South Bend, Indiana, Mayor and Democratic presidential candidate Pete Buttigieg has released his healthcare reform plan, Medicare for All Who Want It. It's a plan that puts a public option on top of the Affordable Care Act, which the campaign says would "create a natural glide-path to Medicare for All," much more in line with the Joe Biden end of the primary spectrum than the Bernie Sanders-Elizabeth Warren end.
Buttigieg would create a government-run public-option plan in which the uninsured would be automatically enrolled and that people with employer-provided insurance could buy into. He'd also increase the subsidies people buying in the Obamacare marketplaces receive and remove the income eligibility cap for subsidies, a subsidy cliff that has kept many middle-class families from being able to afford unsubsidized insurance in Obamacare. He also has a fix for surprise medical bills and an out-of-pocket spending cap for people on Medicare.
The public-option plan would cover all the same essential benefits as private plans are required to under the ACA, though the campaign doesn't make clear what out-of-pocket costs might be. The automatic enrollments would start with Medicaid expansion-eligible people who live in states that haven't expanded. Buttigieg would also expand subsidies for private insurance under the ACA, which are now capped at 400% of the federal poverty level. Everyone would be eligible for the tax credits and would only have to pay up to 8.5% of their income for a private or a public plan. The campaign gives the example of a family of three that currently makes $31,000 a year, and pays about $1,200 annually for "silver" coverage on the marketplace. "Under Pete's plan," the campaign says, "they will pay a maximum of roughly $600 a year for higher quality (i.e., gold-level) coverage."
His other reforms include:
- limiting surprise billing by requiring that "bills related to in-network facilities be billed as in-network. His plan will also place limits on what out-of-network providers, including ambulances and air ambulance services, can charge."
- capping out-of-pocket costs for Medicare beneficiaries, with a lower cap for low-income seniors, but doesn't specify how those caps will be set.
- strengthening the community benefit requirements for nonprofit hospitals, which are exempt from federal taxes, to "ensure that hospitals are investing in the health of their patients and communities.”
- capping out-of-network care charges by providers to private insurance at twice the Medicare reimbursement for the same service.
- enforcing parity for mental health and substance abuse coverage with other coverage.
- bringing down administrative costs "by harmonizing standards for transactions and holding insurance companies accountable for adopting them."
In a sane America, these would have been measure Congress would have taken to improve the ACA and make it stronger. The proposals are all solid, and would make Obamacare much better and much more affordable for more people. A competitive public option could make insurers behave better.
It's a question Democrats have to answer for themselves: Is it time for patching and strengthening what we've got and continuing the power struggle with providers and insurers and profit-making stakeholders as a "glide-path to Medicare for All," as Buttigieg's campaign says? Or is it time for that end goal—Medicare for All? These are key questions that are complicated by a number of factors, not the least of which is that, by the time a new Democratic president is in office in January 2021, the Supreme Court may have ripped down the entirety of the ACA.