Where are the Dems on health care? Our expert panel breaks it down

As the contentious Democratic presidential debate in Las Vegas this week made clear, health care is at the top of many voters’ minds.

But there are crucial differences between the candidates' proposed health care policies, and clearly communicating those fault lines is an urgent task for health reporters right now. With that goal in mind, a recent Center for Health Journalism webinar brought together, Alice Miranda Ollstein, a health care reporter for Politico Pro, Washington Post reporter Yasmeen Abutaleb, and health policy expert Linda Blumberg to describe the candidates’ plans, their tradeoffs and how reporters can help voters navigate the complexities.

“Regardless of what any candidates says, no single reform approach will make all Americans much better off than they are today,” said Blumberg, an institute fellow at the Health Policy Center at the Urban Institute. “Health insurance is much more complicated than that.”

Unraveling the complexities

Many Republicans, including President Trump, support a full repeal of the Affordable Care Act, a possibility that’s currently pending in the courts. Meanwhile, many Democrats, including those competing for the presidential nomination, have proposed policies that range from incremental changes to the Affordable Care Act to a system overhaul that ushers in a single-payer approach, Blumberg said.  

While Elizabeth Warren and Bernie Sanders support a single-payer system known as Medicare for All, candidates Joe Biden, Michael Bloomberg, Pete Buttigieg and Amy Klobuchar support adding a public option to the current health care system.

That public option would be an insurance plan structured and administered by the government or a government contractor that would offer health insurance as a competitive option in the health insurance marketplaces, she said. The idea is that this lower-cost option would reduce health care spending for consumers and the government, particularly in areas plagued by few insurance options.

The public option plan, which would be added to the Obamacare individual insurance market, would pay doctors, hospitals, prescription drug manufacturers lower than typical commercial insurance plans, translating into lower premiums and out-of-pocket costs.

Candidates in favor of this approach also support additional policy changes, such as expanding the marketplace insurance tax credit to people with higher incomes, allowing workers to buy subsidized marketplace insurance even if their employer offers a plan, and ending surprise medical billing.

Meanwhile, Warren and Sanders prefer the single-payer approach called Medicare for All. This would overhaul the entire public and private system: everyone would enroll in a single government-administered health plan. There would be no premiums, no copayments, no deductibles and expanded benefits such as adult dental, vision and hearing, nor a long-term care benefit.

Like the public option, this plan would pay providers and hospitals at a lower rate, but, unlike that option, those lower rates would apply to the only available plan — representing a more sweeping and dramatic cost shift.   Since the government would be taking over health insurance for everyone, it would also require a very large increase in federal government spending, which would translate into higher taxes, she said. That doesn’t mean overall health spending would dramatically increase, but rather current private spending on premiums and other care expenses would be funneled through the government.

In stark contrast to these Democratic plans, Trump supports fully repealing the Affordable Care Act, including its Medicaid expansion, subsidies in the marketplace and consumer protections.

If that effort were to succeed, “there are actually hundreds of policies that would have to be unwound, affecting virtually all parts of the health care delivery system,” Blumberg said. “It would be chaotic at best were this were to occur.”

Keeping these tradeoffs in mind

When thinking about the different reform approaches, Blumberg urged reporters to keep in mind the tradeoffs.

All Democratic options involve more cost sharing between the sick and the healthy. That means care is more affordable when one is sick, but it’s also more expensive for healthy people, either through higher taxes or higher premiums. Meanwhile, Trump’s proposals place higher costs on those needing more care, she said.

While public plans that offer generous benefits and lower premiums create more system equity, they are accompanied by higher taxes.

Similarly, while more government control over provider prices could lower consumer and government costs, that change risks could disrupt our health care delivery system.

What Americans Want

Of all the major campaign issues out there, health care and the anxiety surrounding its costs are front and center for most voters, the Washington Post’s Abutaleb said.

Even though there were significant coverage gains under the ACA, high costs continue to plague consumers. Wages aren’t rising as fast as health care costs, which means people aren’t seeing economic gains. Even Medicare carries high-out-of-pocket costs, averaging about $5,500 a year.

While Medicare for All garners lots of media attention, Abutaleb said voters are more concerned about “immediate, pressing needs” such as lowering prescription drug prices and other costs, maintaining preexisting condition protections and stopping surprise medical bills, she said.

It’s important to keep the candidates’ sweeping election proposals — and their chances of being enacted — in perspective, she said. 

“Congress can’t pass pretty basic fixes to the health care system,” she said. “The ACA passed 10 years ago, and we are still fighting over it.”

She also pointed to the struggle to pass a surprise billing measure and prescription drug pricing bills, which have stalled out despite bipartisan support.

Bring a skeptical lens

When it comes to polls on consumer’s health care policy choices, Politico’s Ollstein said it’s important to look carefully at polling numbers, how poll questions are phrased, and the poll’s funders.  

“I really want to urge folks reporting on this topic to look very carefully and with a lot of skepticism at all the polling that comes out,” she said.  

At the same time, reporters should lean on well-vetted polls to guide their reporting. For example, a recent Kaiser Family Foundation poll shows how the public option is popular with people across the political spectrum. One idea: look at how Democratic candidates are reaching out to Republicans and Independents in favor of this public option. Is it working?

Monitor how candidates’ positions shift over time and what might be influencing that change, such as the influence of organized labor. At the same time, be vigilant of blanket assumptions, such as the belief that organized labor is united in opposition to Medicare for All, which isn’t exactly the case, she said.

“Bringing that nuance in is important,” she said.

When covering a potential policy change, Ollstein suggested reporters look at state, local or international examples of that policy in action, such as Washington state’s experience trying to launch a public option.

And, when faced with wonky policy info, try capturing the key takeaways in an easily digestible list form, such as “5 Things the 2020 Democrats Aren’t Telling You About Medicare for All.” That bullet-point approach to dense policy has been especially effective for Politico, Ollstein said.

Meanwhile, what happens to the ACA?

The Supreme Court won’t hear the ACA case on an expediated basis, which means a decision is not likely until after the election. Meanwhile, the Fifth Circuit Court of Appeals has agreed the ACA is unconstitutional but has sent the case back to the lower court for additional analysis.

“The threat is real but it’s remote,” Ollstein said.

As a result, neither side is focusing much attention on the ACA. Democrats want to instead showcase their own version of healthcare. And, for Trump, not putting out an alternative plan means there’s no plan to criticize, she said.

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Watch the full presentation here: