Lowering medical costs and increasing access to care are among the most important issues for many New Hampshire voters.
We examine how the candidates say they will address this, as well as the political context and core ideas within their proposals.
Find NPR's breakdown of candidate proposals here.
Original air date: Monday, November 4, 2019.
GUESTS:
- Lucy Hodder - Professor at UNH Law, and Director of Health Law and Policy at the school's Institute for Health Policy and Practice.
- Julie Rovner - Chief Washington Correspondent for Kaiser Health News, and author of Health Care Politics and Policy A to Z.
- Dan Gorenstein - Executive producer and cohost of the podcast Tradeoffs, which explores "our confusing, costly, and often counterintuitive health care system." He was formerly the senior health care reporter at Marketplace, where he covered the business of health care.
Highlights from the conversation:
The major policy plans proposed during the Democratic presidential primary are Medicare for All, which would provide government-run health care, eliminating virtually all private insurance plans; a public option, which would allow consumers to choose public health insurance or purchase from private insurers; and similar public-private options.
Below are excerpts from our conversation with Julie Rovner, of Kaiser Health News, and Lucy Hodder, of UNH Law's Institute for Health Policy and Practice. These excerpts are from a computer-generated transcript, and may contain errors.
Voters are more focused on costs... candidates are more focused on the uninsured.
Julie Rovner:
It's a very kitchen table issue. People who can't afford their premiums, who can't afford their deductibles, who, you know, may have affordable insurance, but they can't go to the doctor because they have to pay $5000 before their insurance starts. That's what people are most concerned about. And yet the candidates seem to be kind of stuck in 1992 and 2008 mode talking about the uninsured. And granted, there are still millions of people who don't have insurance. But the bigger political problem right now is definitely the rising cost of health care.
Lucy Hodder:
Our deductibles [in New Hampshire] keep going up as well across every single market, so we're paying more out of our pocket... [Households] pay as much into the health care system as the federal government. So what we're seeing is people feeling that pressure of how much they're spending on their deductible and how much they're spending on their co-pays and how much they're spending on their premium.
Lessons from the Affordable Care Act:
Julie Rovner:
One of the most important lessons that we learned from the Affordable Care Act is that there are always winners and losers... And in this case, I'm not just talking about the doctors and the hospitals and the drug makers, but depending on what your individual situation is with your health care and your health status and the taxes you pay, you might end up paying more. But that was what happened with the ACA. A lot of people suddenly got better insurance, but they had to pay more for it. And those people were not all that happy about it.
Lucy Hodder:
We now really cost-shift to our private insurance, and a lot of providers are paid a lot better rates through private insurance than through Medicare....Those rates that we're paying on the private side are just unsustainable. So how do we get to a place where we actually all discuss the best way to reallocate what we're spending?
Medicare for All:
Who supports it?
The two candidates who have released Medicare for All plans are Bernie Sanders, who first introduced Medicare for All in 2017, and Elizabeth Warren, who released her detailed plan on November 1.
Andrew Yang supports Medicare for All with some changes. Listen to him discuss it on The Exchange earlier this year.
Julie Rovner:
Elizabeth Warren, interestingly, in putting out her estimate of how she would pay for it, also put a lot of meat on the bones of what Bernie Sanders has been talking about. Elizabeth Warren, in order to do her estimate of how much it would cost and therefore how much she would pay for it, had to decide a lot more granular issues. And the three proposals she put out together last week are about 100 pages of footnotes and economic estimates.
Listen to Elizabeth Warren's interview on The Exchange.
What would happen to private insurance companies under Medicare for All?
Julie Rovner:
There would be no private option... Everybody would have a government run insurance plan. That isn’t saying the providers would work for the government. They would still be private. But basically the private insurance industry would cease to exist as it does today.
Would Medicare for All look like the Medicare we have now?
Julie Rovner:
It's important to point out that no one who's talking about Medicare for All is talking about anything that's like the current Medicare system. The current Medicare system is not all that generous. You pretty much have to have supplemental insurance or you could go really broke under the current Medicare system. So what [the candidates are saying] is this would be something entirely new and we would call it Medicare, which I fear is adding to the confusion.
What is "Medicare for all who want it?"
Pete Buttigieg, during the NBC debate in June said:
You take something like Medicare, a flavor of that, you make it available on the exchanges, people can buy in, and if people like us are right, then that will not only be a more inclusive plan, but a more efficient plan than any of the corporate answers out there, then it will be a very natural glidepath to the single-payer environment.
Lucy Hodder:
I think we’ve learned something through the Affordable Care Act experiment, which was fairly disruptive... Consumers are seeing that different people are paying different amounts and having choices in different plans. And some of them want to say, 'Hey, why can't we take advantage of that really sensible plan where we have just a limited cost share and we get to be able to access any providers we want?' And so it's really a desperate and really warranted request for some sanity and rationality in the system that we can choose from. Some consumers are saying, 'Why don't we just get a choice if we want to pick a simple plan like Medicare for all, why can't we use the money we're spending on health care and buy into it?'
The Public Option Plan:
Who supports it?
Joe Biden and Amy Klobuchar have both saidthey want to work within what was created with the Affordable Care Act.
According to NPR, Kamala Harris and Marianne Williamson are among the candidates who have said they support Medicare for All, but with caveats.
Listen to The Exchange's interview with Williamson.
Cory Booker and Tulsi Gabbard were among the early supporters of Sanders' Medicare for All bill, but according to NPR, neither has said they want private insurance eliminated while on the campaign trail.
Listen to Gabbard's interview on The Exchange.
Julie Rovner:
The idea of a public option could be something for people who don't have workplace insurance. They would be able to purchase either from a private company or from the federal government.
Why is health care such a complicated issue?
Lucy Hodder:
We just haven't agreed on what our mutual mission is... So if you decide we want everybody to have insurance, which I think every one of our candidates has decided, then that's a guiding principle. Let's get everyone insurance some way. Then what's our next principle that we believe in? Do we believe if everyone has insurance, that we're all somewhat responsible for supporting those who may have higher risk? If so, how much are we going to support those other people? So I think some of it is we just haven't actually come down and decided our guiding principles... One of the things I love about all these candidates and coming up with these ideas is they're really driving that conversation on the Republican and the Democratic side.
