OK, let's look at Tom Steyer's healthcare plan...

I've been reluctant to add Tom Steyer's healthcare plan into my candidate analyses, but like Michael Bloomberg, Steyer has managed to flood the airwaves with well over $100 MILLION of his own money in TV ads and it's at least partly paid off. He's been in a couple of the Democratic debates, and is placing in 2nd or 3rd in a couple of South Carolina primary polls, so I guess he's justified my taking a look at his plan:

Health care is a right for all

Every American has the Right to Health Care. Health is the foundation for a full and productive life. Yet for far too long, the corporate stranglehold on our health care system has kept Americans from accessing and affording the health care they need.

Costs are simply too high. Patients in the United States spend on average $9,892 a year on health care, which is 25% higher than the next highest-cost nation. Predatory drug companies, insurance providers, and hospitals squeeze every last dollar in profit possible from the system. As these corporations deliver skyrocketing returns to shareholders, politicians in Washington, D.C. do nothing to help the hard-working families whose budgets are being held hostage.

In less than twenty years, U.S. health expenditures have doubled. Americans are stuck in an inequitable health care system that leaves 28 million people unable to afford insurance and tens of millions more for whom health care costs eat up much of their paychecks.

High costs hold Americans back in very human ways. Every week, older Americans make the tough choice to pay the rent or take their medications. Parents hold their feverish child, wondering if they have enough in the bank to risk an emergency room visit. These choices are unconscionable. The American people deserve a system where everyone has access to quality, affordable, and accessible care without fear.

To give Americans a real choice, Tom supports the creation of a public option. Every American should have the ability to choose the plan that best suits their health care needs. But choice is only meaningful if there are good options available. Tom’s public option will compete aggressively with the insurance companies to drive down costs, expand coverage, and deliver quality health care.

We must reorient our health care systems toward people over profits. Tom’s approach to health care is rooted in his belief that all Americans have the Right to Health. For every American to realize this right, Tom knows we must:

• Control Costs: Ensure Affordable Care and Lower Prescription Drug Prices
• Expand Choice and Coverage: Build a Health Care System for All Americans
• Improve Care: Realize Accessible, High-Quality Care

CONTROLLING COSTS: ENSURE AFFORDABLE CARE AND LOWER PRESCRIPTION DRUG PRICES

It is imperative that our nation addresses the high costs within our health care system and puts in place a sustainable system that invests in keeping Americans healthy.

Control the Costs of Premiums and Deductibles

Tom’s public option will be administered by the Centers for Medicare and Medicaid Services (CMS), which charges a far lower overhead than private insurers, but be fiscally separate from Medicare and Medicaid. It will enable the government to negotiate health care costs directly with medical groups and providers, just like Medicare does today.

Providers wishing to participate in Medicare or Medicaid will be required to also participate in the public option, ensuring both wide acceptance and giving patients the greatest possible choice of doctors and providers. This public option will negotiate with medical providers and drug companies while acting as a tireless advocate for the people enrolled on its roster.

With an affordable, quality public option on the marketplace and available to any individual who chooses it for coverage, the message to private insurers will be crystal clear — compete on cost and quality of care, or lose customers.

OK, a standard Public Option proposal, but as part of a separate risk pool. Negotiating prices for drugs and providers, of course.

Eliminate Surprise Bills

Far too many Americans go to the mailbox and are shocked by a surprise bill. These bills push patients and their families to the financial brink, shake patient confidence in the health care delivery system, and spook sick people from seeking the care they need. They also stress the U.S. economy: every minute, an American declares bankruptcy driven by their medical debt burden. Tom will end surprise out-of-network medical billing by ensuring that emergency room expenses are equitably capped, that all medical professionals on call at an in-network facility accept the insurance that the facility as a whole accepts, that the lab contracted by an in-network facility accepts that facility’s coverage, and that there is a cap on the price of services like emergency ambulances and air ambulances to prevent a medical disaster from sending a person into bankruptcy.

All of which sounds great if it can be pulled off. After the failure of the Surprise Bill package last fall, which had wide bipartisan support, I've grown increasingly pessimistic on this front.

Control Prescription Drug Prices

One of the most egregious costs in the health care system today is the price of prescription drugs. If a company or lab invents a new vital cure, their ingenuity will continue to be rewarded when a new drug is released. But when companies rig high profits through pay-for-delay agreements, price-gouging, or other shenanigans, Tom’s government will boldly enforce consumer protections.

