Illustration : Angelica Alzona (GMG

There is one thing we can be thankful for: Medicare for All is now a mainstream position in the Democratic Party, to the point where most of the leading Democratic candidates for president say they support it. The question remains how real their commitment to that goal is, and how far they’re willing to go. Do they support what Medicare for All actually is—a single-payer system where everyone gets their insurance from the government? Or are they co-opting the term while really being more committed to much less ambitious and effective proposals, like a public option—if that?




That question became much more salient this week, when Sen. Kamala Harris, now a Democratic candidate for president, said at a CNN town hall that she supported eliminating the private insurance industry, in response to Jake Tapper asking her about people who currently like their private insurance:


The next day, CNN reported Harris advisers said she would be “open to the more moderate health reform plans, which would preserve the [insurance] industry.”

This approach seems to be an emerging consensus among Senate Democrats to the right of Bernie Sanders: Single-payer will be unpopular once people find out it means they won’t get to keep their private insurance, so a public option is the more pragmatic prospect for healthcare reform. A CNN article this week revealed that several key Senate Democrats seem to believe that a public option is better, with Dick Durbin saying “most of us said we would support a Medicare type plan—a not-for-profit public plan that is available for everyone,” Tim Kaine saying “the idea is to offer a nonprofit insurance plan as an option,” and Chris Murphy saying it would be “a lot more politically palatable and ultimately more popular than statutory prohibition private plans.”

But it’s not just politicians. Last week, the Kaiser Family Foundation released the results of a poll about single-payer, in which one of the questions asked about various arguments against Medicare for All. It found that people like the idea of Medicare for All much less when they hear it would mean the elimination of private insurance, which isn’t all that surprising in a context-free polling question.

This led some wonkish center-left types in the media, like Vox’s Matt Yglesias (in a now-deleted tweet; he deletes his tweets daily) and MSNBC’s Chris Hayes, to praise the idea of Democrats trying to pass a public option instead of single-payer:


(The poll also found that a majority of Americans support “having a national health plan, sometimes called Medicare-for-all, in which all Americans would get their insurance from a single government plan.” Which would seem to be the ballgame, to me, but whatever.)

It’s true that single-payer supporters, myself included, often point to polls showing that 70 percent of Americans support single-payer. It’s always tempting to appeal with polls in advocating for a particular policy. But single-payer supporters don’t say we should have the policy because people support it; we believe it’s good, just, and more humane than our current nightmare, and that the conventional wisdom that it would be deeply unpopular is wrong.


Similarly, polls showing skepticism about some elements of single-payer don’t mean that you should abandon support. You don’t support everything polls say the public supports, nor do I think people like Hayes or Democrats in Congress think we should do that. People still support the death penalty for murder, for example. Does that mean Democrats should campaign on making it mandatory in every state? A majority of white Americans think white people face discrimination. Does that mean they’re right, or that we should enact policies to counteract anti-white discrimination? In both cases, it extremely does not. We acknowledge on some policies that the public needs to be moved but not on others. Why not on single-payer?

A vocal minority of people with employer-provided coverage they actually like doesn’t mean you should ignore what’s best for everyone. Yes, a 71 percent majority of people with employer-provided health insurance are happy with their coverage (at least according to the health insurers’ trade group); 49 percent of people in America have employer-provided insurance. Does that mean the millions of people for whom Medicare for All would mean gaining health coverage or paying thousands of dollars less for it don’t count? What about the 27 million uninsured people who would now have coverage? The 12 million who have to buy their insurance on the marketplace? What about the 55 million Medicare beneficiaries who would no longer have to pay premiums or drug costs? What about the 27 million part-time workers, or the 4.2 million people per month who leave or are fired from their job, whose health insurance would no longer be in peril? Do none of those people count because they’re not the better-off people lucky enough to have their employers pay for most of their premiums? Shouldn’t Democrats be the party that speaks for the people with less, not seeks to preserve the relatively privileged position of people with more?


