The public option won’t fix our system
Why the Less Disruptive Health Care Option Could Be Plenty Disruptive
(Ed. note: the original article appeared in 2019, but the arguments remain sound)
The single-payer health plans proposed by Senators Bernie Sanders and Elizabeth Warren are often assailed as being too disruptive. A government plan for everyone, the argument goes, would mean that tens of millions of Americans would have to give up health insurance they like.
Democratic presidential candidates with more moderate brands have their own proposal: a “public option” that would preserve the current private insurance market, while giving people the opportunity to choose government insurance.
A public option would be less disruptive than a plan that instantly eliminated private insurance. But a public option that is inexpensive and attractive could shake up the private market and also wind up erasing some current insurance arrangements. Conversely, a public option that is expensive and unattractive might not do much good at all.
A public option would cover a smaller population at first, and might have to negotiate with hospitals for good deals, just as other insurance companies do. In those circumstances, several economists said, the public option might look a lot like existing insurance: pretty expensive, and covering a limited set of doctors and hospitals.
“What would happen?” said Sherry Glied, the dean of the N.Y.U. Wagner Graduate School of Public Service, and a former health official in the Obama administration. “Almost nothing.” Ms. Glied said that the public nature of the plan, alone, would not do much to distinguish it from private offerings.
Many of the candidates have been vague on key details, like whether the public-option plan would pay health care providers Medicare prices or some other price. They have also been unclear about whether the government itself would offer the public option, or whether it would allow private carriers to operate it.
NYT Reader Comment:
By Don McCanne, M.D.
The worst feature of the public option is that it leaves in place our highly dysfunctional, fragmented system of financing health care which is largely responsible for our very high health care costs through profound administrative waste and inappropriately high pricing.
Merely adding a public option will not repair these fundamental defects in our financing system but would only add one more player to the egregiously wasteful administrative burden.
Switching to a single payer model of Medicare for All would recover hundreds of billions of dollars in administrative waste while also increasing savings through publicly administered pricing (e.g., lowering excessive drug prices).
Also, public financing of the universal risk pool through equitable progressive taxes would finally make health care affordable for each of us. Plus it returns choice to the patients of physicians and hospitals instead of the choice of restrictive health plans.
Tinkering with a public option totally fails to address the actual monumental problems with our health care financing that are causing us so much grief.
NYT Reader Comment:
By Don McCanne, M.D.
Before we decide whether or not a public option health insurance choice is a good idea, we should define the problems with our current system of financing health care that need to be addressed.
Our system is outrageously expensive, at twice the average per capita costs of other nations
Our administratively complex, dysfunctional multipayer system of financing health care wastes about $500 billion per year which would be recoverable under a single payer model
The combination of insurance premiums, deductibles and other cost sharing creates financial hardships and makes health care truly unaffordable for too many individuals and families
The very high costs of health care now exceed the ability of even middle-income families to meet their proportionate share of costs of plans in which they may be enrolled, at the same time that income and wealth inequality have left too many unable to meet the costs of basic needs – a problem that requires equitable funding (progressive taxes)
Even with basic guaranteed benefits, too many plans leave out coverage for important essential health care services and products
Pharmaceuticals remain outrageously priced, often impairing access to essential medications
Most plans use restricted provider networks, limiting choice of physicians and hospitals, while assessing penalties for out-of-network care
Changing eligibility for various insurance programs based on employment or income or residence or age is disruptive to health care
A well designed single payer model of Medicare for All would correct all of these serious deficiencies in our current health care financing system. Which of these defects would a public option correct? None of them!
So what defect in our financing system would a public option correct? Primarily it would provide one more choice in the market of individual private plans, which didn’t seem to be a problem that was looking for a solution, especially when the optimal solution would provide a single, comprehensive plan for everyone.
The media tell us that polls say that we would rather have the choice of keeping what we have or choosing a Medicare-like option (which is not at all like Medicare) instead of everyone being forced into a single, government-run Medicare for All program. But how many of the respondents are taking into consideration the current health financing deficiencies listed above when they answer the questions posed? Almost none.
Let’s write the poll question they should ask: Would you prefer to continue our current system characterized by (list all of the defects above) with the option of being able to buy another similar individual insurance plan except that it is run by the government, or would you prefer to have automatic comprehensive coverage for life paid for with taxes that you can afford? Oops, lost them one-third of the way through that list. It’s complicated, but the public is being trained to respond with the meme, “I’d rather have the right to choose Medicare if I want it,” not realizing that it’s Faux Medicare they are choosing.