Joe Biden picks up the ACA 2.0 bill Elizabeth Warren seems to have set aside & adds a Public Option to it

I promised to have a writeup about Joe Biden's just-rolled-out healthcare proposal yesterday, but I ended up stuck at the Apple Store for nearly six hours (don't ask).

In any event, let's take a look at Biden's proposal:

On March 23, 2010, President Obama signed the Affordable Care Act into law, with Vice President Biden standing by his side, and made history. It was a victory 100 years in the making. It was the conclusion of a tough fight that required taking on Republicans, special interests, and the status quo to do what’s right. But the Obama-Biden Administration got it done.

Today, the Affordable Care Act is still a big deal. Because of Obamacare, over 100 million people no longer have to worry that an insurance company will deny coverage or charge higher premiums just because they have a pre-existing condition– whether cancer or diabetes or heart disease or a mental health challenge. Insurance companies can no longer set annual or lifetime limits on coverage. Roughly 20 million additional Americans obtained the peace of mind that comes with health insurance. Young people who are in transition from school to a job have the option to stay covered by their parents’ plan until age 26.

As I noted yesterday, Biden couldn't be attempting to tie himself to President Obama more if he had himself surgically grafted to him. He refers to the ACA as "Obamacare" three times in the text and four times in the accompanying video intro. To the best of my knowledge, Biden is the only major Democratic Presidential candidate to formally call it "Obamacare" (as a positive), which is ironic given that the term has been (and still is) used by Republicans as a perjorative for a decade now. But I digress...

But, every day over the past nine years, the Affordable Care Act has been under relentless attack.

Immediately after its passage, Congressional Republicans began trying again and again to repeal it. Following the lead of President Trump, Republicans in Congress have only doubled down on this approach since January 2017. And, since repeal through Congress has not been working, President Trump has been unilaterally doing everything he can to sabotage the Affordable Care Act. Now, the Trump Administration is trying to get the entire law – including protections for people with pre-existing conditions – struck down in court.

All of this is 100% accurate, of course, and I give Biden huge props for being the only major Dem POTUS candidate to mention the Texas v. U.S. (#TexasFoldEm) lawsuit. In fact, as far as I can tell, only Kamala Harris' campaign website even mentions the ACA in the "healthcare" issues section:

  • Elizabeth Warren (amazingly, there's no "healthcare"-specific section on her Issues page whatsoever, even though she's the primary sponsor of her own robust ACA 2.0 bill and is pushing Bernie's Medicare for All bill as well)
  • Kamala Harris (she's pushing Medicare for All, and makes a brief mention of protecting the ACA in general and contraceptive coverage specifically from repeal)
  • Bernie Sanders (he's all in on Medicare for All, of course)
  • Pete Buttigieg (he's pushing "Medicare for All Who Want It", which sounds an awful lot like Medicare for America, which happens to be my preferred plan)

As president, Biden will protect the Affordable Care Act from these continued attacks. He opposes every effort to get rid of this historic law – including efforts by Republicans, and efforts by Democrats. Instead of starting from scratch and getting rid of private insurance, he has a plan to build on the Affordable Care Act by giving Americans more choice, reducing health care costs, and making our health care system less complex to navigate.

This is the crux of Biden's attack on his Democratic rivals; I'll discuss this in more detail below.

For Biden, this is personal. He believes that every American has a right to the peace of mind that comes with knowing they have access to affordable, quality health care. He knows that no one in this country should have to lay in bed at night staring at the ceiling wondering, “what will I do if she gets breast cancer?” or “if he has a heart attack?” “Will I go bankrupt?” He knows there is no peace of mind if you cannot afford to care for a sick child or a family member because of a pre-existing condition, because you’ve reached a point where your health insurer says “no more,” or because you have to make a decision between putting food on the table and going to the doctor or filling a prescription.

As most people know, Biden's son Beau (who was also the Attorney General of Delaware) passed away in 2015 from a brain tumor.

