By Joseph Ax
(Reuters) - All of the Democratic presidential candidates debating on Thursday say universal healthcare is a top priority. They disagree, however, on the best path to achieve it.
U.S. Senator Bernie Sanders has championed the ambitious goal known as "Medicare for All," which would replace the current patchwork healthcare structure with a single-payer system. The plan would provide government coverage to everyone based on the existing federal Medicare program for Americans 65 and older and would effectively eliminate private insurance.
On the other side of the debate, candidates like former Vice President Joe Biden, the current Democratic front-runner, have criticized Medicare for All as unworkable. They have proposed a public option, which would make a government plan available as an alternative to, but not a replacement for, private insurance.
Others have tried to stake out a middle ground, expressing support for Medicare for All as a long-term objective but endorsing steps less far-reaching than a single-payer system that eliminates private insurance.
The differences between the various proposals are often arcane and difficult to explain, leaving voters watching the televised debates unsure where each candidate stands.
"I think for the general public, the debate's been baffling," said Tricia Neuman, the director of the Medicare policy program at the nonprofit Kaiser Family Foundation. "There's been a lot of talk about Medicare for All and a lot of these other proposals, but the differences between them are fairly hard to decipher."
The distinctions pale in comparison to the gulf between the Democratic plans and the priorities of the Trump administration, which has sought to repeal the Obama-era Affordable Care Act in its entirety.
Here is where each of the 10 Democrats who have qualified for this week's debate in Houston stand on universal healthcare:
ALL IN FOR MEDICARE FOR ALL
The U.S. senator from Vermont authored the Medicare for All legislation that would revamp the entire healthcare system, essentially abolishing private insurance in favour of a single government-run plan that covers every American. The ambitious proposal would cost more than $30 trillion over 10 years, according to independent analyses.
Sanders has proposed higher taxes on employers and families to help pay for the program but has argued that the typical middle-class family would save more overall by cutting out health expenses.
The bill would transform Medicare into a universal system and ban employers from offering healthcare plans to compete with the government. Aside from prescription drugs, patients would face no out-of-pocket costs when accessing medical services.
Several Democratic rivals, including Biden, have criticized Sanders' plan as unrealistic.
Warren, a U.S. senator from Massachusetts, is known for releasing policy proposals on virtually every issue – but she has yet to advance her own detailed healthcare proposal.
Instead, she has endorsed the Medicare for All legislation authored by presidential rival Sanders, although she has also said there may be "different ways" to reach universal coverage.
Warren raised her hand at a June presidential debate when asked whether she favoured eliminating private health insurance, unlike some other candidates who had co-sponsored Sanders' plan, such as U.S. Senator Cory Booker.
Like Sanders, Warren and other supporters of the pricey plan have argued that families will save money overall by erasing medical expenses.
IMPROVE OBAMACARE BY ADDING PUBLIC OPTION
The No. 2 to former Democratic President Barack Obama has criticized Medicare for All plans as efforts to dismantle the Affordable Care Act, Obama's signature healthcare law.
Instead, Biden has vowed to "build on" the ACA, popularly known as Obamacare after his former boss, by adding a public option that would leave the current private insurance system in place.
His healthcare plan, estimated to cost $750 billion over 10 years and paid for partly by higher taxes on the wealthy, would let people enroll in a paid government healthcare plan as an alternative to private insurance. The government plan would be modelled on Medicare and available even to workers with employer-provided policies.
The proposal would also expand the ACA's subsidies for private policies, making them more generous and extending them to more people.
Like Biden, Buttigieg, the mayor of South Bend, Indiana, favours a public option, which would allow individuals to opt into a government plan but would preserve the existing role for private insurers.
Buttigieg, who has coined the phrase "Medicare for all who want it" to describe the concept, has argued that a public option will eventually lead to a single-payer system, because individuals will find that Medicare is more cost-efficient than private policies.
He has criticized Medicare for All plans such as the legislation championed by Sanders as unrealistic.
Unlike other fellow senators seeking the Democratic presidential nomination, Klobuchar did not co-sponsor Sanders' Medicare for All legislation.
Klobuchar, a moderate from Minnesota, has not released a detailed healthcare plan. But she has said she would improve on the Affordable Care Act by adding a public option, giving people the chance to choose a government-backed plan.
The U.S. housing and urban development secretary under Obama has said he would offer Medicare to all Americans as a public option. He has also said individuals who prefer private insurance should be permitted to choose that as an alternative.
He has not offered a detailed proposal of his own.
For months, the U.S. senator from California – an original co-sponsor of Sanders' Medicare for All legislation – struggled to clarify whether she would eliminate private insurance in favour of a single-payer health plan, as the Sanders bill envisions. On at least two occasions, she appeared to answer in the affirmative before walking back her statements.
Harris has since released her own Medicare for All plan, which stands somewhere between the sweeping Sanders proposal and more moderate alternatives.
Under Harris' proposal, all Americans would be covered by Medicare. But private insurers would continue to play a role by offering plans within the Medicare system, similar to the current Medicare Advantage program that allows recipients to choose private insurance plans that offer extra benefits.
The plan sets out a 10-year period to phase in the new system, unlike Sanders' goal of four years. Harris has said she would use a mix of new taxes on the wealthy and corporations to finance her plan, although she has not offered a precise price tag.
Sanders' and Biden's campaigns criticized Harris' plan, with the former accusing her of folding to the interests of the health insurance industry and the latter saying she was undercutting the Affordable Care Act.
Yang, an entrepreneur, supports Medicare for All, arguing that the prevailing job-based insurance system discourages businesses from hiring while forcing people to stay in jobs they dislike.
He has said he would not ban private insurers but does not believe they would be able to compete with a no-cost government plan. He has not offered a detailed version of how he would achieve a single-payer system.
Booker, a senator from New Jersey, was one of the co-sponsors of Sanders' "Medicare for All" legislation and has repeatedly affirmed his support for that bill.
But he has also said "pragmatism" may require a more incremental approach, such as a public option, that would eventually lead to a true single-payer system.
Like Harris, he has signed onto several alternative Democratic-backed healthcare bills in the Senate that would create a public option and lower the Medicare eligibility age from 65.
Booker has not yet unveiled a detailed healthcare proposal.
The former congressman from Texas supports legislation in the Senate known as "Medicare for America," which occupies a middle ground between the "Medicare for All" bill led by Sanders and more moderate proposals to create a public option.
Medicare for America would offer a government plan to all Americans, including those covered by employer-provided insurance. The bill would eliminate private insurance sold in the individual market but would continue to allow private insurers to offer plans through the Medicare Advantage system, as they do now.
Notably, the plan automatically enrolls newborns into the public program, making it more likely that job-based plans would continue shrinking in the future. O'Rourke has said the goal would eventually be to reach a single-payer system in which everyone is covered by Medicare.
(Reporting by Joseph Ax in New York; Editing by Colleen Jenkins and Peter Cooney)