Tom will build on his home state work to increase drug pricing transparency and work to significantly curtail the costs of prescription drugs. He will enable Medicare and the public option to jointly negotiate drug prices directly with manufacturers and extend these negotiated prices to private insurers, saving more than $50 billion per year. He will also benchmark the cost of drugs against international standards and institute a price cap. The plan will also enable Americans to purchase FDA approved drugs from across international borders, advance nationwide pricing transparency, and eliminate the ability of drug manufacturers to expense the cost of advertisements and increase advertising disclosure requirements.

...most of which was already included in H.R.3 which passed the House last fall, of course, yet is going nowhere in the Senate under Mitch McConnell.

Break the Corporate Stranglehold

As a businessman, Tom understands the value of a competitive and innovative marketplace. He knows that choice is a fundamental American value and drives markets to respond to consumer demands. The rules that govern markets must be written by the people, not corporations.

It is time for patients and doctors — not the drug manufacturers or insurers — to be in charge of health care. Industry consolidation has markedly increased the power of individual corporations in the health care sector and has stifled economic competition as unprecedented consolidation in drug manufacturing, insurance, hospitals and pharmacies have reshaped the health care system. For example, in rural areas, hospital mergers have decreased the total number of hospitals, closing more than 160 rural hospitals since 2005. For too long, big corporations have written the rules governing the American health care system. It is time to break their influence on our laws.

Tom pledges to appoint officials within the Department of Justice, Department of Health and Human Services, and the Federal Trade Commission who believe strongly in consumer protection and a competitive marketplace. He will vigorously enforce antitrust regulations and consumer protection laws to ensure the health care system remains a truly competitive and innovative ecosystem. He will also crack down on improper payments and fraud in federal health care programs.

EXPAND COVERAGE: BUILD A UNIVERSAL HEALTH CARE SYSTEM

There have been milestone moments in the quest for a better American health care system. Medicare, Medicaid, and the Affordable Care Act were created to cover the most vulnerable Americans. With each step forward, more individuals were covered and more vulnerable individuals were rescued from the brink of financial ruin and offered access to the care they need. Yet with 28 million uninsured Americans, there is still more to do to approach universal access to coverage.

To achieve this, Tom will:

Protect the key provisions of the Affordable Care Act

The ACA provided needed protections for people with preexisting conditions, enabled young people to remain on their parents’ plan through age 26, and established an open marketplace for individuals and small businesses to purchase insurance. Tom reaffirms these commitments to young people and the more than half of Americans with pre-existing conditions, and he will vigorously fight to prevent rolling back these protections. Tom also firmly believes in consumers’ right to shop for the plan of their choice. Tom proposes that his public option be offered side-by-side with private plans on the open exchanges, allowing any individual to purchase a plan on the exchanges if it fits their needs better than their current employer option.

OK, fair enough...pretty much the same as Biden, Buttigieg, Klobuchar and Bloomberg. Sounds fine.

Expand Coverage for the most vulnerable Americans

4.9 million Americans still lack coverage due to the cruelty of the Republican-controlled state governments that failed to expand Medicaid under the ACA. Tom will immediately offer fully subsidized enrollment in the public option for any qualifying individual who should be covered under an expanded Medicaid.

Tom proposes to automatically enroll uninsured Americans in the public option when they engage with public assistance programs such as unemployment insurance, SNAP, or TANF. Medicaid-eligible patients who have not enrolled but seek care will be retroactively added to the Medicaid roster when they seek care, ensuring no American is scared to go to the hospital. He will also guarantee that every child has access to health care by automatically enrolling uninsured kids through their participation in the free and reduced price lunch program or retroactively enroll once they seek care.

For states that have already expanded Medicaid, they will have the choice to migrate their enrollees — with their financial subsidies— to the public option from their state-run program for their basic health care, provided they still support the many other core services provided to enrollees in the program. Tom also proposes to extend access to the public option to all people who call America home, including the undocumented. Those who contribute taxes also qualify for the premium subsidies.

The result of these reforms is that all low-income Americans within 138% of the Federal Poverty Line will receive full coverage and with zero direct cost for their care.

This sounds great, but it also runs into the same problem that some other "Medicaid Gap solution" proposals have: It effectively penalizes the states which did expand Medicaid while rewarding the states whch haven't done so. If I'm reading this correctly, a state like Florida or Texas which has refused to expand the program for hundreds of thousands of people for over 6 years now wouldn't have to pay a dime into the program...but the states which did the right thing and did expand Medicaid would have to continue paying their 10% of the cost of Medicaid expansion.

I can tell you exactly what will happen if this is how it works: Pretty much every state which has already expanded Medicaid will reverse themselves in order to save that money. Since Medicaid is usually more robust than exchange plans and usually only has nominal cost-sharing at most, this would likely be a worse deal for most Medicaid expansion enrollees. Still, the devil is in the details of course...

