By Julie Pease, M.D.
Portland (Maine) Press Herald, September 16, 2019
TOPSHAM — In reaction to public support for universal health care coverage, some Maine health care 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, and will do nothing to control health care 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, essentially 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, giving 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.
Second, a public option will not improve efficiency or reduce waste. At least three major reports estimate that 30 percent to 35 percent of America’s $3 trillion annual health care expenses 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 have 1.5 insurance-related clerical jobs 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 health care needs.
Third, 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 seeking providers, to skip dosages or decline prescriptions, or to delay or refuse essential tests or procedures because they can’t afford them.
Fourth, 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 goes 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.
Finally, a “public option” fails to assist Mainers who have 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, HR 1384 and S.1129, or by enacting a state-based single-payer type of plan such as L.D. 1611. 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 Veterans Affairs 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’ health care needs? Why not just pay for health care 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 Mainers’ health? We cannot afford to wait.