But it’s worth addressing the policy matter, too: Why shouldn’t Democrats aim for a more popular and more achievable public option? Because it’ll end up being neither, because it might actually halt progress toward single-payer, instead of being an “on ramp,” and because it is an insufficient and immoral response to the current crisis of healthcare in America.

What do we mean by a public option? There are many competing bills and plans that would provide what’s described as either a public option or a Medicare or Medicaid buy-in, but they all amount to the same thing: preserving the existing system of mostly employer-based private insurance while adding the option for people to buy an insurance plan from the government. (The key word there is “buy.”)




This would obviously be better than what we have now, since what we have now is lethal, toxic sludge. The questions that matter for politicians and advocates when it comes to choosing between a policy that’s merely better and one that’s actually good is whether the good policy is truly out of reach, and whether the worse policy would prevent reaching a better policy goal.

But first, let’s establish that the policy is indeed worse.

A public option would preserve the fundamental injustices of the current American healthcare system. It actively works to preserve the private insurance industry and their profits, because this allows patients “choice.” Indeed, this false notion of choice is so key to the public option that one of the major recent proposals, introduced by Sen. Whitehouse and Rep. Jan Schakowsky, was dubbed the CHOICE Act. How would this “choice” work? Small employers could choose to offer the public option as well as private plans—but workers at larger firms would be shut out, according to Vox. This means if you’re unlucky enough to work at a large company—and most workers in the private sector work at firms with more than 100 employees—you’re stuck handing over money to private insurance giants like Aetna or CareFirst, and so is your employer. (The Merkley and Murphy “Choose Medicare” bill, meanwhile, would allow large employers to offer the public plan. But remember, it would still be up to management—and not employees—whether they offer the plan or not.)


How many people still struggling under the burden of paying for healthcare is too many?

Premiums, meanwhile, would likely be lower than private plans—a bit. The most recent CBO analysis of a public option was in 2013 and didn’t look at any of these specific plans, but found that premiums would only be “between 7 percent and 8 percent lower” than private plans on the exchange. The average monthly premium on the second-lowest cost silver plan this year was $406 before tax credits—though it’s much higher in some states—so you’re looking at saving about $40. Enough for a couple of pizzas in New York.


What about other costs? The CHOICE Act would “cover between 60 and 80 percent of expected medical expenses,” according to Vox, and the Medicare X bill would have two tiers, covering 70 or 80 percent of costs. That preserves a system in which people whose medical expenses are higher are going to pay more—and remember that affordability already affects sick people more, since almost half of people in poor health struggle to pay for care. It would also preserve a system in which people are left to guess how much care they’ll need in deciding whether it’s worth paying more in premiums or more at the doctor’s office, a system in which some people are covered better than others. Why is that a good policy goal? (Again, the Choose Medicare act is far better on this, as it has only one 80 percent coverage level—but 80 percent still isn’t 100, and how exactly employees’ would navigate getting their bosses to offer the public option remains to be seen.)

Other public option or buy-in plans are worse. Vox reported that Hawaii Sen. Brian Schatz’ Medicaid buy-in plan would “give the states leeway to decide how they want to set premiums, copayments, and deductibles,” all but guaranteeing that people who live in red states, the places currently racing to see who can come up with the nastiest Medicaid work requirements while refusing to expand Medicaid, would end up paying more.


The public option would also entrench the current problems with Medicare and Medicaid. Sen. Bernie Sanders’ Medicare for All proposal, on the other hand, would actually make Medicare better for patients by eliminating prescription costs, premiums, and copays. As Adam Gaffney wrote for Jacobin in 2017, these problems are myriad:

Medicare, like private insurance, often imposes high out-of-pocket payments on enrollees, and it excludes coverage for important health services like dentistry and long-term care. The partial privatization of the program (via Medicare Advantage plans, which are managed by private insurance companies) has yielded little but colossal waste over the years.” And while Medicaid has broader benefits and usually minimal out-of-pocket payments, as a result of its lower reimbursements, it sometimes provides inferior access to providers (a vestige of its heritage as a “poor person’s program).


