The Next Step Toward Universal Health Care
Despite the Republicans’ intention to wreak havoc on the Affordable Care Act (ACA), there’s a great neglected opportunity to take a long stride in the opposite direction: adopting state public health-insurance programs. Although the ACA survives, it was damaged by the December repeal of the individual mandate, which required that all Americans have health insurance. As a result, 13 million Americans may lose their insurance, according to the Congressional Budget Office. We could start reversing that trend through state action.
Last year, Bernie Sanders called for public option health insurance “in every state in this country.” Given political realities, that is not in the cards. But current conditions do favor getting a public option now for a big chunk of the population. There are eight states that have Democratic control of both the legislature and the Governor’s office. Over 20 percent of Americans live in those states, about 65 million people. Any of those states could enact a public health-insurance option in 2018 or 2019. If just one state did so, it would open the door for other states to follow, creating the foundation for further expansion of health coverage in the years to come.
Many Democrats in the U.S. Senate and the House have endorsed Medicare-for-All, a national universal health-insurance program. But such a bill will never pass while Republicans control either house of Congress or the presidency. Even in California, the legislature has been unwilling to pass a full-fledged single-payer system because of the taxes that would be required to fund it and other daunting implementation issues.
I have long been an advocate for single-payer health care and believe it should be adopted as soon as possible. That is why I support the state-operated public option as the best strategy at this political moment. It is a simple idea: The state government creates a new government-operated insurance plan that competes with private health insurers. People are charged for the cost of the insurance, just as they would be for private insurance. Public insurance would have far lower administrative costs — 2 percent of Medicare’s budget goes to administrative costs, as opposed to 13 percent on average for private insurers — and it would not need to generate profits for shareholders. As a result, it could offer the same coverage more cheaply than private insurers. It could include Kaiser and other HMOs, as Medicare does, and offer equivalent or greater choice of providers. All program costs would be included in the premiums, so there would be no extra cost to taxpayers.
Enrollment in the public option would be entirely voluntary — that will be key. The beauty of the public option is that it does not force anyone to lose anything or do anything; it only provides a choice. As people enroll in the public option and find it provides the same insurance for a cheaper price, its popularity will spread, demonstrating that the government really can do this job cheaper and better (as it has for years with Medicare). Private insurance will gradually be reduced to offering Cadillac plans for the wealthy. By demonstrating in practice how Medicare-for-All could work, state public-option programs will lay the foundation for state single-payer programs and for the adoption, eventually, of nation-wide universal health care.
Democrats in California, New Jersey, Washington, Oregon, Connecticut, Hawaii, Rhode Island, and Delaware have the power to enact a state public option now. A majority of those states have operated their own ACA health-insurance exchanges efficiently for four years. That experience has laid the administrative groundwork for a public option.
California, in particular, has the potential to enact an effective public option. Democrats have super majorities in both houses of the legislature and hold the governor’s office, so the law could be passed without Republican support. In addition, the state’s insurance exchange, Covered California, is already very well-run, creating the foundation for a public insurance program.
State-enacted public insurance programs are the only significant health-care reform that could be won in 2018. It’s time to take that step toward health care for all.
A health law attorney in Oakland, Stephen D. Schear is also former co-chair of the Universal Health Care Action Network and a long-time former member of the board of directors of Health Access-California. He has worked on health policy reform for over 30 years and authored one of the first state single-payer plans.