Increase Affordability for the Middle Class

For families, out of pocket costs matter most. Controlling overall health care costs is the most essential step to ensure long-term affordability in the health care system. To help families address health care costs, Tom will expand the financial subsidies offered by the ACA.

In the ACA, individuals and families earning between 138%-400% of the Federal Poverty Line who purchase coverage through the marketplace receive a premium tax credit to help defray the cost of coverage. The subsidy is calculated on a sliding scale. Make one single dollar above the threshold, however, and the financial assistance disappears. This “subsidy cliff” leaves middle-class seniors paying upwards of 20% of their income on premiums with no assistance.

Tom will cap the percentage of income any enrollee spends on their care to make this system more equitable. Those making between 138-400% of the Federal Poverty Line would continue to receive subsidies on a sliding scale, and those making above 400% of the Federal Poverty Line would spend a maximum of 8.5% of their total income on their health care premiums. Families would see additional savings as Tom would calculate the premium tax credit value based upon the cost of the gold plan, rather than the silver plan as it is now calculated. This would enable consumers to purchase a lower-tiered plan — bronze or silver — and still have additional funds from the tax credit left to spend on their deductible.

Heh. This is the identical APTC subsidy structure recommended by the Urban Institute, which in turn was used by Hillary Clinton in her 2016 healthcare plan; by the House Democrats in their 2018 "ACA 2.0" bill (though they removed the Gold upgrade last year for reasons too wonky to get into right now); Elizabeth Warren in her Senate "CHIPA" bill; by Joe Biden in his healthcare plan; by Pete Buttigieg in is healthcare plan; by Michael Bloomberg in his healthcare plan; and effectively by Amy Klobuchar in her healthcare plan (she doesn't list the specific formula she prefers, but she's a co-sponsor of Warren's CHIPA bill).

I'm continually fascinated by everyone agreeing that 8.5% at 400% and up is the Magic Formula to go with.

In Tom’s framework, individuals who receive their care through a large employer’s plan could opt into the public option if it is better for their needs. For businesses with greater than 50 employees, there would be a penalty payment to help defray the cost of that enrollee’s plan. Tom would also grow the Small Business Health Options Plan (SHOP) and allow businesses with fewer than 50 employees to opt into the public option or choose to offer the private plan.

This part sounds similar to my preferred bill, Medicare for All, although it's still a Public Option only since private plans would still be available on the ACA exchanges.

IMPROVE CARE: THE RIGHT TO ACCESSIBLE, HIGH-QUALITY CARE

Every American deserves the Right to Health Care. The ability to access the care they need is foundational to our sense of safety and possibility. It is key to our economic prosperity. Tom understands that different communities face different health care needs. For too long, tribal nations, women, veterans, rural communities, people with disabilities, and communities of color have been denied a full suite of health care services.

Through integrated care, improved digital medical record management, accountability for efficient, quality service and outcomes, and coordination between providers, Tom aims to improve the experience of interacting with the health care system. Tom also understands the importance of caring for those who care for us: we must celebrate health care workers and ensure that doctors, nurses, home health providers, and others who dedicate their lives to treating patients have strong workplace protections, a minimum wage of at least $15 per hour, and the ability to organize.

At the same time, Tom will ensure that we address long-standing racial inequities in the health care system; provide access for women’s reproductive health services, including abortion, as a core part of all health plans; will support the Veteran Affairs hospital system and access to affordable coverage for veterans; will ensure the vitality of rural and low income community health care systems by targeting additional resources to rural hospitals, encouraging community health centers, and investing in telemedicine; ensure that every kid in America has access to dental and eye care; and fight the opioid and mental health crisis with billions of additional dollars for new and innovative programs.

Together, we can create a better health care system that delivers better outcomes for patients in terms of physical health, mental health, and social belonging as core metrics of an improved health care delivery system.

***

Tom’s combined suite of reforms will ensure universal access to affordable coverage, while only costing approximately $1.5 trillion over 10 years.

For the record, $1.5 billion is the same amount Pete Buttigieg claims his similar healthcare plan would cost. Joe Biden claims his would only be half that ($750 billion), but I suspect the $1.5 trillion figure is likely to be more realistic.

Overall, it's a solid plan, if not terribly different from those proposed by the other "moderates" in the field.

NOTE: Of the remaining serious candidates, Andrew Yang is the only one whose plan I still haven't done a write-up about, which I hope to correct this week. I wrote about Michael Bennet's "Medicare X" proposal over a year ago (long before he announced his run for President), and I don't think anyone would object if I skipped John Delaney and Deval Patrick. Finally there's Tulsi Gabbard, who's officially a co-sponsor of the House Medicare for All bill, but who also seems to be a bit confused about what's actually in her own preferred healthcare reform bill...