First, a confession.

I’m the last person you should look to to understand healthcare proposals. I’m one of those people who procrastinate endlessly over even filling up a 1040 EZ and can never keep acronyms like PPO, HMO, HSA, FSA straight. I’ve foregone money in my pocket in order to avoid having to upload yet another medical bill onto websites whose passwords I’ve long forgotten.

Regardless, I am a voter; and I’m willing to squint at wonky websites that other experts with actual bona fides are willing to write, so here goes. This is a guide for dummies, but I myself am prime among them.

Every single one of these plans gets us to a better place than today’s situation; and is certainly much better than Trump, who has and will continue to take us backwards. In fact, as we speak, his administration is supporting a case to rule the entire ACA unconstitutional.

I am classifying these along the lines of Charles Gaba’s super-dense and useful website, ACA Signups; in fact I’ve linked to his website wherever I could, if you are interested in a deeper dive.

ACA Upgrade

It was clear, even when the ACA became law in 2010, that this was merely a step towards a more complete solution: a step whose biggest virtue was that it could actually pass a fractious Congress that for one glorious moment had 60 Democratic Senators. It was debated through 2009 and 2010 amid angry town halls with cries of “Death Panels” and protests. It gave rise to the populist Tea Party movement and ruined careers of many Democratic freshmen in the red electoral wave that followed.

Miraculously, it made it into law, bloodied and broken. Since then, the Trump Administration and conservative Supreme Court have bloodied and broken it some more.

So while it remains law, it is clear that it needs shoring up. What does shoring up mean? Some or all of the following:

• While the ACA subsidizes premium for lower income families, those subsidies fade out and offer no help for families that have higher incomes but are still struggling. No one should have premium costs that are above, say, 8.5% of their income.
• Increase Cost Sharing Reductions that reduce out-of-pocket costs (like deductibles, co-pays, etc.) and lower the maximum out-of-pocket cost you might have to pay. Recently, the Trump Administration killed Cost Sharing Reductions altogether, so it would mean reversing that change.
• ACA had an error in its wording that left some families unable to get coverage at affordable rates. This is known as the “Family Glitch“. This should be fixed.
• Reverse Trump’s sabotage of ACA: ban junk plans, enforce coverage for preexisting conditions, and ensure that Essential Health Benefits are covered.
• Undo Trump’s sabotage of ACA enrollment and enrollment assistance efforts.
• Improve stability in the insurance marketplace, and reduce premiums, through reinsurance programs
• Lowering prescription drug costs by letting Medicare negotiate drug prices
• End “surprise billing” from out-of-network hospitals and doctors
• Use Gold plans as the benchmark for determining tax credits instead of Silver plans (Silver plans are less comprehensive, and less expensive, than Gold plans; and more comprehensive/expensive than Bronze plans).

Variations on the above theme have been knocking around in Democratic policy shops since 2015. That was the year that the SCOTUS case King v. Burwell was decided in favor of the ACA. If the ACA had lost, it would have spelled disaster for household premium costs and their ability to get insured. Since the ACA won, policy shops got busy trying to build on it.

Here are some Democratic plans, all of which could fall under the ACA 2.0 rubric.

• The Urban Institute’s Next Steps for the ACA plan from 2015.
• The Urban Institute’s Healthy America proposal from 2018.
• House bills from 2018 and 2019: the clumsily-named Undo Sabotage and Expand Affordability of Health Insurance Act from 2018, and Protecting Pre-Existing Conditions and Making Health Care More Affordable Act from 2019. Several pieces of the latter, to do with lowering drug costs, have already passed the full House in December 2019.
• Sen. Elizabeth Warren’s Consumer Health Insurance Protection Act (CHIPA) from 2018 and 2019, co-sponsored by several Senators, including Sen. Bernie Sanders, Sen. Kamala Harris, and Sen. Dianne Feinstein. This plan benchmarks tax credits to Gold plans instead of Silver plans like the others above.

Public Option

When I said above that the ACA emerged bloodied and broken from the legislative battles of 2009/10, I was thinking of one particular chopped off limb: the Public Option.

The Public Option would have allowed a government-run health insurance to compete with private insurance on the exchanges; given the government’s behemoth-like size, it would have driven down premiums and basic healthcare costs.

How it was lost is a story of a Senatorial high-wire act that almost resulted in no ACA at all. The House passed its version of a healthcare bill in the Fall of 2009. Upon the insistence of Pelosi and other members of the House, it included a Public Option (at one point, Pelosi derided a healthcare bill with no Public Option as “kiddie care“). The Senate tussled for months, but eventually could not pull together 60 votes for a Public Option. A Senate bill passed without one on Christmas Eve, 2009. Under threat of a filibuster from Joe Lieberman, they had removed the Public Option.