In the coming months, Joe Biden will build on today’s plan by rolling out his proposals to tackle some of our greatest public health challenges – from reducing gun violence to curing devastating diseases as we know them like cancer, Alzheimer’s, diabetes, and addiction.

THE BIDEN PLAN TO PROTECT & BUILD ON THE AFFORDABLE CARE ACT

I. GIVE EVERY AMERICAN ACCESS TO AFFORDABLE HEALTH INSURANCE

From the time right before the Affordable Care Act’s key coverage-related policies went into effect to the last full year of the Obama-Biden Administration, 2016, the number of Americans lacking health insurance fell from 44 million to 27 million – an almost 40% drop. But President Trump’s persistent efforts to sabotage Obamacare through executive action, after failing in his efforts to repeal it through Congress, have started to reverse this progress. Since 2016, the number of uninsured Americans has increased by roughly 1.4 million.

As president, Biden will stop this reversal of the progress made by Obamacare. And he won’t stop there. He’ll also build on the Affordable Care Act with a plan to insure more than an estimated 97% of Americans. Here’s how:

  • Giving Americans a new choice, a public health insurance option like Medicare. If your insurance company isn’t doing right by you, you should have another, better choice. Whether you’re covered through your employer, buying your insurance on your own, or going without coverage altogether, the Biden Plan will give you the choice to purchase a public health insurance option like Medicare. As in Medicare, the Biden public option will reduce costs for patients by negotiating lower prices from hospitals and other health care providers. It also will better coordinateamong all of a patient’s doctors to improve the efficacy and quality of their care, and cover primary care without any co-payments. And it will bring relief to small businesses struggling to afford coverage for their employees.

OK, this is of course the much-ballyhooed (in the past) "Public Option". It sounds an awful lot like the PO portion of Senators Merkley & Murphy's "Choose Medicare" bill. It's important to keep in mind that there's no mention of what reimbursement rates to healthcare providers would be under this bill.

Washington State is the example to watch here: Their recently-passed "Public Option" (which isn't entirely public, depending on your definition of the term since it involves the state contracting out to a private carrier) was originally supposed to pay healthcare providers Medicare rates...but eventually ended up agreeing to pay 60% more than that when they weren't able to get enough doctors/hospitals onboard at 100% Medicare.

Provider reimbursement rates are gonna be one of the toughest battles any major expansion of government-controlled healthcare will face, and is the main reason why the entire industry is dead set on preventing any "public option" whatsoever.

  • Increasing the value of tax credits to lower premiums and extend coverage to more working Americans. Today, families that make between 100% and 400% of the federal poverty level may receive a tax credit to reduce how much they have to pay for health insurance on the individual marketplace. The dollar amount of the financial assistance is calculated to ensure each family does not have to pay more than a certain percentage of their income on a silver (medium generosity) plan. But, these shares of income are too high and silver plans’ deductibles are too high. Additionally, many families making more than 400% of the federal poverty level (about $50,000 for a single person and $100,000 for a family of four), and thus not qualifying for financial assistance, still struggle to afford health insurance. The Biden Plan will help middle class families by eliminating the 400% income cap on tax credit eligibility and lowering the limit on the cost of coverage from 9.86% of income to 8.5%. This means that no family buying insurance on the individual marketplace, regardless of income, will have to spend more than 8.5% of their income on health insurance. Additionally, the Biden Plan will increase the size of tax credits by calculating them based on the cost of a more generous gold plan, rather than a silver plan. This will give more families the ability to afford more generous coverage, with lower deductibles and out-of-pocket costs.

This is taken directly from the "Healthy America" proposal by Linda Blumberg, John Holahan and Stephen Zuckerman of the Urban Institute...as is Elizabeth Warren's ACA 2.0 bill...and, in fact, as was Hillary Clinton's 2016 proposal. This exact formula is also used in the House Democrats' ACA 2.0 bill, although their version sticks with Silver as the benchmark instead of upgrading to Gold.

