At their virtual convention this week, Democrats went to great lengths to communicate that they were united in their quest to defeat President Trump.
Health care would appear to be the exception to that spirit of unity. More than 700 delegates to the Democratic National Convention said beforehand they’d oppose the party platform if it didn’t include a call for Medicare for All. Progressive firebrands like California Rep. Ro Khanna and Michigan Rep. Rashida Tlaib made a big show of publicizing their “no” votes on social media.
In a speech exhorting his supporters to pull the lever for Joe Biden, Sen. Bernie Sanders acknowledged that “Joe and I disagree on the best path to get to universal coverage.” The former vice president, for his part, has long maintained that he plans to “build on the successes” of Obamacare.
That rhetorical moderation is key to his strategy for attracting the votes of centrists and disaffected Republicans. But Sen. Sanders’s crowd should rest easy—Biden is with them. His plan to create a public health insurance option would result in single-payer, just on a different timeline.
The Democratic platform’s language is cagey: “We are proud our party welcomes advocates who want to build on and strengthen the Affordable Care Act and those who support a Medicare for All approach; all are critical to ensuring that health care is a human right.”
One of the most talked-about speakers at the convention also happens to be one of the country’s most prominent single-payer advocates—Ady Barkan, a person with ALS who runs the Be A Hero PAC. Barkan had previously denounced Biden for failing to openly support single payer. Barkan urged Democrats to “put on [Biden’s] desk a bill that guarantees us all the healthcare we deserve.”
During her speech accepting the vice presidential nomination, California Sen. Kamala Harris was studiously vague on the topic of healthcare, saying that Democrats have “shown that, when we vote, we expand access to health care.” And in his speech accepting the party’s presidential nomination, Biden reiterated his promise to deliver “a healthcare system that lowers premiums, deductibles, and drug prices by building on the Affordable Care Act.”
But building a public option onto the Affordable Care Act will unleash a chain of events that results in the end of private insurance.
At the beginning of Barack Obama’s presidency, Democrats conceived of the public option as a Medicare-like program that would be available on the state-level insurance exchanges. People who didn’t receive coverage through work or another source would be eligible. It would compete with private insurance plans and theoretically exert pressure on them to lower prices and boost benefits.
Back then, the public option proved too controversial and was scrapped in the Senate. More than a decade later, the Biden campaign wants to resurrect it—and make it even more expansive, by opening eligibility to essentially all Americans. People offered coverage through work could instead buy into the public option—and perhaps qualify for subsidies. Undocumented immigrants would be able to purchase public option plans but would be ineligible for subsidies.
In other words, the public option would compete with the entire private health insurance market. And the public option would win. Not because it provides better coverage but because the competition is rigged. The government wouldn’t have to play by the same rules as private insurers.
Public insurance already underpays doctors and hospitals. Private health plans pay 143% of what Medicare pays for physician services. Underpayments are even more pronounced at hospitals, where private plans pay an average of 241% of what Medicare does, according to work from the RAND Corporation.
Biden’s public option would do likewise. Underpaying providers would allow the program to charge artificially low prices to patients. People would, understandably, flock to health coverage with lower premiums and deductibles, and the government would steadily take customers from private insurers. Biden’s plan even envisions a version of the public option for some low-income individuals that has no deductible or premium.
Conservative estimates have 40 million Americans signing up for a public option within its first year of operation. That number would only climb in the years that follow, as providers hike what they charge private insurers to make up for underpayments from the public option. Yet more people would flee to the public plan, and the cycle would repeat.
The Democrats are indeed unified behind a government takeover of the health insurance market. While their nominee may not explicitly endorse Medicare for All, that’s exactly what his administration would deliver.
Sally C. Pipes is president, CEO, and Thomas W. Smith Fellow in Health Care Policy at the Pacific Research Institute. Her latest book is False Premise, False Promise: The Disastrous Reality of Medicare for All, Encounter Books, January 2020. Follow her on Twitter @sallypipes.