Health care has been at the forefront of discussion during the 2020 primary season. The debate has boiled down to whether Democratic candidates will embrace single-payer or support an expansion of the Affordable Care Act (ACA) through a public option. While candidates trade jabs and throw around industry talking points, the debate and subsequent media attention has largely excluded how people with disabilities will be affected by the prospective nominees’ health care plans.

People with disabilities are disproportionately unemployed or underemployed and are twice as likely to live in poverty. While some workers with disabilities are paid subminimum wages, the disability community has historically been segregated and 1 in 3 American adults with a disability have an unmet health need due to the high cost of health care.

Though the needs of 61 million people with disabilities (one-quarter of the population) have largely been ignored in primary debates, only one health policy offered would provide meaningful relief for people with disabilities living in poverty. Through a Medicare for All, single-payer model, the crushing weight of an unjust economic and health structure for people with disabilities would be lifted.

Public Option Pitfalls

It is clear from the rhetoric on the campaign trail and the policies offered by candidates that most haven’t embraced a universal health policy that includes disability. Three of the four front-runners — Elizabeth Warren, Pete Buttigieg and Joe Biden — have opted to pursue a public option buy-in, which would keep intact the inefficiencies of the current order.

Although the public option would be a slight improvement to the current system, the policy lacks the teeth and framework to ensure that health care is universal, cost-effective and provides more quality services to people with disabilities.

The main pitfall of expanding the ACA through a public option is the preservation of private insurance, which is why the U.S. consistently ranks worse in health spending per capita, health outcomes and accessibility to services compared to other industrialized nations. Most people would still be covered by a bureaucratic, profit-driven marketplace and denied care while coverage gaps still exist.

The public option structure also creates a two-tiered system, which is currently in place under the means-tested Medicaid program. Patients with private insurance, which would reimburse health providers at higher rates, would be prioritized over patients on the public option plan. Like Medicaid, to reduce costs, the public option model would reimburse at lower rates, resulting in public plan enrollees experiencing reduced choice of providers. The public option model promotes more of the underlying inequities of the current system without remedying the existing ones.

Under the public option model, health services would still be rationed based on the ability to pay. People on the public option would still have to purchase insurance through a public buy-in, and private insurance enrollees would still need to meet premiums, copays and deductibles. For public plan enrollees, the buy-in cost would be reduced compared to private insurance, but a system that is based on the ability to afford the cost of health insurance and out-of-pocket expenses would be preserved.

1 in 3 American adults with a disability have an unmet health need due to the high cost of health care.

A single-payer system would be more cost effective and would achieve universal coverage, unlike the public option. Under single-payer, federal health spending would increase because costs are shifted from the privatized health care to public care, but over $383 to $500 billion in bureaucratic administrative waste would be trimmed annually from the health system and appropriated to care. The public option would add a new complicating layer to administration, further bogging down the system and creating more inefficiencies.

Over the next 10 years, Medicare for All would save $2 trillion in national health spending compared to the current system. In contrast, the public option would preserve the current model while offering a public buy-in, and ultimately it would leave total health spending close to current levels. The public option is unable to achieve universal coverage and fails to include disability.

Private insurance and for-profit medicine would continue to pass the costs (financial or health-related) along to patients and would keep in place a poverty-ensnaring disability benefits system. Overall, the public option fails to recognize the urgency of doing away with a benefits model and health system that keeps people with disabilities confined to economic hardship.

Disability Inclusion Under a Universal Model

A single-payer health system through a Medicare for All framework is the most effective and efficient plan to alleviate the stresses of poverty and integrate disability services into the broader health system.

Under the Medicare for All plan, unlike the various public option buy-in plans, means-testing for people with disabilities would be eliminated. As the Medicaid means-tested system stands today, people with disabilities are forced between choosing life-saving benefits through Medicaid and Social Security Income (SSI) or living in poverty. For Medicaid beneficiaries, the transition to a universal insurance program would mean that there would be the potential to earn more income without losing health benefits and would be an initial step to escaping poverty.

Ending means testing isn’t the only reason that the Medicare for All plan would vastly improve the lives of people with disabilities. The single-payer proposal would lump in Medicaid benefits while making them free at the point of service. Medicare for All would include ending wait lists for long-term services and supports and widening long-term care benefits to the entire population. The policy would also guarantee coverage to services that are often limited to people with disabilities: mental health, dental, vision, hearing and assistive technology.

The public option model promotes more of the underlying inequities of the current system without remedying the existing ones.

The inclusion of these services would overwhelmingly help people with disabilities and the general population. In short, under the Medicare for All proposal, any health need that is experienced by anyone would be covered and includes disability as part of the health and human experience.

The Medicare for All plan would similarly begin to address the segregation and isolation the disability community continues to experience. Under the proposal, Medicaid’s home and community-based services, which offer care outside of institutional and isolated settings to people with disabilities, is included in Medicare for All. The single-payer model would promote a health system that cares for a historically exploited and isolated population in deinstitutionalized settings that best meet their needs.

Strategically speaking, a single-payer system that includes disability would be easier to protect against cuts and caps. Since the inception of Medicaid, the Republican Party and business-minded Democrats have sought to apply cuts and capped rates to any program that helps working-class people, in order to save a buck or balance the budget. This has kept people with disabilities and Medicaid beneficiaries consistently on the defensive with little leverage. When people with disabilities are included into a universal program and disability is seen as a widespread health issue, it creates a program of solidarity. The public can collectively protect against austerity and all would be eligible for disability services should they need it in the future.

Needing Single-Payer Now

In states like California and Illinois, disability rights organizers and activist groups like ADAPT are fighting for a single-payer system that includes disability health care as a human right. The disability community knows the callousness of the current institutionalized system that places profits before human need. Single-payer is needed now.

Those living in poverty or with unmet health needs cannot wait for a public option model that delivers tomorrow what people need today. Incremental steps through a public option buy-in would continue to treat disability as a separate “burden” and keep people with disabilities at the mercy of means testing while failing to expand and decommodify critical disability services.

The public option adopted by centrists does not come close to the material benefits Medicare for All offers people with disabilities and the broader public. The buy-in model would leave the disability community entrapped in means-tested poverty, and does not possess the universality necessary to include disability care as a human right. An incremental policy that leaves the underlying problems of profit-driven health care unsolved is not a policy that recognizes that marginalized people with disabilities need an escape from poverty now.

Medicare for All would serve as an initial step to addressing inequality through eliminating means-tested health benefits and a tiered insurance structure, while expanding and integrating services for the disability community as universal benefits. The way to an equitable economy and just health system is to use movement politics to implement a single-payer Medicare for All model that views disability as part of the human experience.

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