Bernie and Biden duke it out on health care

The Democratic presidential primaries are down to a two-man race. Joe Biden and Bernie Sanders will be fighting it out for the duration, and health care is a top issue for voters. The difference between the two candidates' competing visions mirrors the broader battle between progressive and moderate wings of the Democratic party.

As the two candidates seek to differentiate themselves, each can credibly make claims to expertise on the issue. Sanders rose to prominence in part based on the appeal of his signature Medicare for All plan. Biden has tied his health policy approach to his former boss’s signature initiative: the Affordable Care Act (ACA), commonly known as Obamacare.

Both candidates espouse expanding health insurance coverage, lowering consumer costs, and framing health care as a human right. They diverge, though, in the scale and scope of changes they propose.

Sanders envisions a sweeping overhaul of the US health insurance system. He proposes eliminating private health insurance and virtually all consumer cost-sharing. His benefit package is so generous it offers more than its namesake, original Medicare, and more than most single-payer systems, including that of Canada.

Biden favors an incremental approach that builds on the ACA and offers all Americans the opportunity to buy into an existing public program like Medicare, called a “public option.” A more modest version of the public option failed to pass with the ACA, but Biden’s plan would represent the most dramatic social policy changes since Lyndon Johnson’s Great Society.

Under Biden’s plan, government-sponsored insurance becomes an option for all Americans, even if they already have insurance through their employer. Biden changes little about the other main public insurance programs.

Biden leaves the current private system alone, though it is hard to fully anticipate the impact of a new public option directly competing with existing insurers.

In Sanders’ plan, government-sponsored insurance would ultimately be the only available option. The plan calls for a four-year transition that merges virtually all Americans into common public insurance, including people on Medicaid, which is primarily for low-income and disabled populations, and Medicare, which is primarily for Americans over 65.

Sanders would do away with most private insurance, a point his competitors pressed because it generally makes Medicare for All less appealing. Eliminating employer-sponsored insurance, the source of insurance for approximately 160 million Americans, would not be easy. Employer-sponsored insurance is relatively popular. Americans are twice as satisfied with their own health coverage as they are with the national health care system.

Given that many people do not understand that Medicare for All would eliminate such private plans, true public sentiment is unknown.

Pre-existing conditions would be protected from insurance exclusion or discrimination in both plans. As many as 129 million non-elderly Americans have a pre-existing condition. Protecting this group is popular across party lines; no candidate is likely to do anything but voice support.

Biden’s plan would attempt to improve affordability of coverage by leveraging negotiating power to lower hospital and other provider rates, increasing tax credit eligibility, and using antitrust authority to break up insurance company monopolies. The plan also has measures to reduce drug prices, including using government scale to negotiate prices, limiting prices on new and “abusively priced” drugs, allowing consumers to shop internationally for lower-priced drugs, and improving the availability of generic options. Co-payments, deductibles, and other cost-sharing could still apply.

Sanders’ plan would also negotiate drug prices, and would open up the market to allow consumers to buy drugs overseas. Further, Sanders would eliminate consumer cost-sharing on virtually all health services and coverage. Additional consumer financial relief would come in the form of dental and vision benefits which are not currently part of Medicare, or most other countries’ universal insurance programs. Americans pay 40% of dental costs out of pocket, and many can’t afford to get dental care.

In exchange for lower out-of-pocket costs and more generous coverage, taxes would go up. Sanders does not specify exactly whose taxes would go up or by how much.

A substantial problem faced by many Americans are surprise medical bills, where the cost of care isn’t revealed until the bills start rolling in. Biden proposes ending these surprise medical bills, by prohibiting health care providers from charging “out-of-network” rates when a patient has no “in-network” choice. Essentially, this component extends insurance terms across providers who may not participate in that insurance network. Under Sanders Medicare for All, consumers would receive very few medical bills at all.

Both plans promise coverage expansion to address the 27.5 million Americans who remain uninsured. Biden’s plan offers everyone the option of coverage and makes it easier for lower-income people to pay for it. But as the ACA showed, the availability of options does not guarantee the affordability or appeal of insurance options. Sanders makes universal coverage his central tenet. Every American would be covered by a single government plan.

Both candidates promise to expand coverage and tackle affordability. What the plans would cost and how the candidates propose paying for them remain open questions. According to a recent KFF Health Tracking Poll, Americans view both approaches favorably overall, and 43 percent support both. Six out of ten Democrats favor a government run public option, as do four out of ten independents. While half of Republicans oppose both plans, 17 percent are in favor of either one.