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After spending a few days lying about Medicare for All, Joe Biden has released his big plan to improve health insurance. As you might expect from a guy who held his first fundraiser with a board member of the health insurance companies’ lobbying group in Washington, and whose frontrunner status was seen as a good thing for managed care stocks, his plan ain’t good.



The basic structure of the plan is to create a public option for health insurance, which would also be offered premium-free in states that didn’t expand Medicaid. It would also allow Medicare to negotiate drug prices, allow individuals to buy drugs from other countries, and reform the Affordable Care Act marketplace to limit premiums.


There are massive gaps in the plan as released so far. The words “undocumented” and “immigrants” don’t appear anywhere on the page. Though a campaign official told Politico that undocumented immigrants would be newly eligible to purchase healthcare on the marketplace, they wouldn’t be eligible for the subsidies that make those plans at all affordable. An undocumented immigrant in New York City, for example, would face a monthly premium of $587 this year for a silver plan, regardless of their income.

There’s nothing about narrow networks, except a plan to stop surprise billing. Fifty million Americans are uninsured at some point throughout the year, losing insurance for reasons including job loss or turning 26 and losing their parents’ coverage. What does this plan do to stop that? Likewise, the average deductible for employer-provided plans with deductibles is now $1,573, though millions more face deductibles in the region of $6,000. What does Biden’s plan do to stop this?


Indeed, the only reference to deductibles in the plan comes in the form of explaining how lowering premiums will allow Americans to purchase better health plans with lower deductibles. But this only refers to the individual marketplace, where only 11.4 million Americans get their healthcare. It would do nothing for the roughly half of Americans who have employer-provided insurance. Though some employers are moving away from high-deductible plans, the deductibles themselves keep going up: The Kaiser Family Foundation found that a quarter of workers have deductibles of more than $2,000 for single coverage. Eleven percent of the 156 million people who have employer-based coverage have deductibles of more than $3,000, meaning significantly more people (roughly 17 million total) have deductibles of more than $3,000 than would even be affected by the marketplace reforms that Biden proposes, to give you perspective on how limited this is.

But what of those marketplace reforms? Well, if you buy your plan on the marketplace and your premium is too high, you’re in luck: Biden’s plan would lower the cap on the percentage of income your premium can be from 9.86 percent to... 8.5 percent. Remarkable! Breathtaking! The limitations in Biden’s plan are everywhere: It promises that with better premium tax credits, “many families will see their overall annual health care spending go down.” Wow! Many families? That’s more than some!

Biden’s plan would also allow people with employer-provided insurance to purchase the public option instead. But without knowing how public option prices would be set, whether there would be deductibles and how much those would be, and what drug prices would be, it’s impossible to know whether it would even be worth switching from your employer’s plan. It’s hard to imagine that there wouldn’t be deductibles at all. As it stands now, Medicare has a $1,364 deductible for hospital stays. That isn’t even annual; it resets after a patient hasn’t been in the hospital for 60 days straight.

The cracks in Biden’s prescription drug plan are also immediately visible. Look at this:

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.


First, it’s weird that he even distinguishes between generics and “abusively priced” generics. If the plan is intended to stop abusive price increases, shouldn’t you just be able to say... Generics? What counts as abusively priced?

Second, Biden seemingly can’t decide what he actually wants to do about this problem. The plan says these drugs (only on Medicare and the public option, of course) would be “prohibited” from increasing prices more than inflation, but it also says that it will impose a tax penalty on companies that do that. So is it prohibited, or is it punished with a tax penalty? Last year, according to NBC News, drug manufacturer Eli Lilly paid effectively no taxes. Do we think they’ll feel whatever little tax penalty Joe Biden imposes on them?


But the most egregious part of the plan, as Matt Bruenig has already pointed out, is the fact that it explicitly maintains a “class of uninsured people.” Absurdly, under the heading “Give every American access to affordable health insurance,” the plan says it will “insure more than an estimated 97% of Americans.” Well, that’s not every American, is it, Joe? Or does he think that final three percent are just stubborn libertarians who will simply refuse health insurance despite having that prized access to affordable care?

As Bruenig noted, using the Center for American Progress’ estimate of the number of unnecessary deaths caused by uninsurance, Biden’s plan to maintain almost 10 million uninsured Americans will cause 125,000 unnecessary deaths in its first 10 years.


The fundamental idea behind this strategy is that Medicare for All is simply too hard, politically speaking; Biden said his plan “can be done quickly,” unlike Medicare for All, and supporters of the public option always talk about how much easier it would be.

But look at today’s Republican party and think hard. Do you see any of them getting on board with even something as limited as allowing Medicare to negotiate drug prices? Are they going to be cool with repealing the Trump tax cuts, which is how Biden promises to pay for his plan? Will they even back a public option, something both they and conservative Democrats ardently opposed 10 years ago when the Affordable Care Act was debated?


No. Because what they want is fundamentally different from what Joe Biden wants, which is what he has always failed to accept. This reality doesn’t make Medicare for All any easier to pass, but it does mean that there’s little point in crafting a plan designed to placate Republicans at all. They don’t want anything to get better.

This is why the only candidates worth listening to are the ones who offer serious, systemic critiques, who talk about things like filibuster reform and packing the court—and who, for Christ’s sake, don’t talk about how Republicans will have a fucking epiphany and realize how bad they are. The path to providing healthcare—for every American, not just 97 percent of them—involves decimating the political power of Republicans. You certainly don’t build that movement by promising people that their health insurance will cost 1.36 percent less than it used to.


Biden’s plan is emblematic of the kind of weak policy ideas that Democrats have limited themselves to for decades. It is a cobbled-together mess of tax credits, complicated income calculations, and half-promises. It’s yet another example of Democrats coming up with convoluted ways to avoid doing what needs to be done: promising to provide free care to all Americans, regardless of income or immigration status.

Correction, 12:56 p.m. ET: This post initially identified the source of the Biden campaign statement on coverage of undocumented immigrants as the New York Times. The source was Politico.