NEW YORK — On Monday morning, America’s most prominent beneficiary of socialized medicine, in the process of receiving expensive, taxpayer-financed care at a government-operated hospital, was tweeting furiously. One of President Donald Trump’s manic missives particularly caught the eyes of health care experts: his exhortation to “PROTECT PREEXISTING CONDITIONS. VOTE!”
As always, it’s not clear whether Trump is merely being cynical or whether he is also genuinely ignorant.
He’s definitely lying when he claims to have a plan that’s better and cheaper than Obamacare. No such plan exists, and he has to know that.
But does he know that Americans with pre-existing medical conditions are already protected by the Affordable Care Act, which his administration is asking the Supreme Court to overturn? Does he realize that the reason his party has never offered an acceptable alternative to the ACA, in particular an alternative that would protect pre-existing conditions, is that no such alternative is possible? That’s less clear.
In any case, how the nation votes will indeed make a huge difference to the future of health care — and not just because Trump, if he holds on to power, will almost surely find a way to destroy Obamacare, causing tens of millions of Americans to lose health insurance.
Joe Biden, if he wins (and gets a Democratic Senate), will make a big difference in the other direction, substantially expanding coverage and reducing premiums for middle-class families.
The second part of this statement might come as news to many readers because Biden’s health proposals haven’t drawn much attention so far.
One reason is that the election is — rightly — being seen mainly as a referendum on Trump rather than on likely Democratic policy. Another is that since the Democratic primary fight pitted Biden against rivals calling for radical changes in health policy, many people assume the winner of that fight, who rejected those radical proposals, wouldn’t change much.
But while Biden is indeed proposing incremental change rather than “Medicare for All,” we’re talking about some big increments.
Independent estimates suggest that under Biden’s plan, 15 million to 20 million Americans would gain health insurance. And premiums would fall sharply, especially for middle-class families.
What policy changes are we talking about?
To the extent that the Biden plan has received any attention at all, this attention has largely been focused on his proposed introduction of a “public option” — a Medicare-like plan that individuals could buy instead of purchasing private insurance. This option might be a first step toward a single-payer system, but it would be a small step, and in the near term would be much less important than other aspects of the plan.
First and foremost, the Biden plan — Bidencare? ObamaBidencare? — would substantially increase the subsidies that currently help many but not all Americans who don’t get insurance from their employers.
The Affordable Care Act, as passed in 2010, was underfunded because Democrats wanted to keep down the headline cost. This meant premiums and co-payments were and are too high for many families. Since then, however, the politics shifted: Public opinion shifted in favor of the ACA, the Democratic Party moved somewhat to the left and Republican willingness to ram through expensive, unfunded tax cuts encouraged Democrats to be more aggressive.
So the Biden plan would increase subsidies and also remove the upper-income limit that prevents many middle-class families from receiving aid. This would cost a fair amount of money: The Committee for a Responsible Federal Budget puts the price tag at $850 billion throughout a decade. But it would cost far less than the 2017 tax cut, much of which went to corporations, which were supposed to respond by increasing investment but didn’t.
The Biden plan would also automatically enroll low-income Americans in the public option, which is more important than it might sound. One of the defects of our system is that it’s complex and confusing, and those who need help the most are often the least able to navigate their way to getting it. Ideally we’d just move to a simpler system, but for now auto-enrollment would be an important palliative measure.
Oh, and the plan would also provide significant aid for long-term care, rural health and mental health.
None of this amounts to revolutionary change — in contrast to Trump’s efforts to kill Obamacare, which would drastically change American health care, for the worse. But Bidencare would still be, as Biden didn’t quite say when President Barack Obama signed the ACA into law, a pretty big deal.
True, America would still fall somewhat short of achieving what every other advanced country has — universal health care. But we’d get a lot closer, and many who currently have insurance coverage would see their costs fall and the quality of coverage improve.
So health care, including to protect pre-existing conditions, really does need your vote!
If Trump wins, Americans will lose that protection and many will lose their health insurance or see their premiums soar; if Biden wins, Americans will keep that protection and many will gain insurance or see their premiums fall.
Paul Krugman is a syndicated columnist who writes for the New York Times News Service.