Health Care Reform

Colorado’s Pseudo-Public Option

By Adam Gaffney

Last week, lawmakers in Colorado passed a bill that would establish what some might call a “state public option” plan, although that’s not what it is. The bill would require, as the Colorado Sun and Denver Post describe, private insurance companies to offer a health plan on the individual and small-marketplaces with premiums that are 15% lower in 2025 than they are today after adjustment for medical inflation; if that goal was not met, the state could potentially regulate payment rates under these plans.  

The bill was heavily opposed by state Republicans and, variably, by healthcare industry players. Its advocates tried to achieve more. But unfortunately, the impact of the law is likely to be paltry, potentially even difficult to perceive. If that pans out, it could be used to discredit the notion of true public health insurance.    

For one thing, as the Colorado Sun describes, the source of the 15% savings is not entirely unclear. It quotes one of the bills’ chief sponsors: “The spirit of this bill is to ask everyone to come to the table to work on decreasing cost and increasing access.”  But these plans would still be run by private insurers, so there is no reason to expect any savings on insurer administration — the primary source of savings under Medicare for All according to the Congressional Budget Office. On the other hand, government rate-regulation (or the threat of it) might give insurers more leverage to reduce reimbursements to providers. Whether this process will succeed, however, is uncertain. After all, Colorado is following in the footsteps of Washington state, which passed a quasi-public option in 2019. Premiums for these “public option” plans (which are actually private insurance plans sold on the marketplaces that pay rates tethered at a percentage above Medicare) were actually 5% higher in 2021 relative to 2020 ACA marketplace plans, per Bloomberg Law.

But the reach of these plans, even if they achieved modestly lower premiums, will also be highly limited. They are available only to those buying insurance on the individual and small-business market. They would hence provide no benefits for those with employer-sponsored coverage and high premiums or deductibles, or for those with holes and gaps in their public insurance plans. Moreover, although they have been advocated as a tool to expand coverage, they are unlikely to be more affordable for the vast majority of uninsured individuals even if they achieve lower premiums. That is because, under the ACA, premium contributions for marketplace plans are set as a proportion of income for all those earning under 400% of the federal poverty level, which is now also the case for those of any income under Bidens’ America Rescue Plan (at least through 2022). Hence, there is no real popular constituency for these programs: at best, if totally successful, they would mostly serve to bring about a modest reduction in government expenditures on ACA subsidies, with little gain in coverage, access, or affordability of care for patients. 

And that is not just a policy problem, but a political one. To bring about meaningful change in healthcare, you need a powerful popular constituency behind you, because invariably you encounter opposition from powerful interests. This sort of reform, however, fails to generate such a constituency; its weakness is, in this sense, a feature and not a bug of its design. In contrast, although single-payer reform poses far larger political obstacles for passage, it is unique in that it could benefit nearly every segment of society, and hence potentially help generate the constituency needed to achieve it.

Health Care Reform Medicare For All

The Buffett-Bezos-Dimon-Gawande insurance fail? A powerful policy lesson!

How Amazon, JPMorgan, and Berkshire Hathaway took on America’s health care system—and lost, Fortune, June 1, 2021, By Erika Fry

Was it a press release, or a declaration of war?

How else to explain the media and market frenzy that followed the announcement, issued on Jan. 30, 2018, that Amazon, Berkshire Hathaway, and JPMorgan Chase — three of the nation’s largest, most high-profile, and best-run companies, then with some $534 billion in revenues between them — were teaming up to take on the ever-more-expensive, ever-more-complex problem that is American health care.

To those who had toiled in the world of employer-sponsored health care for decades, trying but never really succeeding to come up with new ways to control costs and improve outcomes … the statement, from three powerful CEOs, was cause for celebration.

Five months in, the team announced another star would lead the venture: Atul Gawande, the surgeon and influential New Yorker writer whose clear-eyed analysis of America’s dysfunctional health care system had earned him the admiration of Barack Obama and Buffett. In March 2019, the venture finally got a name, Haven.

The project officially sputtered to an end earlier this year. Even with its star power, Haven couldn’t break the black box that is U.S. health care.

So, did Haven make a difference? Some argue the effort undermined progress by raising the obvious question: If they couldn’t do it, who can? In a recent Kaiser Family Foundation survey of very large employers, 85% of top executives think government support will be necessary to control costs and provide coverage.

Gawande goes further and has recently argued that the employer-sponsored system can’t be fixed. Noting how many Americans lost their health insurance in a global pandemic, he said, “A job-based system is a broken system.”


Comment by Don McCanne

I contend that the Haven health reform effort of Warren Buffett, Jeff Bezos and Jamie Dimon, along with Atul Gawande, was a spectacular success, as an experiment in health policy. They proved beyond any reasonable doubt that the private sector is incapable of fixing our highly dysfunctional health care financing system. The only model that has shown promise is a single payer Medicare for All system. But you cannot set that up as an employer-sponsored system; it will have to be a public system for all the people.

Health Care Reform

Let’s Not Mourn the Death of the Public Option

The health insurance public option might be fizzling. The left is OK with that., NBC News, June 5, 2021, By Benjy Sarlin and Sahil Kapur

“A decade later, Joe Biden campaigned on making the public option a reality, but so far, he’s done little to get Congress to enact one. Instead of outrage, influential progressives seem to be OK watching the promise go unfilled, preferring to pursue universal health care through other means, like expanding Medicare eligibility.

Elected officials, health care activists and experts who spoke to NBC News said the issue has fallen off the national radar and will be difficult to revive without a major push by the White House.

Responding to the pandemic has consumed much of Biden’s attention in his first months in office. And beyond that, he has a long list of agenda items to get to first, including many that are popular with progressives.

“I don’t think there’s a dynamic where we see it at the center of a political fight again,” said Alex Lawson, the executive director of the left-leaning group Social Security Works.”


Comment by Eagan Kemp

No one should mourn the end of a push for a public option in health care. It was never the solution the country needed for health reform. 

The risks inherent in a public option completely overwhelm any potential gains. Given the rapid rise in for-profit companies gaming Medicare through Medicare Advantage, there is no reason to believe that a public option would be any different when it comes to insurers dumping patients with high health needs, while retaining patients that are profitable. If the for-profit insurers can cherry-pick healthier Americans through seemingly more favorable plans (while they are healthy), then the public option could become overly burdened and unsustainable. 

In addition, a public option would have just been one more area of added complexity in our already fragmented health care system, which already struggled to respond to the COVID-19 crisis

A public option would also further entrench the power of for-profit insurers. And the massive administrative waste of private insurance companies would continue under a public option, whereas under Medicare for All the reduction in administrative savings would be more than $500 billion a year

In terms of political feasibility, there is the perception that less comprehensive reforms could have an easier chance of passing. However, the companies that profit off our healthcare system have shown they are just as opposed to the most basic public option proposal as they are to Medicare for All. Both the Partnership for America’s Health Care Future and Coalition Against Socialized Medicine—which strongly oppose Medicare for All as well as a public option —have shown they will not compromise on behalf of their corporate backers. 

While proponents of a public option may try to make their proposal sound “reasonable,” it wouldn’t come close to matching Medicare for All. Whether it is savings for families, savings for the country or ensuring that everyone in the country has guaranteed access to medically necessary care, only Medicare for All would create the health care system we need.