A tracking poll from the
Kaiser
Family Foundation finds that 56 percent of Americans favor a fully government-run
Medicare for All insurance plan, but that an even larger 68 percent favor a
mixed public-private approach with a public option. The most common reason
given by those who support a public option but oppose Medicare for All is a
desire for choice. They do not oppose the idea of public health insurance, but
they do not want to be forced onto it.
Given those public attitudes, it is not surprising that many
Democratic presidential aspirants have shied away from Medicare for All in
favor of plans based on a public option. Pete Buttigieg emphasizes the element
of choice in the very name of his plan, which he calls
Medicare
for All Who Want It. Other candidates backing
one or another form of public option include Joe Biden, Amy Klobuchar, and
Michael Bloomberg.
There is a dilemma at the heart of the public option
approach, however. Is it possible to offer choice in health care coverage and
still achieve universal coverage, another cherished goal of reformers? Or does
the attempt to achieve universality inevitably require making enrollment
compulsory?
In my view, it should be possible to preserve meaningful choice in health care while ensuring universal access to coverage. But doing so will require attention to some details of program design that the candidates’ plans have not fully addressed.
The issue
Although the universal-vs.-voluntary dilemma is inherent in
all public option plans, the version advanced by the Buttigieg campaign has
drawn the most attention to the issue. At least part of the reason is that the
Buttigieg plan comes closest to addressing the dilemma directly. Writers for
The
Washington Post,
The
New Republic, the
Wall
Street Journal, and
Slate
have all argued that his public option is designed in such a way that it would
inevitably become compulsory.
The central question in all of this is how to ensure that
the risk pool covered by the public option includes an adequate number of healthy
subscribers along with those who are ill. If people can easily buy into
coverage only after they become sick and drop out at will when they recover,
the average cost of claims made by those left in the pool rises and premiums
become unaffordable. The result is the notorious “death spiral,” known to
economists as
adverse selection.