Health care remains the single most important issue to voters in the 2020 election. Yet, heading into tonight’s Democratic primary debate–the final of the year–the party’s position on the topic, tugged in one direction by grassroots activism and the other by political rationalism, has fractured.
Sens. Elizabeth Warren and Bernie Sanders have adopted a single-payer health care plan, “Medicare for All,” in which the majority of health care coverage would be financed through the federal government; private insurers would play a minimal role. Other candidates, including Joe Biden, Pete Buttigieg, Amy Klobuchar, Cory Booker, and Andrew Yang have proposed incremental improvements on the Affordable Care Act to reach universal coverage, most notably the inclusion of a public option to compete with private insurance plans.
Consequently, candidates have spent significant national airtime—both on the debate stage and in political advertising—advocating for the value of the freedom to choose your own health insurance plan rather than prescribe to a single-payer system. In theory, a health insurance marketplace works best when Americans can compare plans and make decisions about coverage based on their needs and each plan’s benefits. Buttigieg went so far as to include this sentiment in the title of his plan itself, “Medicare for All Who Want It.”
The result of this repetitive back-and-forth is that the national discussion on health care policy has largely been unproductive and frustrating for voters. Each primary debate to-date has ignored the crucial questions of rising health care prices, declining life expectancy, and the ongoing lawsuit to dismantle the Affordable Care Act in favor of what has become has become Democrat’s chief health care conundrum: Would voters sacrifice their ability to pick their own health care for a single-payer system? The odd thing about this is that it seems to have taken a very basic question for granted: Do Americans truly like the freedom to choose their own health insurance plan?
For one thing, that freedom itself is out of reach for most. Half of all Americans receive private, employer-sponsored insurance and have little or no choice at all in their plan’s structure. As of 2018, 80 percent of U.S. employers offered only one type of insurance plan. That means many Americans can’t choose their own primary care physician, specialist, or hospital without facing exorbitant out-of-network bills. Although it may be true that the majority of Americans with employer-sponsored insurance are satisfied with their coverage, it’s unlikely that translates into loyalty to a single private insurance corporation. In fact, if an employer changes their insurance benefits or an employee changes jobs, they lose their old plan altogether.
Even when employees have their choice of health care coverage, the typical person cannot reasonably evaluate all the relevant variables available in insurance plan design, including drug formularies, provider networks, covered benefits, and the mental math of choosing between higher premiums versus higher deductibles, copays, and coinsurance, all while selecting the appropriate plan to match their own and their family’s expected health care needs. Difficulty in reviewing and comparing plans has empirically led Americans to stick with the plans they have, regardless of whether they’re the best choice. Over the last decade, approximately 90 percent of Medicare beneficiaries on a private plan chose not to voluntarily switch their coverage for the coming year. Nearly half said they rarely or never compare Medicare options at all.
Americans are increasingly confused about both their health insurance options and what each of those options covers. Fewer than one-third of participants in a recent study were able to define the terms premium, copay, or deductible, and nearly half of participants did not know that health insurance was mandated by law to cover the 10 essential health benefits. Consequently, about 1 in 4 people reported that this uncertainty led them to avoid seeking medical treatment altogether. Confusion over coverage has been intensified by the resurgence of short-term health insurance plans under the Trump administration, which offer low premiums but scant coverage.
Arguably, Americans care much more about health care costs, quality, and choosing their doctor rather than where their insurance coverage comes from. Pivoting public debate to questions of skyrocketing hospital prices, structural barriers to health care access, and the merits of drug pricing regulation versus drug discovery innovation would both amplify the issues closer to Americans’ pocketbooks and patch up a bitter primary fight that might otherwise splinter the party in next year’s general election. If Democratic candidates must campaign on the idea of personal freedoms, they could continue to do so by crafting health care plans that provide the freedom to choose a doctor without the anxiety of navigating the esoteric minutiae of health insurance.