Former Congress member and 2020 Democratic presidential candidate John Delaney poses for a portrait after speaking to patrons during a campaign stop at TC Mae’s restaurant on January 31, 2019, in Fort Dodge, Iowa.

John Delaney has been running for president for nearly two years. Most people haven’t heard of him, and so far, he isn’t getting much traction in the polls.

But the former Maryland Congress member has cooked up one of the more unique universal health care plans of anybody in the 2020 field. Delaney’s plan sticks out for two reasons: He is a former health care financier, so he brings an unusual amount of expertise to the issue, and while his plan is a path to universal coverage, he is going out of his way not to call it Medicare-for-all.

Granted, there are a lot of details Delaney still needs to fill in, but the bones are pretty simple:

Every American under 65 would be enrolled in a new public plan that covers a certain set of basic medical services, comparable to the essential health services covered by Obamacare.

Employers and individuals could purchase supplemental insurance.

Medicare for people over 65 would be untouched.

The plan would be paid for mostly by maintaining the shared state-federal payments for Medicaid and by ending the unlimited tax break for employer health benefits.

I spoke at length with Delaney about his health care proposal; it tells us a lot about the different ways Democratic candidates can think about the issue of universal health coverage and constructing their plans to achieve it. The conversation is below, edited and condensed for clarity and length.

Dylan Scott

Help me understand the most important divergences in your mind between what you’re proposing and what’s in the Bernie Sanders bill.

John Delaney

The most important divergence is the fact that they prohibit any private insurance. That’s not an inconsequential point.

(Author’s note: The latest version of Sanders’s plan does not prohibit any private insurance but does block insurance that would be duplicative of the government-run plan. Supplemental coverage — covering, say, plastic surgery or other elective services — would be permitted. But because Sanders’s plan as written is expansive, it doesn’t leave much room for supplemental coverage.)

If you take a step back and look at health care economics, right now, let’s say the cost of delivering health care is $100; Medicaid pays $80. Medicare pays $95, and private insurance pays $115. If you have the government as the only payer in health care, all the evidence suggests the government will not pay cost. Therefore, no one will invest in health care anymore.

That is just a fundamental market force that will completely, in many ways, explode the US health care system. That’s a big issue, and one that’s not talked about enough. Why would anyone build a hospital? Why would anyone invest in a new surgical care center? Why would anyone go to medical school and incur a bunch of debt? They would never be able to get their cost back. That, to me, is fundamentally bad policy.

If you think about Medicare, which is an incredibly successful program, its success is in part based on the fact that there is private insurance mixed in with Medicare in terms of these supplemental plans. When I do events with seniors and I say how many of you have Medicare, pretty much all the hands go up. When I say how many have a supplemental plan, most of the hands go up. Why do we want to go around most of those supplement plans that are legal?

I think in an effort to try to say I’m gonna move the goalposts further than anyone else, we have created a proposal that actually is really bad economics and also is not what people want.

Dylan Scott

Just to make sure I’m following, the theory being that by maintaining multiple plans, that will dampen the concern that if you have a single plan that pays at Medicare rates, that’s a substantial hit to the health care industry that could lead to less supply?

John Delaney

I don’t think “could” is the right word. I think it will lead to less supply. It’ll lead to less innovation, and it will ultimately lead to limited access. Because when you get less supply, you have less access, and when you have less innovation, you have lower quality, and when you don’t have people investing in industry, you get lower quality.

Whenever I think about health care, I think about three things: access, quality, and cost. In many ways, so much of the health care discussion has been about access. How do we create access? The Affordable Care Act was really about access, and I think it was very successful. I am for, without hesitation, universal access. Every American should have health care as a right of citizenship in this country. You also have to come up with a plan that also creates quality and cost. I think Medicare-for-all, in an effort to make such a strong statement about universal access, they’ve come up with a plan that will be very bad for quality and cost, and then ultimately be bad for access also.

Dylan Scott

The Medicare-for-all theory of the case is if you had a single payer, everybody would accept it because if there’s only one payer in town; you either accept the government plan or you’re not going to have any customers. And by pooling everyone together, you’re going to have such leverage over health care providers in negotiating prices, you’ll be able to bring costs down substantially. That is the explicit goal.

John Delaney

It’s a totally fair point. There’s a byzantine aspect of our health care system right now that, no question, increases cost.

But here’s a simple data point: I think last year, the average reimbursement from a commercial insurance company to a hospital was 200 percent of Medicare reimbursement for the same procedure. So right now, if you’re an administrator of a hospital and I were to say to you, “All of those commercial plan payments are going to come from Medicare and they are going to be half the price. Are you going to be able to keep the doors open?” I think some of them would say, “No, I won’t be able to.” You can bend the cost curve to the point where you lower the quality and access of the system.

There’s a lot of reasons health care costs in the country are high. Part of the reason is individual payment that providers receive; part of is other structural flaws in the health care system. People don’t have enough connectivity to their cost of health care. We allow for completely open-ended formularies. We both consume health care at a very high degree and don’t do a lot of preventive health care, relative to our needs. And then there’s the issue of the per-episode reimbursement. If the only thing you do is cut the per-episode reimbursement, I think you actually hurt access and quality.

