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2020 Democrats who want a ‘public option’ don’t always want the same thing



WASHINGTON — When it comes to health care, every Democrat running for president falls into one of two camps: those who want to put all Americans under a single-payer “Medicare for All” plan, and those who would instead offer a “public option” that competes with private insurance.

So far the debate among candidates has largely been about which path to pursue. But just as important, and far less discussed, is just how massive the differences are among Democrats who favor a public option.

Some are calling for changes so modest that few Americans — by design — would notice they had happened at all. Others are calling for an overhaul so sweeping that they might lead — by design — to something resembling Medicare for All. Many of the candidates have co-sponsored multiple bills with different approaches, while others have left their stance ambiguous.

Here’s a run-through of how some of the different proposals work and the kind of choices Democrats will need to make if they go the public option route.

Who would get covered?

One fundamental divide is who will be served by a public option. Is it a last resort for people who can’t get insurance elsewhere? Or is it a potential first choice for everyone?

On the “last resort” end of the spectrum is Sen. Michael Bennet, D-Colo., who is running on a bill called “The Medicare-X Choice Act” that he co-authored with Sen. Tim Kaine, D-Va.

The bill would create a new “Medicare-X” plan to be sold on the Affordable Care Act’s exchanges, a marketplace for plans that provides subsidies to customers who don’t get comprehensive insurance through their work. It would start out in rural areas with few private plans and then spread nationwide over several years. Small businesses could eventually buy “Medicare-X” for their workers as well.

“It’s really focused on filling in the gaps that exist,” Bennet told NBC News in an interview.

Biden’s new public option plan is similar in this regard. It would be available to individuals who buy coverage through the Affordable Care Act’s marketplace and give people on employer plans more flexibility to switch to a public option.

On the opposite end of the spectrum is “Medicare for America,” a bill by Reps. Rosa DeLauro, D-Conn., and Jan Schakowsky, D-Ill. Former Rep. Beto O’Rourke, D-Texas, has embraced their legislation on the campaign trail while the Center for American Progress, an influential liberal think tank, has promoted a broadly similar plan.

Under Medicare for America, a new Medicare plan with more generous benefits than the existing program would become the first option for insurance. Americans would be automatically enrolled over time and have to affirmatively opt out to purchase private coverage.

Businesses of all sizes would have the option to cover their workers through Medicare. In addition, large portions of the current health care system — including existing Medicare recipients — would move to the new plan.

That’s too much for Bennet, who sees it as taking too many parts of the system and “shoving them together into a new bureaucracy.” But to supporters, the plan’s reach ensures fewer people are left behind and gives more leverage to change the system.

Some candidates, like Mayor Pete Buttigieg of South Bend, Indiana, have said they envision a public option as a pathway to Medicare for All. The DeLauro-Schakowsky bill gives an idea of what that might look like.

What would a “public option” look like?

Depending on the plan, your “public option” might look very different.

In some cases, you’d be joining an existing government program. Sen. Amy Klobuchar, D-Minn., has campaigned on a bill she co-sponsors with several other 2020 contenders that would allow Americans over 50 to buy into traditional Medicare. A number of presidential candidates also co-sponsor a bill by Sen. Brian Schatz, D-Hawaii, that would allow people to potentially buy into a state Medicaid plan.

But in other plans, what you’d be getting would not be quite the same as Medicare or Medicaid as it exists today. Medicare Part B also has no limit on out-of-pocket spending, which is why seniors often purchase supplemental insurance or a private Medicare Advantage plan that caps expenses.

In the case of Bennet, the new “Medicare-X” plan would more closely resemble the private plans offered through the ACA, which have to cover a minimum set of benefits and have maximum deductibles and out-of-pocket costs. The DeLauro-Schakowsky bill’s Medicare option would go further and cover new benefits as well, including dental, vision and long-term care. Biden’s plan doesn’t fully describe how the new public option would be designed.

But there would still be big differences. The main public option proposals would require doctors who accept Medicare patients to also take the new plans as well. Customers would likely be able to access wider networks and be less vulnerable to surprise bills.

“That’s really different from private coverage today,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. “We’re all in and out of network depending on what goes on.”

How much would you pay? And how much would it cost?

