Apart from attempting to dismantle the Affordable Care Act, the GOP presents no health care policy changes leading up to the 2020 presidential election. However, the Democratic candidates have offered a number of changes to health care, which is predicted to be the pivotal issue of the upcoming election. This posting will provide an overview of these policy proposals and will examine these in the Texas context, the state with the highest rates of uninsurance in the nation. Despite recent Gallup polls showing growing public support for expanded healthcare coverage, it seems unlikely that Texas voters will support these proposals in any significant way.
I. Medicare for All
There are a number of versions of Medicare for All. Both Senator Sanders and Rep. Pramila Jayapal have authored bills detailing versions of these plans. Their plans offer comprehensive benefits, they are paid for with tax dollars, they would replace all private insurance as well as the current Medicare program, and eligibility is for life, without premiums. There would also be no deductibles, co-pays, or co-insurance. The Jayapal bill prohibits any out-of-pocket costs, though some plans allow for out-of-pocket costs for services not in the comprehensive benefit package. The Sanders bill allows for some cost-sharing for families and individuals over 200% of the federal poverty level. The Medicare for America Act allows for even more cost-sharing at certain income levels.
Generally, Medicare for All bills build on current provider networks in which providers operate independently. In other words, physicians and other providers currently in the Medicare system will likely continue to see Medicare patients under the new system, though they may not be required to do so. Many of the bills include a private pay option which allows individuals to negotiate with a provider for a service or procedure.
The Medicare for America Act allows individuals to opt-out for qualified coverage, while other bills allow older individuals to buy in to Medicare before the traditional age of eligibility of 65.
Medicare for All has been estimated to cost $30 trillion over 10 years. The Committee for a Responsible Federal Budget has suggested that personal and corporate income tax rates would have to be doubled to raise the revenue to pay for universal coverage under Medicare and that mandatory premiums would, on average, amount to $7,500 per capita. The group asserts that a tax hike on the wealthy won’t be sufficient to raise all the needed funds. Other alternatives proposed would be to double the national debt or to charge a public premium of $12,000 per person to anyone not covered by public insurance. Keep in mind that these estimates are based on current Medicare benefit levels. If benefits and coverage were reduced, less revenue would be needed.
The specific funding strategy offered by Warren totals $20.5 Trillion in new federal spending over 10 years and relies on increased taxes on wealthy individuals and corporations. Sanders claims his Medicare for All plan will be paid for through increased taxes on the middle class initially, but that over time, the impact of this will be decreased through zero deductibles and premiums.
It stands to reason that the cost of Medicare for All will be very expensive due simply to the high cost of health in the U.S.
Private Insurance Impact
An important aspect of these plans is how they address the private insurance industry. Elizabeth Warren has expressed support for eliminating the industry altogether, while others advocate a transition away from private insurance. According to polling, Medicare for All proposals lose a great deal of support regarding the loss of private insurance. Most people in Texas are covered through employer-sponsored private health insurance. The following table from the American Community Survey 1-Year Estimates for Texas show the proportion of Texans who have one type of health insurance that is private, employer-sponsored:
American Community Survey 2017 1-Year Estimates, B27010
These figures underestimate slightly the impact of private insurance because they do not reflect those Texans with more than one type of coverage. Still, they provide important context for proposals that include elimination of private health insurance.
Both the Sanders and Jayapal bills prohibit private insurance companies from offering benefits that duplicate what would be offered under the comprehensive Medicare for All plan. Long-term care benefits are not covered in the Jayapal bill, so private insurance could pick these up. Sanders would allow providers who are not participating in the Medicare for All system to contract with insurance companies. Both bills offer funds to compensate the workforce of the private insurance industry for their dislocation.
Medicare for America would cover everyone under a public program modeled on Medicare but would allow individuals to opt out of program to accept qualified (offers comprehensive benefits) employer-sponsored health coverage. This bill would eliminate the individual market for private insurance.
In response to polling results demonstrating opposition to elimination or changes to the private market, some candidates are supporting Medicare for All type coverage plans that allow for some role for the industry.
II. Other Options Proffered by Democrats
Public option plans are those that allow middle income, working age adults (19-64) individuals to choose a public insurance plan (think Medicaid or Medicare) instead of a private insurance plan. There are several different models, many of which allow people to buy into Medicare or Medicaid, or some propose a new public plan administered by the government that folks can buy into. Many of the plans allow those that have been receiving a subsidy under the Affordable Care Act to retain this assistance to buy into a new or existing public plan.
Public option plans vary widely as to how they will incorporate private insurance. Most seem to allow for people to retain their private plans if they choose. The Public option allows for more choice and flexibility among consumers. Because there are so many models being offered, there is no way to estimate the cost of these systems as a whole, as costs will be driven by what individuals choose.