I don't just mean all of these are kind of taken from the Urban Institute...I mean the exact subsidy formula is identical in all three cases.

Here's where Biden's proposal differs from Warren's and the House Democrats' bill, however:

  • Expanding coverage to low-income Americans. Access to affordable health insurance shouldn’t depend on your state’s politics. But today, state politics is getting in the way of coverage for millions of low-income Americans. Governors and state legislatures in 14 states have refused to take up the Affordable Care Act’s expansion of Medicaid eligibility, denying access to Medicaid for an estimated 4.9 million adults. Biden’s plan will ensure these individuals get covered by offering premium-free access to the public option for those 4.9 million individuals who would be eligible for Medicaid but for their state’s inaction, and making sure their public option covers the full scope of Medicaid benefits. States that have already expanded Medicaid will have the choice of moving the expansion population to the premium-free public option as long as the states continue to pay their current share of the cost of covering those individuals. Additionally, Biden will ensure people making below 138% of the federal poverty level get covered. He’ll do this by automatically enrolling these individuals when they interact with certain institutions (such as public schools) or other programs for low-income populations (such as SNAP).

Back in April 2017, I proposed modifying the ACA's subsidy formula to range from 0% - 10% of income regardless of income (that is, I removed the 400% FPL income eligibility cap), but I also originally proposed removing the lower-bound 100% FPL cut-off as well. HOWEVER, I later scrapped the lower-bound proposal for the following reason:

The original version of this formula restructure included removing the lower cut-off point (<100% FPL) for tax credits as well. My rationale was that if some states are dead-set on not expanding Medicaid no matter what, folks caught in the Medicaid gap should at least be allowed to enroll in ACA exchange policies with full APTC/CSR assistance. Unfortunately, as several people have pointed out, APTC/CSR assistance is 100% federally funded, whereas the states have to pony up a portion of Medicaid expansion funds...only 5-10% of it, but that can still add up. That means that once you allow those below the 100% threshold to receive tax credits via the individual market, that pretty much guarantees that none of those 19 remaining holdout states will budge...and also means that at least a few of the states which have expanded the program would likely drop it, meaning a complete backfire on the goal of this measure. Therefore, sadly, I had to scratch the "APTC under 100% FPL" part of this idea.

Biden is proposing to "solve" this problem by basically punishing the expansion states by requiring them to continue paying 10% of the cost of Medicaid for expansion enrollees (around $10.3 billion/year collectively, I believe)...while letting the non-expansion states completely off the hook.

This may or may not prove to be good politics, but it's pretty rude since it's literally rewarding non-expansion states for being assholes the past six years. It would, however, "solve" the Medicaid Gap problem for millions of people in those non-expansion states, I suppose.

II. PROVIDE THE PEACE OF MIND OF AFFORDABLE, QUALITY HEALTH CARE AND A LESS COMPLEX HEALTH CARE SYSTEM

Today, even for people with health insurance, our health care system is too expensive and too hard to navigate. The Biden Plan will not only provide coverage for uninsured Americans, it will also make health care more affordable and less complex for all.

The plan’s elements described above will help reduce the cost of health insurance and health care for those already insured in the following ways:

  • All Americans will have a new, more affordable option. The public option, like Medicare, will negotiate prices with providers, providing a more affordable option for many Americans who today find their health insurance too expensive.
  • Middle class families will get a premium tax credit to help them pay for coverage. For example, take a family of four with an income of $110,000 per year. If they currently get insurance on the individual marketplace, because their premium will now be capped at 8.5% of their income, under the Biden Plan they will save an estimated $750 per month on insurance alone. That’s cutting their premiums almost in half. If a family is covered by their employer but can get a better deal with the 8.5% premium cap, they can switch to a plan on the individual marketplace, too.
  • Premium tax credits will be calculated to help more families afford better coverage with lower deductibles. Because the premium tax credits will now be calculated based on the price of a more generous gold plan, families will be able to purchase a plan with a lower deductible and lower out-of-pocket spending. That means many families will see their overall annual health care spending go down.

