After months on the presidential campaign trail, alleged Democratic frontrunner Joe Biden has finally rolled out just the sort of health care plan everyone expected of him: a marginal improvement upon the Affordable Care Act, pitched explicitly as a safer, saner alternative to Medicare for All. Bidencare would create a public insurance option to be sold on ACA exchanges and distributed at no-cost to Medicaid-qualifying individuals in non-expansion states, as well as remove income caps for premium subsidies. In isolation, such incremental measures would slightly improve the status quo, while leaving intact the most corrosive features of the health care system that Obamacare failed to fix.

The American health care system is a thoroughly complicated colossus plagued by no shortage of problems, but most boil down to this: it’s run as a business, and patients are framed as consumers. This is why hospitals maximize revenue by building fancy new orthopedics wings adorned with philanthropists’ names, why they hire consultants to teach them new billing code tricks to get more money per patient, and why they merge with other hospitals to increase their market power. And what are insurance premiums but rent payments for a ticket into the health care system, each of which comes with its own stipulations and user fees? What is a deductible but a strategy to force customers to foot their own bill for as long as humanly possible?

Rather than upend this dynamic, the ACA made market-based health care slightly gentler by subsidizing poorer patients and halting the more galling practices of the insurance industry, like denying coverage to people with preexisting conditions. But most mechanisms for harm survived: the astronomical price-gouging, the shifting of those costs onto patients themselves, the millions of people locked out of any care at all, tens of thousands of whom will die because of it.