If we are going to keep having these grim circuses that we call debates, and begin each one with an extended segment about health care, it would be nice if we could stop asking the same questions again and again—but what about taxes?—and try to pin the leading candidates down on the specifics of their plans. They could ask Kamala Harris why anyone would keep their employer insurance if her Medicare plan would limit out-of-pocket spending to $200, or ask Bernie Sanders how a Medicare For All system would decide what to cover. But it’s the frontrunner who is most in need of a grilling, because lately he has seemed incapable of discussing any health care plan, including his own, with any accuracy.
Joe Biden says his plan will “guarantee that everyone will be able to have affordable insurance.” It is impossible to say that his plan will accomplish this. Biden’s plan would increase subsidies on the Affordable Care Act marketplace and lower the premium limit on marketplace plans from 9.86 to 8.5 percent of annual income. As Julián Castro noted, to Biden’s head-shaking, Biden’s own website says it would leave three percent of Americans uninsured, or more than 10 million people. It’s also pretty laughable to assert that lowering the premium limit to 8.5 percent and pegging subsidies to Gold instead of Silver plans will “guarantee” that everyone’s coverage will be affordable, particularly when this only applies to marketplace plans that cover just 11 million people.
Biden’s plan would limit deductibles to $1,000—which, while better than the astronomical deductibles millions have today, would certainly not be affordable for many families to pay in one go—but doesn’t appear to have any mechanism to lower employer-based plan premiums, which continue to rise. (Indeed, it’s hard to imagine that insurers wouldn’t dramatically raise premiums if deductibles were limited; another great reason to get rid of insurers entirely.) And merely promising “affordable insurance” is not enough, of course, when so many expenses are incurred even with affordable insurance, such drug costs and out-of-network bills.
Some health care concepts seem to escape him entirely. When pressing Sanders on the cost of his plan, Biden said that Sanders’s plan promised “a deductible in your paycheck.” This does not make sense. Clearly, he means a tax or a premium, but this is at least the second time he’s said this, and his team pushed the line out on Twitter as well. It is troubling that his proficiency with the jargon of health care financing is so loose after many months of campaigning, let alone after eight years of being vice president in the administration that passed the Affordable Care Act.
The oddest moment arose during a discussion as to whether Biden’s plan would “automatically” cover people. Sanders insisted that his plan was the “only one” that would prevent people going into “financial ruin because they suffered with a diagnosis of cancer.” Biden, as is his wont, said cancer was “personal” to him, and objected to Sanders’s contention: “Every single person who is diagnosed with cancer or any other disease can automatically become part of this plan. They will not go bankrupt because of that. They will not go bankrupt because of that. They can join immediately.”
But it is not true that a person facing such a diagnosis would “automatically” get Biden’s public option, because access to that public option will still be determined by a complicated system of premiums and subsidies—in other words, means testing. We don’t know how much the premiums under Biden’s public option would cost, but it seems clear that his understanding of health care access is very simplistic. To Biden’s mind, if you’re poor enough to have free or subsidized access to the public option, you should be able to afford all associated health care costs. And if you’re not poor enough, it means you’re sufficiently well-off to bear the costs.
This was also clear in his much-noted spat with Castro. Castro mentioned his grandmother, who had Type 2 diabetes but also had access to Medicare, and noted that Biden’s plan would require people to opt in, without being automatically covered. Biden took great issue with the assertion that people would have to “buy in,” leading to the dramatic moment that grabbed everyone’s attention—Castro poking fun at Biden’s memory, asking if he already forgot what he said. Castro was right: Biden did say that people could “automatically” get his “Medicare for choice” plan. But Biden said “buy in,” not “opt in”—so how could people “buy” in automatically? Very few American social programs are automatic, including Medicaid, which is often incredibly complicated to sign up for. Biden then clarified that he meant people like Castro’s mother wouldn’t have to buy in “if they can’t afford it.”
Biden is putting a hell of a lot of faith in his plan’s ability to fairly and accurately determine who can “afford” paying for the public option. His health care plan also does not include any kind of reforms for how seniors pay their Medicare drug costs, which can cost them thousands of dollars per year. (Although he would allow Medicare to negotiate drug prices and peg drug price increases to inflation, Biden’s plan says nothing about lowering the cost of drugs that are already too high and costing seniors thousands.) Without reforming Medicare, it’s impossible to say that no one’s cancer will send them into bankruptcy. His plans for long-term care are laughably weak, as well: A $5,000 tax credit for informal caregivers is like second prize in the Third Way holiday raffle.
However, the most important moment happened so quickly that it was easy to miss. When Sanders noted that the United States spends twice as much per capita on health care as other countries do, Biden replied: “This is America.” Presumably, the implication was that America should spend twice what other countries do, because we do everything bigger, better, bolder, with more flavor and half the fat. (It would have been better if Sanders had finished his thought by noting that America spends twice as much as other countries for worse health care outcomes, but no matter.) This is the essence of Biden’s defense of the broad status quo: a patriotic bumper sticker, felt with such keenness it’s hardly surprising that he doesn’t seem to understand anything else about the issue.
What is usually a dark joke—We’re Number One (In Gun Deaths and Obesity)!—was trotted out as an earnest defense of America’s absurd health care spending. American health care spending is high because we’re America, baby: We’ve got those big-ass trucks, Doritos Locos Tacos, and a healthcare system chock full of profiteering and blood-sucking greed. If you don’t like it, leave—for a country with single-payer.