Even getting to 60 votes without the Public Option had proved to be a challenge. Democrats did not start that term with 60 votes. But then, in April 2009, Arlen Specter defected and joined the Democratic party. In July 2009, Al Franken won his court battle and was finally seated in the Senate as a Democrat. This brought up the total to 60 Democrats.

A month after that, in August 2009. Ted Kennedy passed away after a fight with cancer. While Democrats still had 60 votes—the governor appointed Democrat Paul Kirk in Kennedy’s place—this was not for long. The Special Election of January 2010 brought disaster for Democrats poised to take legislative wins on the ACA: Scott Brown, a Republican, won Kennedy’s seat in MA.

This was devastating for progressive hopes about what the ultimate version of the ACA would look like. The idea had been to come up with a compromise bill somewhere in between the House’s bill that included a Public Option, and a Senate bill that did not. Once they lost that MA Senate seat, passing substantive legislation through a 59-seat Democratic majority became impossible. So, the House swallowed their misgivings about the Senate bill and passed it as it was written in March 2010, with a few minor changes in a second bill.

But it is a new day now. Not only is the ACA hugely more popular that it was at its inception, the two most conservative Democratic Senators (Joe Lieberman and Bill Nelson) are gone from the Senate; and Scott Brown, the Republican whose election sabotaged Democratic hopes, is now replaced by progressive champion Senator Warren. As such, there have been several proposals made to bring the Public Option back.

• The CHOICE Act from Sen. Whitehouse
• HI Senator Brian Schatz’s bill that would provide a public option with an expanded Medicaid for states. This is sponsored by Sen. Corey Booker, Sen. Sanders, and Sen. Dianne Feinstein among others.
• Medicare X by Senator Bennett
• Choose Medicare from Senator Merkley & Murphy. This plan is also called Medicare Part E (for “Everyone”), and is based on Yale Profressor Jacob Hacker’s proposals, described in more detail below. It includes a Public Option that employers can choose to buy into.

And two proposals to permit a Medicare-style Public Option only for people above a certain age:

• Sen. Stabenow’s Medicare at 50 Act
• Rep. Higgins’s Medicare Buy-in for those over 50

ACA Upgrade + Public Option

It’s no surprise that every Democratic candidate who has run for President since then proposed at the very least both the small-bore-with-big-impact ACA improvements, and also bringing back ACA’s lost limb—the Public Option. Every one of these plans envisions changes very similar to the ones laid out in the Urban Institute policy papers linked to above..

• Hillary Clinton’s plan from her 2016 run for President, based on the Next Steps for the ACA plan as described above, also included a Public Option
• Joe Biden’s plan for the 2020 campaign, which includes a “Choose-Medicare“-style of Public Option, and also many of the improvements on ACA as listed above.
• Pete Buttigieg’s plan included much of the above, and emphasis on controlling exorbitant provider costs
• Amy Klobuchar’s plan also included a Public Option
• Mike Bloomberg’s plan included a Public Option, though as Charles Gaba’s post on this states, while Bloomberg’s plan would have pegged tax credits to Silver plans, the rest of the 2020 candidates listed here would have pegged tax credits to Gold plans: which would drastically reduce co-pays and deductibles consumers have to pay.

Other than Bloomberg going with the Silver benchmark and the others going with Gold, these plans are all very similar to each other; and often only differ in emphasis. For example, Biden held up his plan as an alternative to Medicare For All, while Buttigieg framed his as a glide path to Medicare For All. While that difference might help you judge the candidates, it does nothing to help you judge between their plans.

Single Payer

People often think of Single Payer as government-run healthcare, but this is not quite right. Because the healthcare would still be provided by privately-run hospitals, clinics, pharmacies, and doctors; it is just that their fees are paid by a single, giant payer: the federal government. Consumers can still choose where they want to receive care: they are not “assigned” a hospital.

(This is like Canada’s system for healthcare also informally called “Medicare”; and not really much like the UK’s NIH, where the government also runs the providers, such as hospitals. In the US, the closest thing to the NIH is the Veteran’s Health Administration.)

People also often refer to Single Payer as Medicare For All: this this is also not quite right. Because most such plans envision an expanded set of services than what Medicare currently provides: such as dental, vision, and long-term care.

Under a single-payer system, everyone is automatically enrolled in a government-run insurance company that is funded by taxes. No one pays premiums any more: they are gone. Who is taxed more, and who is taxed less, is the entire ballgame: single-payer plans sketch this out in varying levels of detail.