Here’s something you might not know about a public option: On paper, it actually saves the government money (we’ll get into why in a second). The nonpartisan Congressional Budget Office estimated one version of a public option would save $138 billion over 10 years.

But the Biden plan that came out this week costs $750 billion over the same period, according to the campaign. Why the big difference? Like most of the public option proposals, it doesn’t just create a public plan, it also offers new subsidies to help people pay for it.

“If you’re thinking about how much a public option will expand coverage, the action there is on the subsidy,” Matthew Fiedler, a fellow at the USC-Brookings Schaeffer Initiative for Health Policy, said.

In Biden’s case, his plan would boost aid for people with higher incomes who are currently ineligible for benefits and cap maximum premiums at 8.5 percent of annual income. He also would offer low-income customers in states that have not expanded Medicaid the chance to buy a public option plan with zero premiums. Finally, his plan would boost the ACA’s tax credits to help customers buy a more generous plan — private or public — that covers a higher percentage of their out-of-pocket costs.

The Bennet bill would expand subsidies to a lesser degree, allowing higher income customers to access them and capping premiums at 13 percent of income. The DeLauro-Schakowsky bill would cap premiums at 8 percent of income, offer zero-premium plans with no-cost sharing to low-income Americans, and cap out-of-pocket costs at $3,500 for individuals and $5,000 for families, lower than the current limits of $7,900 and $15,800 for ACA plans.

The scale of each plan’s benefits is a major factor in how much they cost the government. Bennet’s bill counts on the savings from the public option to pay for the increase in subsidies. Biden’s plan, with its more generous aid, calls for new taxes on investments and income from high earners to make up the difference.

While there’s no estimate of the DeLauro-Schakowsky bill’s total cost, experts who talked to NBC News expect it to be far more expensive, in part because it expands benefits for existing Medicare recipients. Its authors propose financing it by ending President Donald Trump’s tax cuts and imposing new taxes on higher incomes and investments.

How much would doctors get paid?

Perhaps what distinguishes a public option from private insurance the most is how it would pay doctors and hospitals. This sounds like a wonky technical concern, but it’s critical to understanding how they would function.

The way a public option saves money is by reimbursing providers at rates closer to Medicare, which are far lower than what private insurance tends to pay. One study of hospital systems by the RAND Corporation found they charged private plans more than twice as much on average as they did Medicare.

By paying lower rates, a public option would be able to lower premiums, which would mean fewer government subsidies to help people afford them. It also would put more pressure on private insurers to lower their premiums and give them more leverage to negotiate lower rates themselves.

A coalition of trade groups representing different parts of the health care industry oppose a public option in part for this reason, arguing they need the higher private insurance rates to make up for the lower ones they receive for Medicare.

The United States spends far more on health care per person than other developed countries and experts tend to agree there’s room to close that gap at least somewhat without worsening care. But how much is still an open question.

The various public option plans try to deal with this issue in different ways. Bennet’s “Medicare-X” plan would pay the same rates as Medicare, but they could be boosted as much as 25 percent for rural areas where costs tend to be higher. The DeLauro-Schakowsky bill boosts Medicare reimbursement by 10 percent or more for hospitals. The Schatz Medicaid buy-in raises the reimbursement rate for Medicaid, which is lower than Medicare. The Biden plan is less clear, only saying it would negotiate lower rates.

Gov. Jay Inslee of Washington, another 2020 candidate, recently signed a bill creating a public option that set reimbursement rates at 160 percent of Medicare in the face of industry opposition to deeper cuts. A new Democratic president and Congress would face even more outside pressure, but any boost in the rates would also raise premiums and taxpayer costs.

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After El Paso shooting, Latino lawmakers slam Texas governor for ‘dangerous’ tweets about immigrants



AUSTIN, Texas — In the wake of the El Paso domestic terror attack, lawmakers and Democrats, many of them Latino, are slamming language used by Texas Gov. Greg Abbott in a tweet and a fundraising letter as anti-Hispanic and anti-immigrant.

On Friday, members of the state’s El Paso legislative delegation and the Mexican American Legislative Caucus condemned Abbott’s language on a Twitter thread where Abbott said the state has been forced to pay for the education of “illegal immigrants.”

