by Craig Klugman, Ph.D.
The Democratic Presidential Candidate Debates in Detroit this week often seemed less about differentiating between the candidates and more like the party trying to figure out its platform. Whereas the first set of debates focused a great deal on the new guard versus the old, this one focused on universal health care versus a public option in a health insurance marketplace. On the progressive left stood Bernie Sanders, Elizabeth Warren, Kirsten Gillibrand, Andrew Yang, and Bill de Blasio who want a universal health plan they call Medicare for All. This plan would remove deductibles, copays, and premiums but it would require higher taxes (some in the debate took issue with the idea of taxes even if it overall saves money). Estimates show that much less money would go into administrative costs and most middle-class residents will see a decrease in cost. This move separates health insurance from employment, allowing people more freedom in choosing their employment and removing a burden from employers. Others raised challenges to this approach, claiming that this removes the private system (most versions dismantle private insurance). With a single insurer, costs are controlled, but this may be problematic because Medicare currently only pays 80% of the cost of care. To be viable, everyone would have to participate and Medicare would have to cover the actual cost of care. Sanders pointed out that other countries have successfully gone with such a system.
In the second night, Harris offered a different framework that she also calls “Medicare for All“, but is not a universal health plan. Harris’s plan would require 10 years to transition and would have a private and a public option, which most people would be on.
The moderates were attacking the notion of Medicare for All as to its feasibility. Everyone felt that health care is a right but those in the middle wanted to see a public option added to the Affordable Care Act rather than replacing the current system, making people possibly give up their doctors and hospitals, and having a government run insurance system. Joe Biden, Pete Buttigieg, Beto O’Rourke, Cory Booker, Jay Inslee, Michael Bennet are representatives of this perspective. Biden’s plan would cover 97 percent of people and cost no more than 8.5% of people’s income, an amount that would be unaffordable to many. The criticism on this side was that people would feel government was taking something away from them, and it does keep private (profit-driven) insurance companies in charge.
A different perspective was offered by Marianne Williamson and Tulsi Gabbard, both of whom said that we do not have a health care system. Instead we have a sick care system. Williamson would place more emphasis on preventive measures to help people maintain wellness.
A second point of intense disagreement was over providing insurance coverage for undocumented immigrants. The liberal wing was in favor of covering them, something the current ACA does not do. The moderates felt differently, saying that Americans would never buy the argument of paying for undocumented immigrants health care, a comment that again felt more like a Republican talking point.
Although not explicitly labeled as health, many of the topics covered over these two evenings fell under areas of interest in bioethics and about which people in bioethics have written: Drug pricing, immigration, climate change, social (racial, gender) inequality, lead in water, and the Hyde Amendment. A criticism of the debates overall was that the moderators and the candidates own criticisms of each other seemed to be echoing Republican talking points.
When considering these different plans, it is important to keep in mind what the current administration (seeking re-election) is offering. At the moment, the Department of Justice is not defending the Affordable Care Act against a lawsuit filed by several Republican-led states to declare the entire unconstitutional. If found in the state’s favor, 20 million people would lose health insurance, children would not be on their parents’ insurance until age 26, and people with preexisting conditions would find themselves without affordable coverage. No viable alternative bills have been offered.