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Joe Biden invoked a risky — and familiar — phrase to sell his health care plan. At an AARP event in Iowa, Biden told voters he’d create a government insurance plan to compete with private ones called a public option. It would give consumers, Biden said, another choice.
"If you like your employer-based plan, you can keep it," Biden said July 15. "If you have private insurance, you can keep it."
It was a time warp moment that whipped us back to 2013.
"If you like your health care plan, you can keep it," was President Barack Obama’s go-to pitch point as he stumped for the Affordable Care Act. By our count, Obama said some version of that line 37 times without any caveats or conditions.
For millions of people buying coverage on their own — about 8% of the market — it was wrong.
The claim earned Obama PolitiFact’s 2013 Lie of the Year.
"Everyone knew that (Obamacare) was meant to make certain types of coverage go away," said former Republican congressional staffer Rodney Whitlock. "He kept saying it, even when the whole goal was to push people out of bad plans, junk insurance, and into plans that met a minimum coverage standard."
Today, with the law already in place, the removal of existing plans isn’t baked into Biden’s proposal. Whitlock and other analysts say that technically, Biden can fairly say that he’s not out to cancel anyone’s insurance.
His main idea is to set up a government-run insurance program where people would pay premiums to get covered. The public plan would go head-to-head with private carriers and if consumers preferred it, they could buy in.
Biden would make premiums more affordable with larger subsidies than the current law. On top of that, for states that have expanded Medicaid to any adult just a bit above the federal poverty line, they would have the option to put those people into the public plan, so long as the state continued to pay Washington what it does today.
History has shown that health care promises are tough to keep. The industry has many players, each angling for advantage. People who have spent years watching how it works say Biden’s reassuring words could crumble, as employers, employees and states adjust to the new ground rules.
Biden’s proposal wouldn’t necessarily force insurers to cancel plans, said Melinda Buntin, health policy chair at Vanderbilt University School of Medicine. But don’t expect the companies that buy insurance to sit still.
"Employers — especially small businesses with lower income workers — might choose to drop coverage if their employees would qualify for the public plan with more generous subsidies," Buntin said.
What employers choose to do highlights a widespread feature of insurance in America. Employers decide what plans to offer their workers, and in many cases, the option is take it or leave it. The worker’s personal preference can be irrelevant. Or, anyone who takes a new job likely moves into a new insurance plan. That would be just as true under Biden’s plan as it is today.
How any of this plays out hinges on the details of Biden’s public option, and those remain unclear. New York University’s Sherry Glied said a very generous plan could entice many workers to ditch their employer-based insurance, leaving companies with too few people to attract affordable bids from insurance companies. Glied, though, is generally optimistic that the rules would still make employer plans a cheaper deal for employees.
"The plan retains most of the benefits of employer coverage so people would probably stick with it, and the presence of a public option paying Medicare-like rates would likely lower payment rates all around," she said.
One clear difference between Obama’s and Biden’s use of the line are the politics.
In 2009, the fear was that government would take over the entire insurance market. Obama deployed the line "to reassure already insured Americans," University of North Carolina - Chapel Hill health policy professor Jonathan Oberlander told us.
Biden’s focus today is on his Democratic rivals.
"It is aimed partly as a critique of Medicare for All and those Democratic presidential candidates who have endorsed Medicare for All," Oberlander said.
That would include Bernie Sanders, Elizabeth Warren and Kamala Harris. Medicare for All would essentially ban all private insurance.
Penn Law professor Allison K. Hoffman credits Biden with trying to help those who slip through the cracks, because they can’t get on Medicaid or would need deeper subsidies to buy private insurance. That incremental approach might, Hoffman said, define the plan’s limits.
"It might be a very effective gap filler that would not force anyone off their current coverage, but also might not motivate very many to switch to the public option," Hoffman said.
Hoffman also noted that, while Biden spoke specifically about people keeping their private insurance, the possible impact on people covered by Medicaid expansion under Obamacare are quite different. He gives states the option to shift that group from expanded Medicaid into the public option plan.
Where that happened, those people would see their current plans disappear.
Thomas Miller at the market-oriented American Enterprise Institute takes a more negative view of Biden’s reassuring words about existing coverage. Miller cautioned that there are many ways Biden’s plan could go awry, particularly if the government throws more weight behind the public option, at the expense of private ones.
"How long you can keep your present plan is a matter of how long it can, under its current terms, remain affordable, or how long before it threatens to outcompete the public option," Miller said. "You can have your plan, until it’s not allowed to be around anymore."
AARP, AARP Presidential Candidate Forum: Health Care, High Drug Prices Among Top Issues, July 15, 2019
Joe Biden for President, Healthcare, July 15, 2019
SHRM, ACA’s Affordability Threshold Rises in 2019, May 30, 2018
PolitiFact, Lie of the Year: 'If you like your health care plan, you can keep it', Dec. 12, 2013
Gallup, Most Americans Still Rate Their Healthcare Quite Positively, Dec. 7, 2018
Niskanen Center, What’s wrong with employer sponsored health insurance, Nov. 6, 2018
Interview, Rodney Whitlock, vice president, McDermott+ Consulting, July 16, 2019
Email exchange, Sherry Glied, New York University, July 16, 2019
Email exchange, Melinda Buntin, chair, Department of Health Policy, Vanderbilt University School of Medicine, July 16, 2019
Email exchange, Thomas Miller, resident fellow, American Enterprise Institute, July 16, 2019
Email exchange, Jonathan Oberlander, chair, Department of Social Medicine, University of North Carolina at Chapel Hill, July 16, 2019
Email exchange, Allison K. Hoffman, professor of health care law, University of Pennsylvania Law School, July 16, 2019