extremely difficult politically and is likely to remain so.

Add other questions such as whether undocumented immigrants should be covered or receive subsidies, and whether abortion services should be covered, it gets even tougher.

Unsurprisingly, insurers warn against such plans. One group last year said even the somewhat more modest public option could lead "to higher taxes and premiums, while destabilizing the insurance markets millions of Americans depend on for their coverage."

But other countries have such systems after all, despitedisadvantages such as long waiting times for procedures, the sheer cost placed on taxpayers and the availability of care. There's a consensus, though, that the U.S. overall pays more per capita for health care than most other industrialized countries that have nationalized health plans.

Blumberg said there is no reason a satisfactory health care system can't be designed but it's a matter of how it is developed, whether there is widespread support for what it does and how to finance it, and if the political will exists to make changes when they become necessary to improve it.

"All of these are trade-offs," she said. "There is no heaven on Earth with health care. It's all a series of trade-offs."

Just how modest is the middle-of-the-road option?

The public option is touted as the less disruptive choice, the politically possible choice.

The idea itself is pretty simple: You create a Medicare-like insurance option that's available to everyone to compete with private insurance plans.

By using the government's ability to force health care providers, drugmakers and others to accept certain rates for payment, consumers would be given a choice that, in theory, would push other commercial plans to renegotiate their own payment schedules, give up some profits, and lower premiums and deductibles, to remain competitive. That, in turn, could help slow overall health care costs.

There are lots of questions, though.

People taking the public option would still have to pay for it -- and no one's sure exactly what those premiums and deductibles would look like since that would depend on who signed up, their health care status and financial condition, and how government underwrote it. But there would be government subsidies available for lower-income individuals and families just like on Obamacare.

Typically, the proposals for a public option also call for changes to be made to the ACA that would increase the number of families in the U.S. eligible for government subsidies and lowering their out-of-pocket costs.

In some ways, said Tom Buchmueller, a health economist at the University of Michigan Ross School of Business, those proposals could have even more immediate impact than the public option by strengthening a system that already covers nearly 275,000 Michiganders -- with another 674,000 state residents on Healthy Michigan, the Medicaid expansion plan created under the ACA as well.

"As a practical matter, it would be much easier to tweak the parameters of the Obamacare system to expand coverage. There are real advantages to building on that system," he said.

But in a go-big-or-go-home kind of primary year, it seems as if the starting point for all the major Democratic candidates is, at the very least, the public option, arguing it will help support the ACA, increasing coverage options and lowering costs while allowing Americans to keep the insurance they already have if they want it.

They also argue it won't require the wholesale change a single-payer system would, a point some voters have picked up on.

Susan Anzicek, 62, of Brighton thinks back to the surgeries she underwent when she was suffering from breast cancer -- remembering one that cost some $70,000 -- and all the bills covered by her insurance. She thinks that while it might be ideal to have one health care system for everyone, it may not be realistic to ask the majority of Americans to embrace such a drastic change.

"The psyche of the world we live is wanting choices and not being dictated to do only one thing," she said. "I just think it's too big of a pill to swallow." She's supporting a public option.

Lots and lots of people favor the public option. Last November, the Kaiser Family Foundation, a health care research group in Washington, ran a nationwide poll that found 65% of the 1,205 adults surveyed supported such a plan, compared with about 50% support for a Medicare-for-all single-payer plan.

But it also has its critics

Insurance companies and many Republicans argue the public option sets up a phony competition since government -- in theory -- has the legal tools and financial resources they don't have. They say that, over time, it will result in the public option becoming a de facto single-payer program, as people migrate their coverage to it. That, in turn, would put insurance companies out of business.

That's a possible scenario -- one some Democrats have even applauded. Warren would put in place public options first to transition to a single-payer plan, recognizing that such a plan could serve as an interim step toward a unified government health insurance plan.

But even the most thought-out public option plans leave many questions about coverage and costs unanswered -- and that's if it could somehow be approved in a still-divided Congress, which is unlikely as it stands now. If, however, it were set up in such a way where it had a more limited coverage package -- say, as a way perhaps to keep costs down -- it could potentially leave room for private insurers to compete against it.

For some critics, the problem with the public option is that it doesn't go far enough.

In the Urban Institute report, a public option -- albeit one that isn't available to people with employer-sponsored insurance -- would bring the number of uninsured down to about 21 million people, which is still a far cry from universal coverage. Making enrollment automatic and opening it up to people with employer-sponsored plans brings that down significantly further but may not cover everyone.

It would still cost government -- meaning taxpayers -- between $50 billion and about $160 billion a year, depending on how it's structured. But then, it would also potentially save households between $18 billion and $57 billion a year and employers between $14 billion and $97 billion total at the same time, according to the Urban Institute's figures.

Some of those savings would presumably go to pay for the program -- though, again, who paid what would have to be determined. The Urban Institute did not look at the funding proposals put forward by the candidates.

But critics, including Sanders, say plans like these maintain the status quo. And while that's a difficult position to defend since almost everyone sees a widely available public option as a huge change in the way insurance coverage is delivered, Sanders argues it doesn't do enough to take profits out of the health care business.

"The day has got to come," Sanders said during a December 2019 debate in Los Angeles, "(when we) finally say to the drug companies and the insurance companies, the function of health care is to provide it for all of our people in a cost-effective way, not to make massive profits."

Biden and other supporters of a public option, however, don't believe supporters of single-payer are being honest about the cost and what that change would mean.

The dubious simplicity of a single-payer system

Single-payer, Medicare for All, whatever you want to call a system where the federal government effectively runs one massive insurance plan that covers every American, has many things going for it.

