Joe Biden is taking an aggressive approach to defending the Affordable Care Act, challenging not just President Donald Trump but also some of his rivals for the Democratic presidential nomination who want to replace the current insurance system with a fully government-run model.
The former vice president has spent the past several weeks highlighting his support for the health care law often called "Obamacare." He told voters in Iowa that he was "against any Republican (and) any Democrat who wants to scrap" the law. He's also talked of "building on" Obamacare.
He released a proposal Monday to add a "public option" to the 2010, paying for expanded coverage paid tax increases on the wealthiest Americans. Returning to Iowa, he touted the public option as "the quickest ... most rational way to get universal coverage." A sudden transition to "Medicare for All," he said, "is kind of risky."
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Biden hopes his positioning as Obamacare's chief defender will remind voters of his work alongside former President Barack Obama, who remains popular among Democrats. And it could reinforce his pitch as a sensible centrist promising to rise above the strident cacophony of Trump and more liberal Democrats who are single-payer advocates.
The emerging divide between Biden and his progressive rivals could allow him to go on offense ahead of the next debates at the end of the month. Biden spent recent weeks on defense, reversing his position on taxpayer funding for abortions and highlighting his long-ago relationships with segregationist senators. During the first debates, Sen. Kamala Harris of California slammed Biden for his Senate recollections and his opposition to federal busing orders to desegregate public schools during the same era.
Those episodes called Biden's front-runner status into question, and it was clear over the weekend that he wanted to turn the tables on his rivals backing Medicare for All.
"I think one of the most significant things we've done in our administration is pass the Affordable Care Act," Biden said in New Hampshire. "I don't know why we'd get rid of what in fact was working and move to something totally new."
He argued that his 2020 opponents, with the exception of Sen. Bernie Sanders of Vermont, aren't fairly representing the consequences of their proposals.
"Bernie's been very honest about it," Biden said. "He said you're going to have to raise taxes on the middle class. He said it's going to end all private insurance. I mean, he's been straightforward about it. And he's making his case."
Sanders will deliver a health care speech Wednesday and is already hitting back at Biden. The senator insists his plan would be a net financial benefit for most households by eliminating their insurance and co-pay costs, even if their taxes go up. And he rejects any suggestion that he hasn't supported the Affordable Care Act.
"I traveled all over the country to fight the repeal of Obamacare," Sanders tweeted Monday. "But I will not be deterred from ending the corporate greed that creates dysfunction in our health care system. We must pass Medicare for All."
Speaking at an AARP forum in Iowa on Monday, Biden took pains to say he wasn't criticizing rivals. "I'm about what I'm for, not what they're for," he said. "I'm not in that game because that just elects Donald Trump."
Biden's health care proposal is anchored by a "Medicare-like" plan that any American, including the 150 million-plus Americans now covered by job-based insurance, could buy on Affordable Care Act exchanges.
The proposal would make existing premium subsidies more generous and expand eligibility for middle-income households, lowering their out-of-pocket costs. It also would extend premium-free coverage to lower-income Americans who have been denied access to Medicaid in Republican-run states that refused to participate in the Affordable Care Act.
The campaign puts the taxpayer cost at $750 billion over 10 years, which would be covered by returning the top marginal income tax to 39.6%, the rate before the 2017 GOP tax cuts . Some multimillionaires also would lose certain capital gains tax advantages.
Biden's aides framed his plan as more fiscally responsible and politically realistic than a single-payer overhaul. The idea behind a public option is to extend coverage to those who can't afford decent private coverage while forcing corporate insurers to compete alongside the government, theoretically pressuring those firms to lower premiums and out-of-pocket costs for their customers.
The former vice president did perhaps lay for himself a future trap as he drew distinctions with proposals that would gut private insurance. "I'd like to get people the option: If you like your health care plan, or your employer-based plan, you can keep it," Biden said. "If in fact you have private insurance, you can keep it."
It was reminiscent, at least rhetorically, of Obama promising during the 2009-10 debate: "If you like your doctor, you can keep your doctor. If you like your health care plan, you can keep your health care plan."
Indeed, the law did not directly force patients away from their doctors. But regulatory changes did lead insurers to change or cancel certain policies, even if they had to offer consumers new options; and health care providers left certain networks without consumers having a say.
At the least, the 2020 campaign dynamics illustrate Democrats' overall leftward shift on health care.
A decade ago, the public option was the left flank for Democrats, a reality made obvious when Obama angered House liberals by jettisoning the provision to mollify Senate centrists. Now, after Sanders' insurgent 2016 presidential bid and his promise of "health care as a human right," the left embraces single-payer, with moderates moving to the public option.
Some Democratic presidential hopefuls echo Biden's approach, with a handful of them sounding alarms about moving too far left and allowing Republicans to reclaim the health care advantage Democrats enjoyed in the 2018 midterms.
Colorado Sen. Michael Bennet, who's pushed a public option on Capitol Hill already, urged Sanders, Harris and Sen. Elizabeth Warren to rethink their approach, which he warned would put Democrats in peril in 2020, even in his increasingly liberal home state.
Citing Medicare for All, Bennet declared, "I think that Colorado would be at risk if Bernie Sanders were the nominee."