The bullets above are just rehashes of the PO/subsidy expansions. As far as I can tell, this is what Biden's plan looks like compared to the ACA 2.0 bills being pushed by the House Democrats and Elizabeth Warren:

I could be wrong about Biden's plan in the CSR portion of the table, since he doesn't specify whether or not he intends on keeping CSR in place at all, although the upgrade from Silver to Gold would accomplish quite a bit of that anyway.

I gave Senator Warren huge praise for introducing the Consumer Health Insurance Protection Act (CHIPA) over a year ago, and was happy to see her re-introduce it this year. I lterally gave her a standing ovation when I watched her "many paths to get there" response to the "Medicare for All" question at a CNN Town Hall back in March.

About a month or so ago, however, she seemed to make a conscious choice to abandon (or at least, tuck away) not only her own ACA 2.0 bill but several other strong healthcare expansion and/or universal coverage bills on the table, seemingly abandoning her own "many paths to get there" mantra in favor of a simple "I'm with Bernie on Medicare for All" stance.

It's possible that Warren will come back around to her own bill in the near future, or that she'll return to her March stance...but at least for the moment, until I hear otherwise, she seems to be firmly onboard the M4All train.

The two biggest differences between Warren's bill and Biden's proposal is that Warren's S.1213 is presumably intended as a stopgap measure until a more comprehensive proposal is put into place (whether it's "Medicare for All", "Medicare for America" or another bill)...whereas Biden's proposal appears to be his "final word", at least during the 4-8 years he'd presumably be in office. That's why his proposal includes a national Public Option as well as "solving" the Medicaid Gap issue, albeit via a proposal which seems awfully unfair to expansion states.

The Biden Plan has several additional proposals aimed directly at cutting the cost of health care and making the health care system less complex to navigate. The Biden Plan will:

  • Stop “surprise billing.” Consumers trying to lower their health care spending often try to choose an in-network provider. But sometimes patients are unaware they are receiving care from an out-of-network provider and a big, surprise bill. “Surprise medical billing” could occur, for example, if you go to an in-network hospital but don’t realize a specialist at that hospital is not part of your health plan. The Biden Plan will bar health care providers from charging patients out-of-network rates when the patient doesn’t have control over which provider the patient sees (for example, during a hospitalization).

Surprise Billing, of course, has been very much in the news of late. Eliminating it has been included in Elizabeth Warren's bill for over a year, and it's part of several other proposals.

  • Tackle market concentration across our health care system. The concentration of market power in the hands of a few corporations is occurring throughout our health care system, and this lack of competition is driving up prices for consumers. The Biden Administration will aggressively use its existing antitrust authority to address this problem.
  • Lower costs and improve health outcomes by partnering with the health care workforce. The Biden Administration will partner with health care workers and accelerate the testing and deployment of innovative solutions that improve quality of care and increase wages for low-wage health care workers, like home care workers.

III. STAND UP TO ABUSE OF POWER BY PRESCRIPTION DRUG CORPORATIONS

Too many Americans cannot afford their prescription drugs, and prescription drug corporations are profiteering off of the pocketbooks of sick individuals. The Biden Plan will put a stop to runaway drug prices and the profiteering of the drug industry by:

  • Repealing the outrageous exception allowing drug corporations to avoid negotiating with Medicare over drug prices. Because Medicare covers so many Americans, it has significant leverage to negotiate lower prices for its beneficiaries. And it does so for hospitals and other providers participating in the program, but not drug manufacturers. Drug manufacturers not facing any competition, therefore, can charge whatever price they choose to set. There’s no justification for this except the power of prescription drug lobbying. The Biden Plan will repeal the existing law explicitly barring Medicare from negotiating lower prices with drug corporations.

Letting Medicare negotiate drug prices is part of a bunch of Democratic healthcare proposals; Biden gets no special brownie points for including it here but it's still a good thing.