According to a 2018 survey by eHealth.com, almost 40 percent of Medicare enrollees say they skip medical care, like doctors’ visits or prescriptions, because of cost. The Commonwealth Fund released a study in 2017 that found more than a quarter of Medicare beneficiaries “spend 20 percent or more of their incomes on premiums plus medical care.” Just this week, the Kaiser Family Foundation reported that Medicare beneficiaries without low-income subsidies can “expect to pay thousands of dollars out of pocket for a single specialty tier drug in 2019.” The public option would not eliminate those costs, although it could reduce them significantly if the government were allowed to negotiate drug prices, as Medicare X would, and if it wielded that power effectively. The question remains: How many people skipping care because of high costs are you willing to accept? Thirty percent of Medicare beneficiaries? Twenty? How many people still struggling under the burden of paying for healthcare is too many?

Then there’s the question of how a public option would affect those who choose to keep their private insurance. Most importantly, since this is what people say they worry about most, would it lower their premiums? It’s possible that it would—the pressure of competing with a lower-cost public plan could force prices down. But again, it’s not guaranteed, and it’s likely that the impact would be very limited.


Just as with Medicare for All, a lot depends on unspecified details about how these plans would work, which is a conversation that we’ve yet to have. But the public option’s scope is vastly limited by actively seeking to keep most people on their employers’ insurance, and preserving the broken, profiteering private insurance industry. It’s not that it would make things worse—it’s that things are already catastrophically bad, and anything that just tinkers around the edges keeps us in dire straits.

This leads us to the political questions. Would the public option serve as an “on ramp” to Medicare for All? Would a public option actually be easier to pass?




Let’s think about who opposes single-payer: insurance companies, pharmaceutical companies, the American Medical Association, and hospitals, among others. Hospitals, for example, oppose it because they currently make most of their money from private insurance.

Presumably, if more people are covered by public plans which pay only Medicare rates, overall provider reimbursements will go down, which is exactly what they hate about single-payer. The more people who get on the public option, the less money providers will make from private insurance—the CBO found last year that Medicare pays about half what private insurance pays for the same procedures. Do you think doctors and hospitals are likely to support a public option if it only reduces their reimbursements by a bit instead of a lot? The public option also lacks the cost-saving virtues of single-payer, which would eliminate hospitals’ administrative costs of dealing with hundreds of insurance companies and billing systems.


How about pharmaceutical companies? Big pharma is currently trying to prevent the Trump administration from even the slightest effort to control drug prices: a proposal to base drug prices paid by Medicare Part B, which only covers drugs administered in the doctor’s office, on what the prices are in foreign countries. (Actually, hospitals and doctors complained about that plan, too.) The American Conservative Union, which received $150,000 from the Pharmaceutical Research and Manufacturers of America (PhRMA) in 2017, paid for a website attacking the “foreign” price limits.

Perhaps the best evidence of this came last week, when the Partnership for America’s Health Care Future—an advocacy group whose members include PhRMA, America’s Health Insurance Plans, and the American Medical Association—came out with its first TV ad attacking single-payer, which conveniently lumped the public option in with single-payer.


Screenshot : YouTube

(PAHCF promoted the Kaiser Family Foundation poll that showed decreased support for plans that eliminate private insurance last week, too.)


How does that bode for the public option’s prospects of being easier to pass than Medicare for All? Not great. But this should be obvious from experience: The Republican Party and Fox News and every addled conservative in America smeared Barack Obama as a socialist over the Affordable Care Act. Do you think they’re not going to call you a socialist for adding a public option, which would go even further than the ACA? Sure, they’ll likely go more all-out bonkers on single-payer—they started a whole advocacy group opposing it—but they hate the public option, too. And it’s going to be a lot harder to rally and energize the public with “if you work for a small company you can buy your plan from the government instead of Aetna” than “everyone gets healthcare for free and no one has to ever call an insurance company about a bill ever again.”

