Tonight is the final Democratic debate before the hugely influential Iowa caucuses on February 3 and there's, uh, a lot of news the candidates could talk about. Most of it is worthwhile (possible war with Iran, the terms of Trump's impeachment trial), some of it not (Mom and Dad are fighting). But there's one story that hasn't gotten much attention, and voters in Iowa and across the country deserve for it to get more air time: Former South Bend Mayor Pete Buttigieg is proposing a very messy health insurance plan.


Much of the primary has consisted of the Democratic candidates sparring over how to move forward from Barack Obama's Affordable Care Act, which was landmark legislation but far from perfect: 10 years later, 28 million people still don't have health insurance (that number has increased under the Trump administration). The progressive wing of the party supports ending for-profit insurance companies and funding universal health coverage through taxes (hello, Medicare for All), but moderates like Buttigieg, Joe Biden, and Amy Klobuchar don't want to shake things up that much—they claim that it's more practical to keep the insurance companies around but also offer a government-run insurance that people can buy if they chose (this is called the public option). In a feat of centrist branding, Buttigieg calls his plan "Medicare for All Who Want It."

But of those three moderates, only Buttigieg claims his plan will guarantee that every person in America has insurance while still preserving people's "choice" of a private plan or the public option. How does PeteCare pull this off? By automatically enrolling anyone without insurance in the government plan and then back-billing them, potentially via tax filings, for a year's worth of coverage, which could be thousands of dollars.

The Washington Post noted this "retroactive enrollment" provision in a story published on Christmas Eve (it's mentioned on page 4 of the campaign's white paper). The Post compared it to the penalty for not having insurance under the Affordable Care Act, which was $695 or 2.5 percent of income, whichever was higher, paid when people file their taxes. Under Buttigieg's plan, people who are retroactively enrolled would owe up to 8.5 percent of their income, because that's the upper limit for monthly premiums under Pete's plan.


Let me repeat that: People who don't get insurance from work or choose not to proactively buy the government plan wouldn't merely be paying a fine, they'd be paying an entire year's worth of premiums for coverage they may not even know they had. As in, you could go all year without using any health insurance, because you thought you didn’t have it, and then owe thousands of dollars at the end of the year. Buttigieg has repeatedly characterized his plan as a "glide path" to achieving full Medicare for All, but retroactive billing could very well be a large pothole in the runway.

Matt Bruenig, head of the left-leaning People’s Policy Project, told the Post: “Instead of paying a $695 fine at the end of the year for being uninsured [as Obamacare required], you are hit with a bill to pay an entire year of premiums that could be ten times that amount. This will be a political nightmare.”

This tidbit was then picked up by Slate and the Wall Street Journal but the former mayor has not yet had to address this on a debate stage. He's in the top three in two recent Iowa polls.

A spokesperson for the Buttigieg campaign said in a statement that back-billing is a feature not a bug—it's how the plan achieves universal coverage. Otherwise, people would just wait until they're sick to sign up.

Besides, the spokesperson said, people are getting something for their money, which distinguishes owing past premiums from the penalty under Obamacare. You're getting coverage in return for your payment, they said.

The "coverage" under PeteCare is that, should people who didn't enroll in the plan go to a doctor, their provider will get reimbursed via what the Buttigieg campaign calls a "backstop fund." That arrangement really only counts as coverage if people know they can see a doctor without having to pay—which presumably they would not know, since no one would actively choose to get billed up to 8.5 percent of their paycheck at the end of the year.


Here’s the other thing: The government collecting taxes in exchange for paying for healthcare, while people pay next to nothing out of pocket, seems like an altogether easier solution than having people pay premiums for a government plan, either in advance or retroactively via Pete's backstop fund. As Libby Watson at the New Republic deftly summarized: "Isn’t this just a very convoluted way of providing government insurance to anyone who—stay with me—wants it?" Pete's plan twists itself into a pretzel in order to be able to tell people they still have a "choice."

Watson also noted that the plan doesn't outline at what rate doctors would be reimbursed from the "backstop fund" and if providers would chase down the uninsured people for the difference between that rate and whatever they'd charge someone with private insurance.

PeteCare has a lot of unknowns. Even the Post acknowledged last month that Buttigieg has gotten a relative pass on this front:

Buttigieg’s health plan has gotten less attention than the Medicare-for-all proposal supported by Sanders and Warren but may garner further scrutiny in the coming weeks as voters seek more information about the moderates vying for the Democratic nomination for president.

The moderators of tonight's debate—and even the other candidates—would do voters a service by bringing it up.