Tuesday’s Democratic Healthcare Debate: Distinctions Without a Difference?

Democrats dueled vociferously on Tuesday night over healthcare. Three seemingly different positions were debated. But are the distinctions made in an effort to differentiate themselves meaningful, or are they in effect simple distinctions without a difference? Let’s try to be fact-based and rational.

Let’s begin by reviewing each option as proffered by their various proponents.

First, there is Medicare for All (MFA), written by Sanders and endorsed by Warren. MFA entails an immediate move to a single-payer system. Assuming that private insurance companies are eliminated and that drug and other healthcare prices are negotiated, Sanders believes that total healthcare costs will decline to the levels experienced elsewhere in the world. To pay for the program, he anticipates that taxes will be increased across the board, but that the increases on the “middle class” will be less than the reduction of premiums, deductibles, and copays. As a result, he believes that net costs to “middle-class families” will decline.

(An interesting subplot of the MFA debate is that Warren is not willing, as Sanders is, to acknowledge that “middle-class taxes” will go up. Instead, she prefers to rely on the semantic argument that overall “costs” for the middle class will come down.)

Buttigieg has proposed a second approach, arguing that the best way to achieve MFA is to begin with “Medicare for All Who Want It.” In other words, he proposes to create a Medicare option that would be sufficiently subsidized to make it affordable for anyone who wants it. He believes that the uninsured and underinsured would move quickly to the option. Once the option is proven, he anticipates that it will provide a “glide path” to full implementation of MFA. He argued aggressively with Warren in particular that this approach has the benefit of being more affordable and more palatable to Americans who like their employer-based healthcare.

Biden and Klobuchar prefer yet a third option, which is to “preserve and expand” the Affordable Care Act (ACA). The expansion would include adding a “public option like Medicare.” Again, as in the Buttigieg proposal, the public option would be sufficiently subsidized to enable access by the uninsured and underinsured as well as anyone who prefers it over their employer-provided healthcare. And again, just like Buttigieg, they argue that the Sanders/Warren MFA is not affordable.

Fully distilled, and after twenty-four hours of examination, there simply is no apparent difference between the Buttigieg and Biden/Klobuchar proposals except in what they call them. Both provide a public option that is made affordable through subsidies.

Furthermore, the only real difference between Warren/Sanders and Buttigieg/Biden/Klobuchar is in timing. Sanders and Warren would move quickly to implement a single public option, whereas Buttigieg/Biden/Klobuchar would allow Americans to opt in voluntarily. As a result, the speed of the “glide path” to MFA, to use Buttigieg’s words, would be determined by the voluntary choices of Americans. If Buttigieg is right and the public option proves to be the superior one, then MFA becomes the universal solution and the cost of the two proposals is ultimately the same. Therefore, if, as he argued, the Sanders/Warren MFA is unaffordable, it should follow that Medicare for All Who Want It and the ACA with a public option will ultimately be equally unaffordable. In essence, it is a distinction without a difference.

A simple follow-up question by CNN could have highlighted this reality, elevated the debate, and muzzled the “mutual firing squad.” Instead, they gave the candidates a platform for generating unimportant sound bites and did a disservice to the audience.