However, Single Payer systems might still require you to pony up on co-pays, though most envision a yearly out-of-pocket maximum. The reason for this is simple: “free” plans such as this have to discourage running willy-nilly to the doctor or specialist for every little thing that doesn’t necessarily need medical attention.

Another sure-to-be contentious issue is who the Single Payer system actually covers. They all claim “universal” coverage, but who is in the universe? Is it only citizens and permanent residents, or are undocumented immigrants included? Some plans address this head-on, some don’t.

So why is Single Payer better than what we have now? For one thing, everyone is automatically enrolled, with pretty much the same coverage. This means no more medical bankruptcies; government-provided coverage leaves workers free to move between jobs or get out of the workforce for a while without worrying about illnesses tanking their savings.

Single Payer would save massively on administrative costs (though obviously the federal government would be picking up those costs rather than people paying premiums).

Consider the sort of things the current system needs to keep track of: it involves a mish-mash of private insurers, each striking their own deal with providers. Every person covered has their own level of coverage, premium, and out-of-pocket costs based on income. All of this necessitates large billing departments that have to keep track of these details. As journalist Jon Walker says in The Road to Single-Payer:

…traditional Medicare has an overhead cost of 1.8 percent. The average private insurance company has an overhead cost of about 13 percent.

Transitioning to Single Payer

People are extremely risk-averse when it comes to healthcare. This is why the signing of the ACA into law caused nationwide anger even though ultimately it was a small-to-medium-sized change to the existing system that had already been successfully implemented in Massachusetts.

Single-payer advocates have already bowed to this reality by branding it as “Medicare”—thus using the name of a plan that most are familiar with and isn’t scary, even though all Single Payer plans would offer much more than Medicare.

So a lot depends on how we take healthcare in America from Point A to Point B.

Backend Transition and Auto-enrollment

This type of transition aims to minimize disruption by keeping the great bulk of the employer coverage system in place, with one major difference: a new government-provided Medicare-like insurance, that employers can choose to redirect their dollars into, instead of into private insurance. This is why I refer to it as transitioning through the “backend”—it would not be consumer-facing.

Employers can choose to remain with private insurance. But, it would be heavily regulated, both in terms of coverage and in terms of cost: following rules much like the ACA Upgrade plans above. Given these set of rules, the government insurance would most likely be cheaper; thus most employers will prefer to purchase it rather than the private one, with a gradual changeover.

So far it looks like a hefty Public Option. What makes it a Single Payer plan at all? This is because of auto-enrollment. People who do not have coverage would be automatically enrolled into the expanded Medicare-like insurance: in addition, so would all newborns. In a matter of one generation, all would be covered through Single Payer.

The virtue of this sort of plan is to minimize political opposition to the drastic nature of a transition to Single Payer, while getting its foot in the door. Since it is financed by redirecting existing payments into the new program, the “how will you pay for it” question has a ready answer.

There are a number of such plans knocking around in various Democratic policy shops, sketched out in varying levels of detail. But they all owe their intellectual allegiance to Yale’s Jacob Hacker, the man who invented the Public Option.

• Jacob Hacker’s Medicare for Everyone plan is based on both of these core concepts: an employer option to purchase a Medicare-like plan for employees, and automatic enrollment for the uninsured and newborns. It, in turn, was based on his own Health Care for America plan from 2007.
• Healthcare expert Jon Walker’s MICA (Medical Insurance and Care for All) from 2017
• The Center for American Progress came out with their Medicare Extra for All plan in 2018. It rolls up Medicaid and CHIP into their new Medicare-like plan, with a Public Option for both employees and employers as laid out above, and auto-enrollment for newborns and uninsured. Even in the years before everyone is covered through government-plans, it gets to universal coverage—Ezra Klein of Vox explains how.
• Rep. DeLauro and Rep. Schakowsky’s bill introduced in Congress in 2019, called Medicare for America, that is based on CAP’s proposal. It is described here at Vox by its intellectual progenitor, Jacob Hacker.

Sometimes these sorts of plans are seen as Single Payer with a Private Option: in other words, the default choice for most would be government-funded Single Payer, but consumers would have the option to buy private insurance instead.

Frontend Transition

For many years, Rep. John Conyers introduced a “Medicare For All” bill in each session of Congress. By the millennium, the Medicare program had become quite popular, and it was trusted by lawmakers as capable of reducing costs. Although the notion of “Single Payer” had been created by the doctors’ group Physicians for National Health Program (PNHP) in the 1980s, by 2003, when Rep. Conyers first introduced his bill H.R.676, Medicare had become the most often cited vehicle for instituting a Single Payer system. In recent years, Rep. Pramila Jayapal introduced a more detailed version of the Medicare For All bill in the House, and Sen. Sanders introduced one in the Senate.

