Dan Gorenstein: It’s Week 2 of our special series on health policy and the 2020 election.

After a week exploring President Trump’s record, we now turn to the plans of his opponent, former Vice President Joe Biden.

First up, what impact would Biden’s plan to expand on the Affordable Care Act have on one of our country’s most persistent problems: 30 million Americans uninsured before the pandemic and more than 40 million more underinsured?

From the Annenberg Studio at the University of Pennsylvania, I’m Dan Gorenstein, this is Tradeoffs.

Joe Biden: I introduced a plan to build on Obamacare.

Biden: Building on Obamacare.

Biden: Building on the Affordable Care Act.

DG: If you had to describe Joe Biden’s plans on coverage in one word or phrase, what would it be?

Christine Eibner: It’s really about shoring up the Affordable Care Act.

DG: Christine Eibner is a senior economist at the RAND Corporation who has researched health policy reforms for more than a decade.

CE: So we’re not talking about a major transformation or a move to a new health care system. This is about ensuring the affordability of existing options and closing some gaps that were left when the Affordable Care Act was enacted. 

DG: What are the big holes and shortcomings Biden is aiming to fix with his health plan?

CE: Well one big hole is the issue that there are about 4.5 million people who are uninsured who would’ve been eligible for Medicaid had their states expanded, and so Biden’s plan aims to provide an option for that group. In addition, even for those who have access to insurance, many find it unaffordable, and Biden’s plan aims to shore that up by reducing both premiums and the out of the pocket costs people will face.

DG: So really Biden has three plans to address these and other holes, right? 

One: a public insurance option that would be available to just about anyone.

Two: expand the pool of people eligible for ACA subsidies and increase the size of those subsidies.

And three: lower the eligibility age for Medicare from 65 to 60.

CE: That’s right.

DG: Alright, Christine, on today’s episode, we’re borrowing from one of our favorite shows and do health insurance reform in three acts plus an epilogue. 

Stay with us.

I’m just kidding. 

DG: Act I: The public option. 

Biden: I’ve added to the Obamacare plan, the Biden initiative, which is a public option

Biden: Public option.

Biden: We need a public option, now more than ever.

DG: Christine, first, just explain in a sentence or so, what is a public option?

CE: A public option is a government-run health plan that would compete with private insurance plans such as those offered by companies like Aetna, BlueCross, UnitedHealthcare. 

DG: Right, and Biden has said his public option would be “like Medicare” — negotiating lower prices from hospitals and doctors — but the former Vice President hasn’t offered any details beyond the one paragraph you can find on his website.

We reached out to his campaign several times but didn’t hear back.

Christine, you’ve modeled what would happen if a version of a public option was introduced. How many people did you find would gain coverage as a result?

CE: We have found that the increase in coverage could range anywhere from 100,000 to as much as 3 million. And that’s a pretty large range partly because some of these details still need to be clarified. So one important question is, how much leverage is the federal government really going to bring to reducing prices? So if they bring stronger leverage and premiums get much cheaper, that’s when we see something closer to 3 million. If they don’t, and it’s just a little bit cheaper than a private option, then maybe not as much of an effect.

DG: So when it comes to the public option, it would also have some effect on Medicaid too, right, Christine?

CE: That’s right, so those 4.5 million people who remain uninsured because states didn’t expand Medicaid, Biden would offer the public option for free to this group and take aggressive steps to get them enrolled.

DG: Act II: Subsidies.

Subsidies are one of the wonkiest parts of health insurance, and Biden’s plan talks a lot about them. 

So first some basics: An ACA subsidy is effectively the federal government picking up a chunk of the monthly premiums for most of the roughly 11.5 million people who buy insurance on the exchanges.

They’re calculated based on people’s income and the price of a mid-level insurance plan where they live.

The less you make, the more the government picks up.

At a high level, Christine says Biden wants to make these government subsidies more generous and available to more people.

CE: So right now the subsidies are only available to people with incomes below 400% of the federal poverty line. That’s about $100,000 for a family of four. Biden would eliminate that cutoff. 

DG: Another part of this is just trying to make insurance cheaper, helping, in part, the more than 40 million Americans who are underinsured, according to the Commonwealth Fund. 

CE: The subsidy is currently pegged to the value of a medium generosity or so-called silver plan on the health insurance marketplaces. Biden’s plan would peg the subsidy to a gold level plan, which is more generous. And it would enable people to purchase more generous health insurance options that have lower deductibles or lower out-of-pocket costs.