  • Limiting launch prices for drugs that face no competition and are being abusively priced by manufacturers. Through his work on the Cancer Moonshot, Biden understands that the future of pharmacological interventions is not traditional chemical drugs but specialized biotech drugs that will have little to no competition to keep prices in check. Without competition, we need a new approach for keeping the prices of these drugs down. For these cases where new specialty drugs without competition are being launched, under the Biden Plan the Secretary of Health and Human Services will establish an independent review board to assess their value. The board will recommend a reasonable price, based on the average price in other countries (a process called external reference pricing) or, if the drug is entering the U.S. market first, based on an evaluation by the independent board members. This reasonable price will be the rate Medicare and the public option will pay. In addition, the Biden Plan will allow private plans participating in the individual marketplace to access a similar rate.

Again, this has been in the news a lot lately, and even the Trump Administration has at times been open to letting other countries determine what we pay for prescription drugs. The irony of that coming from a xenophobic nationalist bigot like Trump is staggering, of course.

  • Limiting price increases for all brand, biotech, and abusively priced generic drugs to inflation. As a condition of participation in the Medicare program and public option, all brand, biotech, and abusively priced generic drugs will be prohibited from increasing their prices more than the general inflation rate. The Biden Plan will also impose a tax penalty on drug manufacturers that increase the costs of their brand, biotech, or abusively priced generic over the general inflation rate.

If you're wondering why the healthcare lobby is opposed to even a plan from a market-friendly, "corporate" type of Democrat like Biden, here's part of your answer. Price controls don't go over well with that group no matter who proposes them.

  • Allowing consumers to buy prescription drugs from other countries. To create more competition for U.S. drug corporations, the Biden Plan will allow consumers to import prescription drugs from other countries, as long as the U.S. Department of Health and Human Services has certified that those drugs are safe.

Again: A great idea but hardly a new one.

  • Terminating pharmaceutical corporations’ tax break for advertisement spending. Drug corporations spent an estimated $6 billion in 2016 alone on prescription drug advertisements to increase their sales, a more than four-fold increase from just $1.3 billion in 1997. The American Medical Association has even expressed “concerns among physicians about the negative impact of commercially driven promotions, and the role that marketing costs play in fueling escalating drug prices.” Currently, drug corporations may count spending on these ads as a deduction to reduce the amount of taxes they owe. But taxpayers should not have to foot the bill for these ads. As president, Biden will end this tax deduction for all prescription drug ads, as proposed by Senator Jeanne Shaheen.
  • Improving the supply of quality generics. Generics help reduce health care spending, but brand drug corporations have succeeded in preserving a number of strategies to help them delay the entrance of a generic into the market even after the patent has expired. The Biden Plan supports numerous proposals to accelerate the development of safe generics, such as Senator Patrick Leahy’s proposal to make sure generic manufacturers have access to a sample.

These make sense, of course. Not huge but still important.

IV. ENSURE HEALTH CARE IS A RIGHT FOR ALL, NOT A PRIVILEGE FOR JUST A FEW

Joe Biden believes that every American – regardless of gender, race, income, sexual orientation, or zip code – should have access to affordable and quality health care. Yet racism, sexism, homophobia, transphobia, and other forms of discrimination permeate our health care system just as in every other part of society. As president, Biden will be a champion for improving access to health care and the health of all by:

  • Expanding access to contraception and protect the constitutional right to an abortion. The Affordable Care Act made historic progress by ensuring access to free preventive care, including contraception. The Biden Plan will build on that progress. Vice President Biden supports repealing the Hyde Amendment because health care is a right that should not be dependent on one’s zip code or income. And, the public option will cover contraception and a woman’s constitutional right to choose. In addition, the Biden Plan will:

Well, now. After all the fuss over his stance on the Hyde Amendment a few months back, this makes it official: Pretty much the entire Democratic Party, including Biden, now agree that #HydeMustGo.