What do Texas Voters Want?
In a March 2019 Texas Tribune/University of Texas poll, 45 percent of Texas voters indicated that they actually prefer the current system, defined as that which affords health insurance to most individuals through their employers though not to all workers, some of whom who remain uninsured. Forty-four percent (44) indicated preference of a universal system, which was defined as one that is funded by taxpayers, run by the government, and offers insurance to everyone. The remaining 10 percent said they don’t know or have no opinion. If we break down these responses along party lines, we see that:
- 12% of Texas Democrats favor the current system and 79% favor a universal system
- 77% of Texas Republicans favor the current system and 14% prefer a universal system
- 38% of Texas Independents favor the current system and 46% favor a universal system
As long as the majority of Texas voters are in support of the current system and huge resistance can be expected from doctors, hospitals, and other powerful members of the healthcare industry to a universal system, it seems unlikely that Texas voters will vote for or support Medicare for All or a similar system.
On the whole, voters in Texas have also resisted the Affordable Care Act (ACA) and have enthusiastically supported governors and a President promising to dismantle it. This includes the expansion of Medicaid to working age-adults which was originally a tenet of the ACA but was later reduced to an option under the Act. This expansion would make very low-income adults (100-138% of the Federal Poverty Level) eligible for Medicaid coverage. This option would provide health care coverage for up to one million adults.
Based on what we know about who votes in Texas, the prospects of changes to expand Medicaid coverage or to move toward universal coverage models are dim. While the electorate is changing, Texans who vote are, in the majority, 65+ and white. Consider the last presidential election results: 4.7 million Texans voted for President Trump and 3.8 million voted for Clinton. Texas voters on the whole largely don’t favor expanded healthcare coverage. President Trump has announced that one of his major campaign pledges will be to defeat most of the options Democrats are proposing to expand coverage through public systems.
Armour, Stephanie, “States’ Attempts at Medicare for All Proposals Haven’t Ended Well”, Wall Street Journal, November 5, 2019, https://www.wsj.com/articles/states-attempts-at-medicare-for-all-proposals-havent-ended-well-11572957714
Center for Public Policy Priorities, “What is the Texas Coverage Gap?”, https://forabettertexas.org/images/HW_2016_WhatIsTheCoverageGap.pdf
Dallas Morning News’ Curious Texas, “Are all Texans Republicans?”, Dallas Morning News, https://www.dallasnews.com/news/curious-texas/2018/01/17/curious-texas-are-all-texans-republicans/
Jagoda, Naomi, “Budget Watchdog group outlines ‘Medicare for all’ Financing Options”, The Hill, October 28, 2019, https://thehill.com/policy/healthcare/467775-budget-watchdog-group-outlines-medicare-for-all-financing-options
Kaiser Family Foundation, “What’s the Role of Private Health Insurance Today and Under Medicare for All and Other Public Option Proposals”, July 30, 2019, https://www.kff.org/health-reform/issue-brief/whats-the-role-of-private-health-insurance-today-and-under-medicare-for-all-and-other-public-option-proposals/
Pearl, Robert, “Healthcare Promises: What 2020 Presidential Candidates Aren’t Telling You” Forbes, https://www.forbes.com/sites/robertpearl/2019/08/26/healthcare-promises-what-2020-presidential-candidates-arent-telling-you/#7513a794e788
Ramsey, Ross, “Texans Don’t See Eye-to-Eye on Climate, Health Care, or Taxes, UT/TT Poll Finds”, Texas Tribune, March 4, 2019, https://www.texastribune.org/2019/03/04/texans-disagree-on-climate-health-care-taxes-uttt-poll/
Sanger-Katz, M. “The Difference Between a Public Option and Medicare for All? Let’s Define Our Terms”, The Upshot, The New York Times, February 2019, “https://www.nytimes.com/2019/02/19/upshot/medicare-for-all-health-terms-sanders.html
Scott, Dylan, “The Big Difference in 2020 health plans isn’t among Democrats”, Vox, October 28, 2019, https://www.vox.com/2019/10/28/20928474/2020-health-care-plans-obamacare-medicare-for-all
Ura, Alexa, “Why is Texas voter turnout so low? Demographics play a big role”, Texas Tribune, https://www.texastribune.org/2018/02/23/texas-voter-turnout-electorate-explainer/
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- This bill was authored by Reps. DeLauro and Schakowsky. ↑
- Rep. Higgins and Sen. Stabenow’s bills. ↑
- The funds needed, according to the Committee, would equal a 32% payroll tax or a 25% income tax. ↑