DG: And finally, Biden would boost subsidies by lowering the maximum amount of a person’s income that they’d be expected to put toward their premium.

CE: The maximum percentage contribution is about 9.5%. That would fall to 8.5% of income under the Biden plan.

DG: It sounds like this would go a long way to expanding coverage, reducing the 30 million uninsured. Is that what you found?

CE: Well not necessarily. So our best estimate is that this would increase the number of people with insurance by about 2.4 million. And so a lot of the effect of a proposal like that may be helping people who already have insurance coverage in that their premium payments become lower, but it’s not necessarily bringing new people onto the market.

DG: Quick little footnote before we move on: Remember when we were talking about the public option? If the public option passed and ended up influencing that benchmark plan, which dictates the value of the subsidies, some consumers could end up seeing smaller subsidies.

DG: Act III, a super short one, Medicare. 

DG: Ok, Christine, finally, let’s turn to Biden’s plan to lower the Medicare eligibility age from 65 to 60. Is this likely to make much of a dent in the uninsured rate?

CE: Well, the issue with this reform is that there’s really a finite population of people who are between the ages of 60 and 64 who don’t have health insurance coverage. So a recent estimate from the Census Bureau suggests that there are only about 1.6 million people who are uninsured. So there’s a limit to how far this policy can go.

DG: This brings us to our epilogue: putting Biden’s plans into context. 

The Biden campaign has made a particular point of saying their health care proposals are going to really help communities of color. Based on the research, should we expect large numbers of people of color to gain insurance through these proposals, Christine?

CE: So one of the features of the Biden plan would provide the public option for free to people who are in that Medicaid expansion gap. 

Biden: Are you eligible now for Medicaid? Well if you are, you’re in. Come one, nothing, free, move, we’ll move you in. 

CE:  So that’s that 4.5 million people who would have been eligible for Medicaid had their states expanded the Medicaid program. We know from prior literature that states that expanded their Medicaid programs saw a bigger decline in both the Black-white insurance gap and the insurance gap between whites and Hispanics. So if that follows through to allowing this population to enroll on the public option, it may further reduce those gaps.

DG: Joe Biden says the price tag for his health care package, including these three big pieces would be about $750 billion over the next decade. Other estimates have put it a shade higher and a lot of it depends on variables like how much the federal government would pay doctors and hospitals under the public option plan, a total unknown right now. 

So, Christine, I guess, the real question here is what  impact would that $750 billion in new spending have on overall federal health care spending? 

CE: Well, currently, the federal government spends about a trillion dollars a year on health care. And so $750 billion over a ten year period is a relatively small increase. I mean, we’re talking less than 10% a year on an annualized basis.

DG: At least one group has estimated that Biden’s plan might push total U.S. health care spending — what everybody pays — up or down a little. But when you think of a 7 or 8% increase in federal spending per year, what would actually we get from that?

CE: You know, the most optimistic estimates are saying you’re 15 to 20 million people could get insurance through this plan. Now, some other estimates are lower, and a lot depends on some uncertain elements that haven’t been fully specified yet. And then beyond that, there’s the issue that health care may become more affordable for some people through this plan.

DG: Right. So you’re saying is millions more people would get insurance, but not all, not the full 30 million. And of the estimated 40 million more who are underinsured, some percentage of those folks would have an easier time affording and meeting their health care needs.

CE: That’s right. 

DG: And what would it take to get all the way? Is there anything short of Medicare for All, which Biden has opposed, that would fully insure those 30 million people? 

CE: Well, there’s always going to be a challenge with covering the undocumented population because that group currently is not eligible for any of the coverage reforms on the table. But beyond that, I think the only other thing to do is a really aggressive form of the individual mandate that has serious penalties attached to not being insured. At some point it requires a little bit more of an aggressive push to try to bring people in who have decided not to purchase insurance for whatever reason.

DG: The problem Joe Biden is trying to solve — making it easier for Americans to access care — has been around for generations.

President Harry Truman: I have repeatedly asked the Congress to pass a health program. The nation suffers from lack of medical care. .

DG: President Truman tried to address it and Nixon, too

President Richard Nixon: We will establish a new system that makes high-quality health care available to every American in a dignified manner and at a price he can afford.

DG: Biden’s solutions are also nothing new. 

President Bill Clinton: People between the ages of 62 and 65 would be able to buy into the Medicare program.

President Barack Obama: One of the options in the exchange should be a public insurance option.

DG: Same problems. Same solutions. The question is, would Joe Biden be able to get a different result if he became president?

I’m Dan Gorenstein, this is Tradeoffs.