    • Reverse the Trump Administration and states’ all-out assault on women’s right to choose. As president, Biden will work to codify Roe v. Wade, and his Justice Department will do everything in its power to stop the rash of state laws that so blatantly violate the constitutional right to an abortion, such as so-called TRAP laws, parental notification requirements, mandatory waiting periods, and ultrasound requirements.
    • Restore federal funding for Planned Parenthood. The Obama-Biden administration fought Republican attacks on funding for Planned Parenthood again and again. As president, Biden will reissue guidance specifying that states cannot refuse Medicaid funding for Planned Parenthood and other providers that refer for abortions or provide related information and reverse the Trump Administration’s rule preventing Planned Parenthood and certain other family planning programs from obtaining Title X funds.
    • Just as the Obama-Biden Administration did,President Biden will rescind the Mexico City Policy (also referred to as the global gag rule) that President Trump reinstated and expanded. This rule currently bars the U.S. federal government from supporting important global health efforts – including for malaria and HIV/AIDS – in developing countries simply because the organizations providing that aid also offer information on abortion services.
  • Reducing our unacceptably high maternal mortality rate, which especially impacts people of color. Compared to other developed nations, the U.S. has the highest rate of deaths related to pregnancy and childbirth, and we are the only country experiencing an increase in this death rate. This problem is especially prevalent among black women, who experience a death rate from complications related to pregnancy that is more than three times higher than the rate for non-Hispanic white women. California came up with a strategy that halved the state’s maternal death rate. As president, Biden will take this strategy nationwide.
  • Defending health care protections for all, regardless of gender, gender identity, or sexual orientation. Before the Affordable Care Act, insurance companies could increase premiums merely due to someone’s gender, sexual orientation, or gender identity. Further, insurance companies could increase premiums or deny coverage altogether due to someone’s HIV status. Yet, President Trump is trying to walk back this progress. For example, he has proposed to once again allow health care providers and insurance companies to discriminate based on a patient’s gender identity or abortion history. President Biden will defend the rights of all people – regardless of gender, sexual orientation, gender identity – to have access to quality, affordable health care free from discrimination.
  • Doubling America’s investment in community health centers. Community health centers provide primary, prenatal, and other important care to underserved populations. The Biden Plan will double the federal investment in these centers, expanding access to high quality health care for the populations that need it most.

I rip on Bernie Sanders a lot, but I do owe him a shout-out for ensuring this funding was included in the ACA back in 2009.

  • Achieving mental health parity and expanding access to mental health care. As Vice President, Biden was a champion for efforts to implement the federal mental health parity law, improve access to mental health care, and eliminate the stigma around mental health. As President, he will redouble these efforts to ensure enforcement of mental health parity laws and expand funding for mental health services.

In the months ahead, Biden will put forward additional plans to tackle health challenges affecting specific communities, including access to health care in rural communities, gun violence, and opioid addiction.

When I first gave Biden's plan a once-over, I quipped that it looks like Elizabeth Warren's ACA 2.0 bill with a "Choose Medicare"-style Public Option added to it, and I still stand by that, although it's obviously more complicated than that. Over at Xpostfactoid, Andrew Sprung describes it as more like a cross between ACA 2.0 & Medicare for America, which seems like a pretty good summary as well...although Med4America guarantees 100% coverage, while the Biden plan (as with Choose Medicare) does not appear to include mandatory enrollment.

This last point is interesting to me since just a week or two ago Biden specifically said that he supports bringing back the ACA's individual mandate penalty...yet I don't see it mentioned in his own proposal. Huh.

To his credit, Biden also makes sure to include how to pay for his plan (not that this makes his pay-for any easier to achieve, but it's good to at least spell out what he has in mind):

SUPPORTING HEALTH, NOT REWARDING WEALTH

Joe Biden believes in rewarding work, not just wealth – and investing in hard-working Americans’ health, not protecting the most privileged Americans’ wealth. Warren Buffett said it best when he stated that he should not pay a lower tax rate than his secretary.

