WASHINGTON — America's health care debate has been called an unhealthy political obsession. But if the 2016 presidential hopefuls have any say, it's about to get bigger.
The candidates in both parties are offering options across the political spectrum, from a system wholly run by the federal government to dialing back Washington's commanding role. Behind the rhetoric, each approach has its pitfalls.
On the left, part of the appeal of Vermont independent Sen. Bernie Sanders is his years-long advocacy of "single payer," a tax-supported, Medicare-like plan for all. The idea is in the political DNA of liberals, and Sanders as president would lead a movement to make it happen, his campaign says.
On the right are the Republicans, united on repealing President Barack Obama's health care law, but unable to agree on what should replace it. They wouldn't stop with the Affordable Care Act, either. Republicans also want curbs on Medicaid, to reduce spending and let states, not Washington, set the tone. Medicaid covers low-income and disabled people.
In the middle — if one still exists on such a polarized issue — is Democrat Hillary Rodham Clinton. She would keep the basic structure of Medicare, Medicaid and the Obama health law while making incremental changes.
"The only person not in favor of 'repeal and replace' is Hillary Clinton," quips Republican economist Douglas Holtz-Eakin. "There is a debate being presented to the American people: Do you want to go further left, or do you want to go in the direction conservatives are advocating? The person who is basically arguing for the status quo is Hillary Clinton."
This week Clinton proposed repealing an insurance tax in the health law that's opposed by unions and big business but seen by experts as a needed brake on costs. She also wants to curb prescription drug prices and limit insurance cost-shifting to consumers.
A look at the three approaches, and their potential drawbacks:
If Sanders keeps gaining traction, the wonkish term for a government-run health care system could become a household word. His supporters say Obama's hard-fought health overhaul hasn't done nearly enough.
"People are still one illness away from becoming bankrupt," said Dr. Deb Richter, who practices near Montpelier, Vermont, and focuses on addiction treatment. "Obamacare was hyped as this savior, and it has not been that."
Supporters say having the government take charge of health care finances would slow the growth of spending, keep things affordable for patients, and improve overall quality.
A major pitfall is the switch from employer-based and private coverage to the single-payer plan. Money that employers and individuals now pay for premiums would have to be diverted to government coffers — a massive tax increase.
"It's a dead end," said Princeton sociologist Paul Starr, a historian of the U.S. health care system. Supporters "don't face up to the significant tax changes that would be necessary."
Repeal and replace
The Supreme Court upheld Obama's law, and the president won re-election in 2012. That didn't settle the debate, but 2016 may.
"For Republicans it's their last chance to litigate the Affordable Care Act," said Jim Capretta, an expert on entitlement programs at the conservative Ethics & Public Policy Center in Washington. "If they lose the election, the ACA is likely to become even more entrenched."
"Repeal" is a winning issue with the GOP's political base, but the "replace" part gets tricky because Republicans don't agree on an alternative. In the general election, the GOP counterproposal will be measured against the health care law's progress in reducing the number of uninsured. A plan that repeals federal mandates and reduces insurance subsidies would probably leave more people uncovered.
Republican front-runner Donald Trump says his replacement plan would be different. He'd make sure everybody in the country is covered, something not even Obama accomplishes. Trump says he'd make a deal with hospitals, and most people would still have private coverage.
"There is not nearly enough to go on from Trump's statements to assess what he actually has in mind," said Capretta.
But the biggest pitfall for Republicans could be Medicare, not "Obamacare." The party has previously advocated privatizing the insurance program for older Americans. In 2016, that would be asking for trouble.
"Seniors have been tilting Republican in the last elections," said Robert Blendon, a public opinion expert at the Harvard T.H. Chan School of Public Health. "The only thing that could get them to tilt the other way is a Medicare proposal."
Hillary Clinton established her credentials on health care in the 1990s, although she and her husband, then-President Bill Clinton, failed to pass the overhaul legislation they proposed. She lost the 2008 Democratic nomination to Obama, but he adopted key parts of her health plan.
This time, Clinton is promising to build on Obama's coverage expansion and smooth its rough edges, while keeping Democrats' traditional commitment to Medicare and Medicaid.
The drawback is that Clinton's middle way may be seen as uninspiring. "I think there is a hunger among Democrats to see something more happen," Blendon said.