Let’s consider the other question, then: Would passing a public option act as an “on ramp” to Medicare for All, setting us up to achieve universal healthcare shortly after? That question is much harder to answer, but wherever you fall, it’s undeniably not even close to a guarantee.


What if, instead, it takes the wind out of the sails of reform for—how many years? It’s 10 years since Obama took office and the process of getting the ACA passed began. If a public option passed in 2021, the absolute best case scenario, is it going to be another 10 years before we get around to fighting for single-payer? How many people would die in that 10 years because of the cost of medical care? Fewer, sure, than if we’d done nothing, but many more than if medical care was universal, comprehensive, and free at the point of use. What if it’s more than 10? It’s been more than 50 years since Medicare was created. What if this is the big chance we miss, and it’s another 20 or 30 or 50 years before another one comes along?

Democrats frequently admit defeat before they’ve even got their trousers on. This is one of the major differences between establishment Democrats and the newly popular leftist politicians, like Sanders and Alexandria Ocasio-Cortez: They understand that you don’t turn up to a knife fight with a banana and a shirt that says I Am So Frightened on the front. But prominent Senate Democrats and at least one presidential candidate have already shown that they’re willing to compromise on single-payer. That is not how you win a fight.


The basic structure of all insurance is at best a gamble and at worst a scam. You pay your premiums in case a bad thing happens—a car crash, your cat gets sick, you have a heart attack—so that you hopefully don’t have to pay the very high costs associated with that bad thing down the line. If you never get in the car crash, lucky you, but your money bought nothing. If you do, you might find your money doesn’t buy you as much as you expected it would. Insurance policies have a lot of fine print to allow companies a way out of paying for all of the costs you incur if the bad thing happens so that they get to keep as much of your premiums as possible. Or, they have fun little tricks they came up with, like deductibles and copays, so that they can pay less and charge you more, on top of the premiums you’ve paid. This is how they make a profit: by taking in more in premiums than they spend on paying for the things they cover.




It’s not that it would make things worse—it’s that things are already catastrophically bad, and anything that just tinkers around the edges keeps us in dire straits.

This is one thing when you’re insuring something optional, like a pet. It’s another thing when it’s healthcare, which is something everybody needs and deserves, and without which you’re likely to incur thousands and thousands of dollars in costs. Not having health insurance is a crazy risk; having health insurance is expensive.


This is the system a public option would preserve. Indeed, the CHOICE Act one-pager says the bill aims to “strengthen” the Affordable Care Act, and that it would “increase the choices available to consumers shopping on the health insurance exchanges.”

Lack of choice isn’t the problem. It’s that the lack of choice drives up premiums—when one health insurer has a monopoly in an area, they can charge higher prices, just like Comcast can charge more when it knows they’re the only cable provider who serves your area. If there was one plan that covered everything and cost a nickel, consumers wouldn’t care about not having choice. We’re not talking about cereal or cars here.


The public option is a neoliberal wet dream, underpinned by the big lie that competitive marketplaces can fix anything. It promises “affordable” healthcare, not guaranteed healthcare. It promises “choice” of plans, not plans that cover everything. It promises the same convoluted system of subsidies and incentives that Democrats have been obsessed with for decades, instead of universal programs for all.

The American healthcare system is fundamentally broken. We spend twice what other rich nations do for much worse outcomes, with the highest infant mortality and the lowest life expectancy. Like the Affordable Care Act before it, the public option would preserve the rotten system that leads to this. It is motivated by a cowardly, straight-up wrong idea of pragmatism, the kind of half-hearted idea that Democrats—willingly bullied for 30 years by Reaganite, anti-government, Chamber of Commerce-funded slimeballs—think is all we can possibly achieve.




Fuck that. Fight for single-payer or get kicked out of Washington trying; if you have to go back to your district after a barrage of pharma-funded ads gets you kicked out, you’ll have been sent home for the right reasons. And after all, it’s not like you’re going to die.