For one, it's simple to understand: Everybody's covered. For another, if conceived as a plan where commercial insurance no longer exists, and it's presumably fair. Everyone, regardless of income, age, or any other demographic, gets the same insurance. There's no buying extra plans to cover what isn't covered because the plans being promoted are largely comprehensive.

Sanders' plan, for instance, would be more generous than most of those offered by other nations with national health care and more generous than most employer-sponsored plans, with no premiums and no deductibles. The only out-of-pocket cost would be on prescription drugs.

But behind such a proposal -- and any proposal for single-payer care -- are a couple of major issues. The first would be the cost. The second would be how to pay for that cost.

On the issue of cost, Buchmueller is among those who speculate whether a health care system that doesn't have more cost-sharing might encourage people to use more health care services than they need. And it's long been believed that letting people use as much health care as they want stretches resources and pushes overall costs and spending up.

"Having some cost sharing is probably a good thing to remind people this isn't free," he said.

And while a comprehensive benefits package is desirable, it comes with a steep price. For instance, Blumberg and her colleagues estimated in a report last October that a comprehensive single-payer plan without cost-sharing could cost the federal government an additional $32 trillion over a decade. Currently, the Congressional Budget Office expects all federal spending under current law to be about $60 trillion over the next 10 years.

It's a lot of money. But the argument is that households and employers would save money they spend now on coverage. Still, the cost would have to be covered somehow. Sanders has proposed a system of payroll taxes on employers, higher taxes on wealthy people and other measures; Warren would have businesses effectively pay most of what they are already paying to the government to cover the plan and increase other taxes on wealthy people to make up the difference.

But there are also questions as to what it means long term. Blumberg, for example, has estimated that national health care spending overall would go up by some $8 trillion over 10 years compared to current spending under a comprehensive single-payer plan.

And getting from the system we have now to single-payer would be enormously disruptive, with payments to hospitals and doctors being revamped, tax structures changing to move money from one place to another, and systems being put in place to make sure that no one fell through the cracks.

Stacy Staggs, a 42-year-old mother who grew up in Ypsilanti and now lives in North Carolina, works with a group called Little Lobbyists, which advocates for policies to help children with complex medical issues like her 6-year-old twin daughters, both of whom were born early. One can't breathe on her own and relies on a feeding tube inserted in her belly; the other doesn't have as many medical issues but still has developmental issues. Both are covered by Medicaid.

Like Sarah May, Staggs, speaking for herself and not Little Lobbyists, wants everyone "to get the care they need and not have to worry about it," and is concerned that a public option leaves in place commercial interests and profit motives that, to her mind, hurt families. "But," she warned, "this is a huge rock to move ... It has to be deliberate, it has to be well-tested. We have to ensure that not one single person is adversely affected when we make this change."

The political reality is it's unlikely to occur anytime soon

Critics of Sanders' and Warren's plans, like Biden, Buttigieg and others, have questioned whether Sanders, Warren and others backing a single-payer plan are being straight with the American people, suggesting that any generous and comprehensive plan is probably going to cost middle-class taxpayers more than they are letting on. Supporters of single-payer have said the middle class won't pay any more than they do now.

The critics could be right. Certainly, other countries have, at times, had to deal with finding money to make up shortfalls in their health care systems. A more generous program might require more in taxes in order to be funded -- or need to be scaled back. Raising taxes on wealthy people sounds to many like a solution but the political reality is that may be tough to sustain.

And when it comes to campaign promises, they often bend to other realities.

President Donald Trump not only said he'd build a wall across the southern border, he'd get Mexico to pay for it -- and that hasn't happened. President Barack Obama, when he was a candidate for president, argued against mandating that every American have insurance or pay a penalty -- only to embrace it as part of the eventual coverage policy that many use his name to describe.

"I don't think that was necessarily negative," said Buchmueller, speaking of Obama's comments. "Things change."

But it's fair to wonder whether the political reality of the Democrats' health care proposals is more along the lines of insisting Mexico would pay for the wall along the U.S. border or arguing over an important, though realistic, policy matter.

It's likely more the former than the latter.

The Affordable Care Act passed by the slimmest of margins during the fallout of the Great Recession, with Obama in the White House, Democrats in charge of the U.S. House and having, briefly, a filibuster-proof majority in the Senate. Still, compromises had to be made. And still it set off a political fight that is being fought a decade later.

At present, Democrats look like they may retain control of the House in this year's elections. But Republicans hold 53 seats in the 100-member Senate. And while it's possible they could take back the majority, to do so, they will have to beat several incumbents in Colorado, Arizona, Maine or elsewhere, while holding on to their own seats in states like Michigan. Even then, getting to a 60-vote margin needed to overcome a filibuster is all but impossible in 2020.

Some argue the debate is the wrong one to be having at all. Doug Holtz-Eakin, a former director of the Congressional Budget Office who now heads the American Action Forum, which does economic policy research from the center-right political perspective, believes it should be simpler to figure out ways to get the 15 million or so people who are currently eligible for coverage through the ACA, Medicaid expansion or their employers -- but don't have it -- to get it without upending the existing health care system.

And while single payer is dramatic, he said, it doesn't solve the problem of lowering health care costs.

"To get at costs you have to do something that's really unpopular," Holtz-Eakin said. "Hospitals have to make less, and doctors have to make less."

Democrats may have an edge on Republicans on the question of health care, he acknowledged, but they could also squander it. "The things you're hearing from the Democrats are either fantasyland or they are politically attractive empty promises," Holtz-Eakin said. "And none of them solves the real problem."

Contact Todd Spangler: [email protected]. Follow him on Twitter @tsspangler. Read more on Michigan politics and sign up for our elections newsletter.

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