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The fallacy of expanding ACA and adding a public option

September 5, 2019

Topics: Quote of the Day

By Munira Z. Gunja and Sara R. Collins
The Commonwealth Fund, August 28, 2019

In 2018, an estimated 30.4 million people were uninsured, up from a low of 28.6 million in 2016. Coverage gains have stalled in most states and have even eroded in some. In addition, more people have reported problems getting health care because of cost. To examine why so many people remain uninsured, we use data from the 2018 Commonwealth Fund Biennial Health Insurance Survey.

  • Uninsured Working-Age Adults Disproportionately Low-Income, Latino, and Under Age 35
  • Nearly Half of Uninsured Adults May Be Eligible for Marketplace Subsidies or Medicaid
  • One-Third of Uninsured Adults Who Did Not Visit Marketplace to Get Coverage Cited Affordability Concerns
  • One-Third of Adults Who Lost Coverage and Were Previously Covered Through the Individual Market Cited Affordability Concerns
  • Majority of Adults Who Had Lost Coverage and Were Previously Covered by Medicaid Said They Were No Longer Eligible
  • More Adults Had Difficulty Finding Affordable Coverage in the Individual Market in 2018 vs. 2016

Policy Recommendations:

  • Expand Medicaid without restrictions.
  • Lift the 400-percent-of-poverty cap on eligibility for marketplace tax credits.
  • State or federal reinsurance.
  • Reinstate outreach and navigator funding for the 2020 open-enrollment period.
  • Ban or place limits on short-term health plans and other insurance that doesn’t comply with the ACA.
  • Make premium contributions for individual market plans fully tax deductible.
  • Fix the so-called family coverage glitch.
  • Inform people about their options.
  • Reduce churn in Medicaid.
  • Extend the marketplace open-enrollment period.



By Don McCanne, M.D.

In spite of enactment and implementation of the Affordable Care Act, 30 million people remain uninsured and tens of millions remain underinsured. In spite of spending twice the average of other wealthy nations, access to health care and affordability of care remain a uniquely American problem.

The Commonwealth survey quantifies these problems, and then they propose incremental tweaks that would expand access and improve affordability, but they would do so at a cost of increasing our already excessive administrative complexity and increasing further our very high level of spending. Further, they would not eliminate the problems of access and affordability as many would still fall short of qualifying for public programs or of being able to pay for private programs.

Yet many recommend that we build on ACA and add a public option (Medicare buy-in) as another choice. The options listed by Commonwealth are those that would build on ACA, and yet we see that they are costly and increase administrative complexity while falling far short of the goals of universality, accessibility, and affordability. Adding the option of buying a public plan does not work for the great majority of those who would remain uninsured simply because the plan would not be affordable for them.

The single payer model of Medicare for All would recover hundreds of billions of dollars in administrative waste while automatically making health care affordable and accessible for absolutely everyone.

Enough with the deficient tweaks. Let’s go directly to a system that would work for all of us: Single Payer Medicare for All.

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About the Commentator, Don McCanne

Don McCanne is a retired family practitioner who dedicated the 2nd phase of his career to speaking and writing extensively on single payer and related issues. He served as Physicians for a National Health Program president in 2002 and 2003, then as Senior Health Policy Fellow. For two decades, Don wrote "Quote of the Day", a daily health policy update which inspired HJM.

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