The Biden Plan will make health care a right by getting rid of capital gains tax loopholes for the super wealthy. Today, the very wealthy pay a tax rate of just 20% on long-term capital gains. According to the Joint Committee on Taxation, the capital gains and dividends exclusion is the second largest tax expenditure in the entire tax code: $127 billion in fiscal year 2019 alone. As President, Biden will roll back the Trump rate cut for the very wealthy and restore the 39.6% top rate he helped restore when he negotiated an end to the Bush tax cuts for the wealthy in 2012. Biden’s capital gains reform will close the loopholes that allow the super wealthy to avoid taxes on capital gains altogether. The Biden plan will assure those making over $1 million will pay the top rate on capital gains, doubling the capital gains tax rate on the super wealthy.

I'm all for doing this, of course. Note that everything in Biden's funding proposal hits those at the very top of the income mountain. Getting that done, of course, is a whole different discussion...

UPDATE 7/19: D'oh!! I just realized that I completely forgot to follow up on my "I'll discuss this in more detail below" bit regarding Biden attacking his Democratic rivals over Medicare for All "eliminating Obamacare" and "eliminating (current) Medicare".

Since I first posted this entry, however, Jeffrey Young of the Huffington Post has done a pretty good job of addressing this issue, so I'll defer to him:

At a forum sponsored by the AARP and the Des Moines Register in Iowa, Biden trotted out scare tactics about health care reform that would make President Donald Trump proud.

...Then Biden began to make the case against Medicare for All. It rested largely on trying to scare old people, a tactic Republicans frequently use to whip up anxiety about any Democratic plan to reform the health care system.

“Medicare goes away as you know it. All the Medicare you have is gone,” Biden said as he leaned down toward moderator Kathie Obradovich from the Des Moines Register for effect. “The transition of dropping 300 million people on a new plan ― totally new ― is, I think, kind of a little risky at this point."

As a point of fact, the “Medicare” program envisioned under Medicare for All is not the program as it exists today. Unlike what Biden insinuated, however, it would have more generous benefits and little to no out-of-pocket spending. Senior citizens, like everyone else, would be enrolled in a single-payer, national health care program.

This attack utilizes classic Republican “Mediscare” tactics designed to foment discontent among older Americans that anyone else’s gains come at their expense.

In other words, Biden's claim that Bernie's "Medicare for All" bill would "eliminate Obamacare" and "replace Medicare" is technically accurate, but it's still pretty disingenuous of him for two reasons:

Regarding the ACA: Obamacare was never intended to be the end of the road for healthcare reform. The 1332 Waiver provisions specifically allow individual states to experiment with ways to improve and expand healthcare coverage, up to and including even the prospect of state-level single payer.

Vermont, in fact, attempted to use a 1332 Waiver to do just this, as did Colorado. Both ended up failing, of course, but if either one had been successful, those states would have achieved statewide Single Payer healthcare coverage under a provision ofthe ACA itself.

So let's suppose that both Vermont and Colorado had successfully used 1332 waivers to transition over to single payer systems...and that the other 48 states had then followed suit, resulting in 50 (51 w/DC) state-level single payer healthcare systems. Would anyone say that they "eliminated Obamacare"? Well, yes and no...it depends on your perspective.

Regarding Medicare: Regular readers know that I'm not a proponent of Bernie's specific bill (I'm a huge fan of the "Medicare for America" approach) for several reasons, one of which is that yes, forcing ~160 million people to drop their current private employer coverage and transition over to a new, untested government-run system would be extremely disruptive.

HOWEVER, as Young also notes, there's a big difference between being understandably concerned/wary about doing this and deliberately scaring the living crap out of old people about it. Under Bernie's plan, there'd be a 4-year transition period in which people are phased in by age group. I happen to think his transition period is too short, but there is a phase-in period.

Bottom line: There's nothing wrong with Biden addressing legitimate concerns over M4All, but he's cranking up the hyperbole meter to 11 in a naked play to scare Obama supporters and old people into voting for him.