WASHINGTON – Medicare-for-All, or Medicare-for-More?
That's the question facing a Democratic Party that's veered to the left in the nine years since Congress passed the Affordable Care Act, which didn't push any younger people into the popular federal health plan for the elderly.
Now, though, several of the party's presidential candidates – including Sen. Kirsten E. Gillibrand of New York – back a "Medicare-for-All" bill sponsored by another presidential hopeful, Sen. Bernie Sanders of Vermont. That measure would create a Canada-like "single payer" health care program that would put today's health care insurers out of business.
On the other side of the debate are bills like the one being pushed by Democrats led by Rep. Brian Higgins of Buffalo and Sen. Debbie Stabenow of Michigan. That narrower measure would make Medicare an option for anyone over the age of 50 who is shopping for insurance on one of the Obamacare exchanges.
The nation's health care industrial complex opposes both proposals, depicting the first as socialized medicine and the second as a gateway to socialized medicine.
But the real debate on the two proposals is taking place within the Democratic Party.
Medicare-for-All advocates argue that their bill would provide all Americans with better, cheaper health coverage.
But those who back Medicare-for-More say it's a more politically doable way to help the people most in need of help on health care: those in late middle age.
Here's a closer look at those two alternatives:
No more high co-pays. No more fights with insurance companies over reimbursement. No more steep hikes in your insurance premiums.
That's what advocates of the Bernie Sanders version of Medicare-for-All promise.
"My bill would provide comprehensive and cost-effective health care for everyone – without out-of-pocket expenses," Sanders said in a USA Today op-ed last fall.
In addition to Gillibrand, three other Democratic presidential candidates – Sen. Kamala Harris of California, Sen. Elizabeth Warren of Massachusetts and Sen. Cory Booker of New Jersey – co-sponsor the measure.
Sanders' plan would, over four years, shut down insurance companies and replace them with federally funded health care.
How to pay for that?
On the campaign trail, Gillibrand has been touting a part of the Sanders bill that she authored.
“It’s a four-year transition where anybody can buy in at 4 percent of their income to create competition in the market and let people begin to choose what works for you," she said on the "Pod Save America" podcast. "That’s how you get to single payer."
There's only one problem with that formula, said Bill Hammond, director of health policy at the right-leaning Empire Center for Public Policy in Albany.
"It doesn't work," Hammond said.
The nation's total gross income in 2016 was $10.2 trillion, and a 4 percent tax on that would bring in a little over $400 billion annually, he noted.
"That would cover just one-sixth of the $2.5 trillion annual cost of Medicare-for-All, as estimated by Urban Institute, a left-of-center think tank," Hammond noted in a recent blog post.
Gillibrand's campaign said she understands that other revenue sources – such as repealing the corporate tax cut passed in 2017, reinstituting the estate tax and passing a financial transaction tax – would also be needed to pay for Medicare-for-All.
But some health care experts wonder if the Sanders proposal is so extravagant that no number of new taxes could ever pay for it.
"He intends to cover a lot more than Medicare covers now, and that's important," said Dr. Nancy H. Nielsen, a University at Buffalo professor and former president of the American Medical Association. "And he also has absolutely no co-pays in there. Oh, my goodness, that will drive the cost way up as well. So there just isn't any way that the country can afford what he is talking about."
Under the Sanders plan, even the most popular part of the current health care system would go away – including the Medicare Advantage plans that serve many of Western New York's seniors.
That points to another concern Nielsen has about single payer: that people will turn against it as soon as they realize that it means they would lose the coverage they have now.
Grounds for that concern can be found in a Kaiser Family Foundation poll released in January. That poll found that 56 percent of voters surveyed backed a government-run Medicare-for-All plan – but that support for that plan falls to 37 percent when respondents are told the plan would eliminate private health insurance.
That makes Nielsen wonder if Republicans will demonize Medicare-for-All just as they did Obamacare. Campaigning in part on the notion that the Democratic health plan would take voters' health insurance away, the GOP won back control of the Congress in 2010.
At the time, when many voters looked at Obamacare, "the fear factor just overcame all of the beneficial parts," Nielsen recalled.
The over-50 set faces many worries, among them being sudden job loss and its evil twin, the eventual loss of health care coverage.
Higgins' Medicare-for-More plan would make that last worry a lesser evil. The 60 million people between age 50 and 65 would have the option of buying into traditional Medicare or a Medicare Advantage plan.
The Buffalo congressman has also signed on to a broader Medicare-for-All bill similar to the Sanders plan, but Higgins said it could be years before Democrats get a big enough Senate majority to pass such a plan. He said his plan could pass much sooner than that.
"The question is: What can be implemented as quickly as possible to provide the protection of Medicare to an age demographic that desperately needs it?" he asked. "Medicare at 50."
Only a year ago, Higgins' proposal to let people older than 50 buy into Medicare seemed to be on the left side of the Democratic spectrum – so much so that it helped create a temporary rift between him and then-Democratic Leader Nancy Pelosi, whose staff opposed pushing Higgins' plan forward.
Now, though, Higgins' plan has some juice behind it. Co-sponsors include two House committee chairs and a former member of the party leadership. And in the Senate, three of the presidential candidates who favor Medicare-for-All – Gillibrand, Harris and Booker – back Higgins' plan as a step toward a single-payer plan. A presidential candidate who has not endorsed single-payer, Sen. Amy Klobuchar of Minnesota, has also signed onto the Higgins plan.
Stabenow, the Higgins bill's chief Senate sponsor, said the measure micro-targets an audience that's in most dire need of federal help on health care.
"So many folks have said to me they're holding their breath until they get to age 65," Stabenow said. "I want people to stop having to hold their breath and to be able to get the affordable healthcare they need."
But the medical industry sees the Higgins-Stabenow plan as a dangerous step toward socialized medicine.
"This proposal – whether you call it Medicare-for-All, Medicare buy-in, single-payer or a public option – moves us toward a one-size-fits-all health care system that is wrong for America," said Lauren Crawford Shaver, executive director of Partnership for America’s Health Care Future, a coalition of insurers and health care providers.
Some in the health insurance industry offer more nuanced takes on Higgins' effort.
"We're neutral on it at this point," said Donald R. Ingalls, vice president for state and federal relations at BlueCross BlueShield of Western New York. "It would provide a voluntary option. It could be an alternative for early retirees or those who don't have employer coverage."
Meantime, Dr. Michael W. Cropp, president and CEO of Independent Health, said: "Brian's approach here makes some sense in terms of expanding upon an existing system that some would say works. But even with Brian's plan, there still has to be some mechanism to pay for it."
Higgins maintains that if the Medicare buy-in is priced correctly, it would pay for itself.
What's more, some 77 percent of the people surveyed by Kaiser favored a Medicare buy-in for people over age 50, which is why Higgins thinks it's the Democratic Party's best political option.
"It's the highest percentage of public favorability for any of these options," he said. "I think it is good in and of itself, because it would provide the protection of Medicare now. And it could be a pathway to something greater."