If you think about the cost you need to run health care at a high level, you need facilities, you need equipment, you need technology, you need software, you need providers. That’s a fixed cost. Then you have what I call the frictional cost, which is reimbursement, administration, multiple layers of third-party providers and all of that stuff. That’s the stuff you want to try to get out of the system. And I agree simplifying payment would do that.

But if the track record of the government paying health care bills is one where they don’t actually pay cost, we would have to have a bit of a leap of faith that we’ll now have the government pay all the bills and that they’ll actually pay at a higher rate, so there is incentive for people to run this scale health care system at the quality we have in this country.

Dylan Scott

So as I understood it, under your plan, we would create a new public plan that would cover everyone under the age of 65. But it would instead provide a baseline, covering a basic set of certain services. What would this new public plan actually cover?

John Delaney

If you think about the Affordable Care Act’s minimum coverage, that’s kind of what we’re thinking about as a good starting point for this thing.

Dylan Scott

The other feature of the Medicare-for-all bills is they not only expand but improve the Medicare program. There are certainly flaws in Medicare as it exists. You have the need for these supplemental plans. I understand the political calculus, but do you worry that there’s an opportunity lost to do what I think some people believe are some necessary repairs and improvements to Medicare by taking it off the table?

John Delaney

If a Republican was running against Medicare-for-all, they would look at seniors in this country and say, “Let me tell you what these Democrats want to do, they want to take the Medicare that you paid for, yes, you paid for, and they want to give it to everyone else.”

Leave Medicare alone, which doesn’t mean you don’t try to improve it. But it stays as an independent thing. Maybe in 50 years, these programs merge together.

So you start this new program. A basic plan that everyone gets, from when they’re born until they’re 65. We roll Medicaid into this new program.

I think a lot of Americans would also want to buy supplementals. The way it would work is there would be a robust individual marketplace for supplemental plans. But also employers would be able to negotiate group supplemental plans.

So let’s say you have Aetna; once my proposal became law, what your company would do is go to Aetna and say, “I want to negotiate a supplemental plan for my employees.” Aetna would work with the government to basically merge their supplemental into the basic government plan. Aetna would then pay your bills, but they would get reimbursement for part of your coverage through the government plan, which you get as a right and is portable to you.

So you as an employee, the day after we pass our health care plan, your health care actually doesn’t change; how it gets paid for changes. I think that’s incredibly important because most Americans who have commercial insurance are pretty happy with it.

Dylan Scott

But if you have a system with supplemental coverage, there will be some degree of inequality. Certain people will have a more robust health care access, if they have a job with really good supplemental insurance, versus someone who would be only able to rely on your new baseline plan.

So why preserve even a limited degree of inequality versus the argument the Medicare-for-all folks would make, that a version like what Bernie Sanders has proposed would lead to a more truly egalitarian health care system? Because you’ve designed a program that does still maintain some degree of disparity even while trying to achieve a baseline universality.

John Delaney

I think it depends how you measure success. I measure success by everyone in this country having access to quality health care. Does that mean every single person in the country has to have access to quality health care from always the same provider in always the same ways? No. But they have to have access to quality health care as a basic right.

Dylan Scott

This kind of program needs sustainable funding, not just setting it up and not just making the CBO score work, and I know one of the points of pride you have in this proposal is it would be paid for. You propose paying for your plan in part by capping the tax exclusion on employee benefits.

Is that really a reliable revenue stream, given the way your program would presumably shrink the tax base that exists for employer-sponsored insurance, if you only get supplemental insurance through work? And I don’t think we can assume any loss of benefits will translate into wages.

Is it really fair to think of that as a dependable revenue stream that this program could rely on, or is it more of a budget gimmick that makes it sound like this program is paid for, but in reality, this won’t actually bring in the funding you need to keep this program?

John Delaney

I tend to be somewhat cynical about a lot of CBO forecasting. Not that they’re not trying to do their best. But we all know that this notion of dynamic scoring, which is fraught with all kinds of pitfalls, is premised on an idea that’s sound, which is that certain things will change behavior in ways we sometimes can predict and sometimes we can’t.

I think what you’re getting at, what’s gonna change in terms of people’s behavior that will make these static CBO score numbers not relevant. I think it’s a really good question, and I don’t have an answer to it because we haven’t had anyone try to dynamically score it at all.

We’ve looked at static scoring, which I’m the first to acknowledge is a flawed way of thinking, because in the real world, when you actually change things and incentives, behavior does change in ways sometimes you can’t predict. And I think that’s a lot of the work that would have to be done as part of a serious legislative analysis of something like this.

But what I do think is this deduction, this corporate tax deduction, is a really weird system, and there’s a lot of money obviously lost in that. That money would move around and would clearly increase the tax base, and it would generate a lot of revenue.