What all of these bills have in common is that they both transition to the full system by gradually expanding the age groups covered by Medicare. Rep. Jayapal’s bill does this over two years, while Sen. Sanders bill does this over four years. This is why I call it a “frontend” transition—it is consumer-facing.

There are other differences between the House Jayapal bill and the Sanders Senate bill. According to Single Payer activist Kip Sullivan, Jayapal’s bill is a true Single Payer bill, while Sanders’s bill is not. This is because Jayapal’s bill includes a provision to set budgets for hospitals (much like the federal government sets budgets for fire departments), while Sanders’s bill does not.

According to Sanders’s bill, the federal government does not, in fact, pay hospitals directly. Rather, it makes payments to ACOs—these organizations are the latest version of “managed care”—a sort of hybrid of hospital chains and private insurance companies (Kaiser Permanente is an example). Thus, Sanders’s bill cannot set budgets for hospitals: it sets premiums for ACOs instead. This means it foregoes the major cost-containment feature available to the Jayapal plan.

As Kip Sullivan says in this interview: “Single Payer with ACOs is an oxymoron.”

Transitioning through States as Laboratory

After decades of failures of health care reform in the US, the Affordable Care Act finally passed after Massachusetts implemented a similar plan successfully. Obamacare for the country followed RomneyCare in a state, four years after.

We now think of Canada as a country where citizens harmoniously voted in a Single Payer system. But Single Payer was first implemented in the 1960s in a single province: in Saskatchewan, where the proposal led to widespread protests and doctors’ strikes. The government pushed through regardless. Compared to the first implementation of Single Payer in a province, the transition to it in the entire nation was relatively smooth and quick. Within ten years of the doctors’ strike, all of Canada was covered by Single Payer.

States often act as laboratories that countries use to judge the practicality of plans and gain political support.

In the case of Single Payer, the States-As-Laboratories in the US has had a shaky start. Green Mountain Care in Vermont, which was to be a version of Single Payer (Sen. Sanders later picked up a similar plan under his bill), failed just as the Affordable Care Act was being implemented in the country. It failed for one primary reason: they could not find a way to pay for it. The doubled state budget would have required higher state taxes and payroll taxes, neither of which were palatable.

At the same time as Green Mountain Care failed, the ACA was offering dollars to states who expanded their Medicaid program. Many states took advantage of it, including Vermont. If those federal dollars could have been rerouted into paying for a brand new Single Payer program, could it have bridged the gap and stayed afloat?

Rep. Ro Khanna of California has released a bill that addresses this very shortfall. Called State-based Universal Health Care Act, it provides federal dollars and regulatory flexibility to states that want to experiment with universal healthcare (including Single Payer). He wrote this bill responding to a call from California’s Governor, but if this plan passes, it is quite likely that at least one state out of fifty will implement a version of Single Payer; and show the way to the other forty-nine.

“Two-stage rocket booster” Transition

I will admit I am stealing Charles Gaba’s colorful phraseology to describe Elizabeth Warren’s plan for transitioning to Single Payer.

As far as I am aware, hers was the only plan that not only included multiple planned bills, but also separately mapped out Executive Actions that are within a President’s power to take unilaterally, all as steps in a roadmap to full Single Payer.

The Executive Actions she would have taken are obvious. The sabotage of healthcare by Trump has all been done by choosing to not enforce regulations and defend laws; those can simply be reversed by the next President: laws regarding coverage of preexisting conditions, banning junk plans, etc.

In terms of legislation, Warren’s roadmap included all of the ideas I have outlined above, but as milestones, instead of as the final destination. It included ideas from her own ACA Upgrade bill, CHIPA. It included a Public Option of the kind proposed by Rep. Stabenow, that could pass through budget reconciliation with 50 votes. It included automatic enrollment for the uninsured, along the lines of the Medicare for America bill mentioned above.

And then the money shot: if these transitional steps are completed, instituting a full Medicare For All bill, like the one proposed by Sen. Sanders, would be a relatively mild proposition.

If you are interested in a deeper dive, Charles Gaba has one; and of course you can go to the source.

Warren may have left the race (much to my dismay), but her roadmap is still out there, sketched out in great detail: ready for the next Democratic President to take up whoever and whenever that might be.

Further Reading:

1. Charles Gaba’s website ACA Signups is chock-full of useful information
2. Vox is a wonk’s paradise, in particular Sarah Kliff and Dylan Scott
3. Vox’s The Weeds podcast often has deep-dive discussions
4. Jon Walker’s series in ShadowProof is extremely valuable