All three would offer government-run health insurance options on the Affordable Care Act exchanges that would compete with private insurance plans. All would allow those with employer-sponsored policies to sign up for the public plan. All promise to make the coverage more affordable. And all would automatically enroll low-income Americans in coverage.
To start, it would be the first step toward adopting a government-run Medicare for All system in the US, which is Sen. Bernie Sanders’ brainchild. Also, her option is far more generous and is aimed at building support for full universal coverage by quickly immersing tens of millions of Americans in Medicare for All.
“It looks like a very substantial down payment on Medicare for All,” said Chris Jennings, a health policy expert and former official in the Clinton and Obama administrations. “It may be more than halfway there.”
Sanders’ transition plan, which he first introduced in 2017, would, in its first year, place every American 55 or older, along with people up to age 18, into his version of the Medicare for All program. People would also have the option to buy in immediately. Over the next two years, according to the current bill’s language, the Medicare for All enrollment age would drop to 45, then 35. By the fourth year, everyone would be covered.
Buttigieg’s emergence as the front-runner in Iowa means his own proposal is about to come under increased scrutiny. Buttigieg’s plan, which he describes as “Medicare for all who want it,” is a thinner version of what Warren is planning to do off the bat, and neither the South Bend mayor nor Biden has drawn up a clear path to universal coverage — a priority for almost every Democrat running in the primary.
Here are some notable ways the leading primary contenders’ plans differ:
How much people have to pay
Biden and Buttigieg aim to expand coverage in part by enhancing federal premium subsidies — both for those currently eligible under the Affordable Care Act and those who now earn too much for assistance.
They would provide access to premium subsidies to everyone buying insurance on the exchanges. Under Obamacare, only those making less than 400% of the federal poverty level, or roughly $50,000 for an individual and $103,000 for a family of four, qualify for federal help.
Those subsidies would be used to cap premiums at a maximum of 8.5% of income, rather than roughly 10% under Obamacare. And Biden and Buttigieg would tie the premium subsidies to more generous gold plans — which have lower deductibles and out-of-pocket costs — rather than silver policies so enrollees would spend less when they visit the doctor or a hospital.
And Buttigieg would allow those with access to employer coverage to buy policies on the Obamacare exchange and receive federal subsidies, while Biden would open up the subsidies to workers who select the public option. Currently, those with affordable policies at their jobs don’t qualify for Obamacare subsides.
Also, Biden and Buttigieg would automatically enroll uninsured, low-income Americans either in the public option or in Medicaid, depending on whether their state expanded Medicaid to those making less than 138% of the poverty level, or roughly $17,250 for an individual or $35,550 for a family of four.
Buttigieg also wants to create a fund that would reimburse health care providers for caring for the uninsured. Those lacking coverage would be retroactively enrolled in the public option.
Warren’s option, which she is proposing to pass in the first 100 days of her administration, would have no monthly premium for children under 18 and people below 200% of the federal poverty level, or roughly $25,000 for an individual and $51,500 for a family of four.
For everyone else, premiums would be capped at 5% of income — making her option cheaper and, in theory, more attractive as she seeks to build public support for a full transition to Medicare for All.
Plus, deductibles wouldn’t exist in Warren’s plan. Children and those earning less than twice the poverty level would have no out-of-pocket costs for care. Others would have to pay something, though it would be capped.
Over time, premiums and cost-sharing would gradually decrease to zero.
What benefits enrollees would receive
The public option plans envisioned by Biden and Buttigieg would provide the same broad coverage as the policies on the Affordable Care Act exchanges today. Obamacare requires insurers to cover 10 essential health benefits, including mental health, prescription drugs and maternity, at a minimum.
Warren’s option would be even more comprehensive, providing the same benefits as the Medicare for All bill introduced by Sanders, who is committed to passing his legislation in one shot. It would cover vision, dental, hearing aids and some long-term care.
How much it will cost
Biden says his plan would cost roughly $750 billion over 10 years, which he would pay for by raising the top marginal tax rate and the rate on capital gains for the wealthy. Buttigieg’s proposal would come in at $1.5 trillion over a decade, which he would cover by rolling back President Donald Trump’s corporate tax cuts and through cost savings from allowing the federal government to negotiate drug prices.
Warren hasn’t specified the cost of the first step of her plan. However, her campaign said it would be “significantly higher” than her rivals’ proposals but less than the $11 trillion Americans are expected to shell out for health care over the next decade.