“Our community is trying to heal from racially driven violence. This hurts. It is dangerous,” the El Paso state lawmakers tweeted individually from their accounts.

The caucus went further saying the “attack on a child’s right to an education is immoral and infuriating, regardless of citizenship status”, said Abbot has “demonized” the immigrant community “since day one” and “fueled the widespread hate towards our Latino family.”

The backlash over Abbott’s tweet comes the day after the governor held a roundtable on the El Paso attack that left 22 people dead. Abbott said helping El Paso heal, particularly its children, is a priority. It also comes amid outrage over a fundraising letter dated the day before the Aug. 3 attack. In it, Abbott decries illegal immigration and calls on supporters to “DEFEND Texas.”

In the U.S., children cannot be turned away from schools for their immigration status, after the landmark Supreme Court ruling Plyler v. Doe, which Abbott mentions in his tweet. The case originated in Tyler, Texas.

El Paso sits on the Texas border and some of its students come legally from its adjoining city Juarez, Mexico. Not all are undocumented.

Abbott’s office did not respond to NBC News’ requests for comment. In public comments after Thursday’s roundtable, Abbott struck a different tone. He said the roundtable in Austin and another planned Aug. 29 in El Paso are intended to find ways for “rooting out hateful ideologies.”

“We know you feel you are attacked as human beings. We want you to know that we as Texans come shoulder to shoulder and side by side with you, as one family working together,” he said.

James Dickey, Republican Party of Texas chairman, said it’s an “absurd stretch to argue that language like ‘defend Texas’ can be construed by any sane person to mean ‘go murder people.'”

Political mailing stirs controversy

Abbott’s political mailer, which was provided to NBC News by the Texas Democratic Party, told supporters that “if we’re going to DEFEND Texas, we’ll need to take matters into our own hands.”

After citing immigration apprehension statistics and criticizing Rep. Alexandria Ocasio-Cortez, D-N.Y., Abbott warned of a plan by liberals to “transform Texas — and our entire country — through illegal immigration.”

Police said the gunman who opened fire on an El Paso Walmart told them his target was “Mexicans,” and that he posted an anti-Hispanic and anti-immigrant screed that stated the attack was a “response to the Hispanic invasion of Texas.”

The screed also states Democrats are trying to “enact a political coup” by opening borders and legalizing millions of new voters to transform Texas from a Republican-controlled to a Democratic-controlled state.

U.S. Rep. Veronica Escobar, whose district is El Paso, criticized Abbott for his letter in a tweet Thursday.

“If Greg Abbott ever wonders why there is so much hate and anger toward Mexicans and immigrants, he should take a long look at his rhetoric, policies and now his mailer,” she said.

Texas Democrats blasted the governor’s letter Thursday in a news release that was issued while Abbott was holding the roundtable. Texas Democrats said the language in Abbott’s letter is the sort that fueled the hatred of the suspected shooter.

“It’s long past time for Republicans to eradicate white supremacist language from their discourse — people are dying,” Democrats said in a statement.

Rep. Rafael Anchía, chairman of the MALC, listed actions Abbott has taken as governor and the state’s attorney general regarding immigrants, including supporting Arizona laws that give law enforcement officers more power to investigate individuals’ citizenship status.

Anchía called on the governor to end the rhetoric, his mailers and “anti-immigrant policies.”

“All Texans, including the Latino community, should feel safe in their home. Governor Abbott is instead doing the exact opposite by promoting fear,” Anchía said in a statement.

Members of El Paso’s delegation said they raised the issue of anti-Latino and anti-immigrant rhetoric with the governor, Lt. Gov. Dan Patrick and House Speaker Dennis Bonnen, R-Angleton, and other participants in the Austin roundtable.

Texas Rep. Cesar Blanco, D-El Paso, said after the meeting there was consensus that the El Paso attack was an atrocity that happened to Latinos, that it was racially based and that “a racist white nationalist” did the attack.

State Rep. Joe Moody, D-El Paso, the House Speaker pro tem, said Thursday there was a “very poignant” moment during the discussions when a participant said that “language matters and it matters more when its (from) leaders in our state.”

“I think that point was made very clearly,” he said.

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