In reaction to public support for universal healthcare, some Maine healthcare reform advocates promote a public option. From my perspective as a physician who has advocated for universal coverage, a public option is NOT enough.

First, a public option will never cover everyone.

Second, a public option will do nothing to control healthcare costs. A relatively small number of people would be enrolled, and the plan would have limited bargaining power. It is likely that many of the sickest of Maine’s uninsured would join a public option plan, making the plan a “high-risk pool.” This dynamic would drive the public option prices higher. Health insurance plans will always be unaffordable unless a healthy patient pool balances the sickest.

In contrast, universal coverage would put everyone in a single large “risk pool," and would give the state the bargaining power to achieve cost control. Maine would negotiate global budgets with hospitals, negotiate drug prices and set fair fee schedules for providers. Streamlining payment would offer vast cost savings. With a simplified system, providers would face just one set of billing rules and processes, greatly reducing their operating costs. Having everyone in the system limits opportunities for unscrupulous providers to exploit desperate patients.

Third, a public option will not improve efficiency or reduce waste. At least three major reports estimate that 30% to 35% of America’s $3 trillion healthcare bill is not spent on effective care. None of this waste disappears by adding one more insurance “option.” Without transformative change, some hospitals will continue to employ one insurance-related clerk for every bed they operate. Physicians will continue to spend time and money fighting insurance company barriers, negotiating multiple different plan coverage options and pharmacy formulas and restrictions, and dealing with duplicative documentation efforts. Patients will continue to negotiate the hassle of annual enrollment with its array of options and guesswork about what plan will meet their future healthcare needs.

Fourth, like current health insurance, public option funding will be through premiums and co-pays, least affordable to those in the greatest need. Some Mainers can’t or won’t pay those premiums and will go without coverage. Patients will risk serious illness or financial disaster or both. They will continue to delay seeing providers, to skip dosages or decline prescriptions, or to delay or refuse essential tests or procedures because they can’t afford them.

Fifth, adding a public option maintains Maine’s current employer-based health insurance system. Job changes that many people experience each year mean loss of insurance. (Currently 1 in 4 Americans go through an uninsured period annually.) Those who get new insurance often must search for a new doctor, and work with new co-pays and deductibles.

Last, a “public option” fails to assist Mainers with insurance. Thousands would still have high deductibles. They would still be restrained by networks that restrict choice of doctors and hospitals. They would still be forced to be on constant guard for surprise medical bills and charges, even when they go to in-network hospitals. Thousands still would not have access to dentistry, eyeglasses and hearing aids.

Each of these problems would be resolved by passing one of the federal Medicare for All bills, H.R. 1384 and Senate Bill 1129, OR by enacting a state-based single-payer type of plan such as envisioned with LD 1611 or the MECEP economic feasibility study. Each of these plans features tax-funded comprehensive benefits with no premiums, no co-pays, no surprise bills and patient choice of doctors and hospitals.

It remains unlikely that the U.S. Congress will enact Medicare for All soon. Maine can lead by enacting a state-based single-payer type of plan that would provide coverage for an estimated 650,000 individuals, and supplemental coverage for those Mainers with Medicare, Medicaid and VA benefits.

Why settle for a public option? Why continue the nightmarish tangle of public and private options, with people constantly moving on and off? Why perpetuate a dysfunctional, wasteful, expensive system that does not meet Mainers’ healthcare needs? Why not just pay for healthcare with taxes, cover everyone, and make services free at time of use? Why not work for a single state health plan that would control costs, save lives, and improve Maine’s health? We cannot afford to wait.

by Julie Pease, MD, Special to the Press Herald, September 16, 2019

Dr. Julie Keller Pease is a founding member and past president of the Maine AllCare board.

Additional references, including the link to the above article as published in the Press Herald:

Institute of Medicine. Best Care at Lower Cost: The Path to Continuous Learning Health Care in America. (Washington, DC: National Academies Press; 2012.)

Administrative Costs Associated With Physician Billing and Insurance-Related Activities at an Academic Health Care System; JAMA. 2018;319(7):691-697