Is A Public Option Enough?

Saw a tone-deaf Joe Biden ad on Twitter where he talks to a retired union worker who wants to keep her private health insurance. Of course, it irked me. Then I looked into Biden’s health care plan and it’s… ACA plus a public option.

Is there any reason to prefer Medicare for All to a public option? Because, in a lot of ways, all I want is the choice.

If having that choice compels my private insurer to lower premiums and increase benefits, great! If I can save money and get better care through the government, equally great. If the public option wrecks private insurance by outcompeting it, fine. If private insurers manage to compete, also fine.

I’m still voting for Warren but am I missing something when I say that I can not only live with Biden’s plan but kind of like it?

If a public option has lower premiums because it pays less to providers, private insurance will be popular by extending to providers and networks that do not take the public version.

To the extent cash flow through private insurance is reduced, profits would also be, but the largest insurers are non-profit or a hybrid, I think (Blue Cross non-profit and Kaiser Permanente a consortium of the two types). But employment might be affected only slightly, as the number of claims might be roughly constant, thus the amount of work also.

One advantage to the concept is its capacity of being brought into application gradually, starting with eligibility at 55, for example, and moving it lower on a schedule. Because it would be less that total coverage, it could start with modest reach and over time increase.

This is harder to sell to revolutionaries but easier to sell to the middle and those not wanting large-scale upset. That would be pretty much all business, and many of the employees of those businesses. My layman’s guess is there are more of those voters than the Medicare-for-All enthusiasts.

That question, it seems to me, is too low a level of abstraction at which to start. Logically working one’s way down the ladder of abstraction tends to clarify the issues quickly.

Do you know how/why you arrived at this binary question? What caused you to eliminate all other possibilities?

Because I’ve been following candidates pursuing Medicare for All and Biden’s plan seemed “not so bad.”

It is ironic that the ACA, with or without a public option, is now seen as a “centrist” approach. The Overton Window has indeed shifted.

Then you’ve considered nothing else? Are you sure that either of these is the optimal solution?

Feel free to toss out some other ideas @noonm

The Right has its favorites that need to be batted down (usually, ERs and charity). There is the nationalization model (UK’s NHS and the US’s VA System). I suppose that a universal voucher in a private system is possible. (This is like a heavily subsidized public option but with private insurance and far less government control.)

I’m not a close reader of the healthcare issue, so there may be others.

This is what Pete Buttigieg calls “Medicare for All Who Want It”: basically a public option to compete with private plans and continue the ACA trends of lowering costs. Private health care insurance can work just fine, if it is regulated like a utility and if profits are constrained, as they were with the ACA. For political reasons, our system is a kind of heffalump or woozle creature, but it was the best that Pelosi and Obama could do at the time, and it was pretty damn good under the circumstances. The ACA brings us closer to German or Swiss systems. Medicare is France or Canada, but only for the old and disabled. Medicaid is France or Canada for the poor, but is funded and administered in such a way that it significantly restricts access to care. So: a hodgepodge.

The American for-profit system prior to the ACA was more like Thailand’s: great care for those who can afford it, no care for those who can’t pay; remnants of that persist in those states that did not expand access to Medicaid under the ACA.

A hybrid system would likely work the best and constrain costs. For example do we all need health insurance to see a primary care physician when you have the flu? The private market would work better for that aspect of healthcare. Personally I would have universal coverage for catastrophic conditions like cancer for example. Bottom line find where the free market works better and keep that and have government involved where the free market doesn’t work.

Remove government regulations to:

  • open up the health insurance market across state lines so insurance companies can compete against each other for the best plans and premiums.
  • allow higher deductibles to lower premium costs.
    require medical services to advertise costs for basic services so the consumer can comparison shop.
  • expand tax free health savings accounts higher amounts, inheritable, expanded permissible uses of the funds.
  • remove/relax licensing requirements for technical services, i.e. X-ray, dental technicians, physician assistants.
  • tort reform to reduce frivolous lawsuits to reduce malpractice insurance costs passed through to patients.

What you would not want is an expanded version of the existing government run health care system, the VA.

But then how would the regulators/legislators get their kickbacks?

Let’s be clear about one thing…no one’s in love with medicare. It is just more palatable (and survivable) than private insurance, which is quite literally incentivised to kill some of its customers for profit. And please verbally smack in the face anyone spouting rhetoric or push polling about keeping your private plan. No one “gets to keep their plan”. You don’t own your plan, the insurance company does. They can change the drugs and services list next January. They can terminate the plan altogether, if the member list gets too sick. Your employer hires a new CFO whose bright idea is to drop the PPO and offer an HMO only? Tough beans. VA patient? They’re busily turning worthless service reimbursements into valuable middle-man commissions (I’ve seen this first-hand while helping my father navigate the VA system).

In America no one gets to “keep their plan” regardless of any medicare buy-in option and anyone telling you otherwise is trying to stampede you. Medicare is the one plan where they have to take you and keep you instead of throwing your sick ass out in the street.

Part A hospital inpatient deductible and coinsurance You pay:

$1,364 deductible for each benefit period
Days 1-60: $0 coinsurance for each benefit period
Days 61-90: $341 coinsurance per day of each benefit period
Days 91 and beyond: $682 coinsurance per each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over your lifetime)

Part B premium The standard Part B premium amount is $135.50 (or higher depending on your income).
Part B deductible and coinsurance $185 per year. After your deductible is met, you typically pay 20% of the Medicare-approved amount for most doctor services (including most doctor services while you’re a hospital inpatient), outpatient therapy, and Durable medical equipment (DME)

No max out of pocket and the very best, more f you want supplemental plans, part D.

All this for people on a fixed income.

And of course some doctors refuse medicare patients as payments are substandard.


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The analogy comes to mind: I have $100 in my pocket. I need to buy an item that’s going to cost me $90. Government comes along and collects $30 of my income and now I cannot afford it on my own. Government promises to give me $20 back so I can afford the $90 item and I’m supposed to tear up, thanking government for helping me afford the item.

What’s the point? Get the damn government out of the middle of the private health care industry and reduce the regulatory burden by 75% and all of the sudden, people can pay for their own health care again. Right now, they’ve screwed things up so much that it’s getting to the point of where the average person can’t afford health care.

So what’s the long term solution?

#1. Government run clinics to cover Medicare and Medicaid costs. Completely segregate them from the private system.
#2. Debt forgiveness for college for new doctors that work a minimum of 7 years for the government clinics.
#3. College grants for new doctors, agreement applies of 7 years of service to the public sector.
#4. Open up insurance markets across state lines and let the free market work.
#5. Fund necessary medical R&D costs to reduce the price of pills. Company X pays $100MM to develop a new drug or procedure to fix something, we subsidize it with the agreement that the drugs are limited to 10% margin on cost.
#6. Treat medical debt for people that scam the system the same as taxes. If you go to the ER to avoid having to pay a bill, we bill you and eventually haul your ass to jail if you don’t pay your bills.

Honestly, government has screwed things up so badly at this point that we need a massive restructure of the relationship at this point. Want to go to a free clinic? Use the government provided ones and the service is going to be crap with long wait times but that’s the price you pay if you don’t insure yourself.

Access to health care is a right but making others pay for it ISN’T a right. There are things we can do within the limits of the Constitution (General Welfare of the United States) that don’t rise to the level of individual welfare but turning the entire system over to the government when they’re the ones that screwed it up in the first place is just flat out stupidity.

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On #5, instead tackle the $1,500,000,000 cost to have the FDA approve any new medication.