Bernie Sanders

During his presidential campaign, Vermont Sen. Bernie Sanders called for "Medicare for all."

(Jacquelyn Martin)

Medicare for all. Every Bernie Sanders voter knows what that phrase means.

"Health care must be recognized as a right, not a privilege," the Vermont senator has declared time and again.

"Bernie's plan would create a federally administered single-payer health-care program," his campaign website states. Sanders insists his plan, which would completely sever health insurance from employment, would save the typical middle-class family more than $5,000 per year. It would also cost, the Sanders team estimated, $1.38 trillion per year, to be paid for by employers and various new taxes on the wealthiest Americans.

The problem for those who like this idea is that Sanders will not be the next president of the United States. And Obamacare, which Sanders calls a good start but not a solution, is struggling.

Aetna announced this week that, with a few exceptions, it would no longer participate in Obamacare exchanges run by individual states. The health-insurance powerhouse is following UnitedHealth and Humana out the door, leaving some state exchanges on, well, life support. Blue Cross and Cigna have also indicated they might get out too.

What's the answer? Many left-leaning health-insurance experts and pundits say there's only one way to save President Barack Obama's signature domestic-policy achievement: the public option.

"Big commercial insurance corporations continue to put profits before patients' health, which is why Hillary Clinton's call for a public-insurance option so that everyone in every exchange in the country has a choice of an affordable option is more essential than ever," Roosevelt Institute senior fellow Richard Kirsch declared this week through the Progressive Change Campaign Committee.

Hillary Clinton

A "public option" might sound familiar, because it was originally part of the Affordable Care Act, before centrist Democrats killed it at the eleventh hour. Writes Yale University professor and long-time public-option advocate Jacob Hacker: It is "not 'Medicare for all,' a dream of the left for decades, but 'Medicare for more,' a public-insurance plan for working-age people that could compete with private insurers and use its bargaining power to push back against drugmakers, medical-device manufacturers, hospital systems and other health-care providers." In short: it would offer single-payer benefits without all the socialist-bogeyman baggage.

President Obama, recognizing that his health-reform ideal is foundering in practice, has called for a renewed debate on the public option. "Now, based on experience with the ACA, I think Congress should revisit a public plan to compete alongside private insurers in areas of the country where competition is limited," he wrote last month in the Journal of the American Medical Association.

As Kirsch indicated, Clinton, who defeated Sanders in the Democratic presidential primaries, agrees. This is not the pragmatic Hillary buckling under to Sanders' progressive wing of the party. She's been in favor of a government-run insurance option, in one form or another, going back to "Hillarycare," when her husband's administration failed to push through health-care reform in the early 1990s.

Hacker, writing on the Vox website, argues that the public option would make the health-insurance system more efficient (building on the way that Medicare simplifies the pricing process -- paying hospitals, for example, on "initial diagnosis" rather than on every single service provided) and would help make universal coverage a reality. "[T]he public option is one of those policy ideas that hits the trifecta: simultaneously simple, popular and effective," he writes. "It's not the be-all and end-all of reform, but it would make a big positive difference." (Read Hacker's in-depth case for the public option.)

The politics of the issue, of course, haven't gotten any easier. Big health-insurance companies are losing millions of dollars in the exchanges, and at the same time they have good reasons to resist a government-run option that would likely stabilize the business at the lower end of the market. (It would, for starters, attract new, specialized players into the game, and even red-blooded American companies don't actually want competition if they can avoid it.) The Aetnas and Humanas of the insurance world, needless to say, remain lobbying behemoths.

"[E]ven if Clinton wins and the Democrats take back control of Congress in November, a public option remains a political long shot," NPR wrote in July.

There hasn't been much discussion so far in these early days of the general-election campaign about how to improve Obamacare (or even how to "repeal and replace" it, as Republicans would like to do, chiefly through tax credits for individuals and allowing greater flexibility for insurance companies).

But this much is undeniable: The Affordable Care Act is at a crossroads. Whether it's a featured topic in the fall presidential debates or not, it's going to end up high on the agenda of the next president and Congress.

-- Douglas Perry