Single Payer vs Public Option

I am following up on my last post regarding healthcare – and the different approaches in the Democratic primary.  I am going to do my best to (over)simplify the differences between Single Payer and Public Option approaches.

Single Payer (or “Medicare for All”)

There are a lot of positive things to be said of a single payer system, and most of the top tier candidates actually agree that this is the right aspirational goal for healthcare in the United States.  However, only Sanders* and Warren are still pushing for a Medicare for All right out of the gate. 

The benefits of a single payer system are pretty significant:

  1. Negotiating power for prices of healthcare and prescription drugs will mean lower overall costs to patients,
  2. A single payer system eliminates a huge amount of the overhead costs (for providers and the insurer), which will mean lower costs passed along to patients,
  3. There will be higher incentives to focus on preventative care and community health initiatives to keep all Americans healthier and costs lower, and finally,
  4. All Americans will be covered, allowing us to start working on the systemic injustices that have impacted the health of lower income communities, including rural communities and communities of color.

Most people think of cost as being the primary downside, but it’s too simplified to think of “cost” as a single issue here.  In aggregate, the cost of healthcare will decrease.  America will spend less and be healthier.  Insurance premiums will go away, most visits and procedures will be fully covered, and you’ll have little to no out of pocket costs for prescriptions.  For most Americans, healthcare costs will decrease.  

The actual downsides are… complicated.  

Sanders acknowledges that taxes will go up to cover the cost of healthcare.  That will impact different groups in different ways:

  • For most Americans with health insurance today, the increase in taxes will be less than the decrease in insurance and healthcare, decreasing overall cost.
  • For anyone paying for insurance out of pocket now or anyone who has maintenance medications and numerous doctors visits, your costs will undoubtedly decrease significantly.  
  • If you do not currently have health insurance and you never go to the doctor or have any healthcare expenses, the increase in taxes will not be offset by any reduced costs for you immediately.  (On the flipside, bankruptcy due to medical bills will no longer be a thing that happens, and you will have access to care.)  
  • If you are extremely wealthy, you will pay more in tax increases than will be offset by a reduction in healthcare costs.  (But your community will also be generally healthier and health risks overall will be reduced.)

Elizabeth Warren has pledged that taxes to cover a Medicare for All plan will actually not come from an increase in middle class taxes at all, but would come from tax increases in other places (corporate taxes, taxes on employers, wealth taxes, and tax increases on the wealthiest Americans).

It is also true that it may be more difficult to schedule appointments and access providers, as there will be more people with access to care.  More patients with the same number of healthcare providers will be a difficult problem that will require innovative solutions.

And in Elizabeth Warren’s plan, healthcare providers (doctors, hospitals, etc) will be required to accept lower costs than they do now for many procedures.  Ideally, this could be offset with the savings on overhead in managing insurance, but it’s not clear that this would be true.

The bottom line is that Single Payer is a very big shift in the way that Americans think about healthcare.  In theory, it’s the most cost-effective and efficient way to get healthcare for all Americans, but the transition to change our thinking and to change the industries that support healthcare would be tough.

Public Option (or “Medicare for All Who Want It”)

The public option approach essentially allows any American the option to select a health insurance plan that is managed by the federal government.  In other words, regardless of age, you could choose to enroll in Medicare instead of your employer’s plan. Those that do not have an employer option for health insurance today, and can’t afford private insurance, would be automatically enrolled and covered.   

In my opinion, Mayor Pete Buttigieg has articulated the clearest vision of this approach, although many of the other candidates have proposed similar programs.  

The advantages of a public option are also pretty significant:  

  1. Negotiating power for healthcare costs and prescription drug costs increases, and increases more as even more and more people enroll;
  2. Overhead costs start to decrease (albeit not as quickly or dramatically as a single payer option, given that private health insurance still exists);
  3. All Americans have an affordable option to buy in for insurance, with advantages in overall public health;
  4. Unlike single payer, it provides a choice for consumers, and so private insurance companies are now incentivized to compete with the public plan, potentially lower costs and increasing innovation and other perks;
  5. Because individuals buy into it (ostensibly with premiums based on income), the full cost of the program doesn’t have to be “made up for” in taxes or other revenue streams.

There are disadvantages, though – particularly over a single payer system:

  • Success of a public option depends a great deal on individuals choosing to adopt the plan.  More importantly, it depends on healthy, young people to be included in that group of people who buy into the plan.
  • There is less negotiating power and not as great of a decrease in overhead costs as a single payer system, as private insurance still exists.
  • There are still program costs to be covered by the federal government, as more individuals would be covered by insurance that is fully or partially subsidized.

For many, including Buttigieg, the assumption is that a public option approach will eventually lead to Medicare for All.  If the government provided program (“Medicare”) is a great option with lower costs and better coverage, then lots of Americans will want to use it.  As more people move over to it, private insurance companies either find a way to compete and offer better plans, or they simply start to fade away. 

Where do I land?

I am for a public option, rather than a straight transition to Medicare for All.  Even though I know all of the benefits of single payer, I’m naturally risk-averse; the public option approach is still a huge step forward in terms of the accessibility of healthcare coverage for all Americans, without requiring an enormous change quickly.  (For the same reason, I think it is also politically the better option, as it allows more people to get on board with change in phases.)

As always, if I said something incorrect or incomplete, please feel free to correct me in the comments.  If I was wrong, I’ll definitely update the post to ensure accuracy.  

Also, I do think there will be a third part in this series to address myths, because there are a lot of them out there related to the healthcare debate.

* I really dislike the arguments between candidates and their supporters about which candidate came up with an idea “first”.  However, I do feel the need to give credit to Sanders here, as this really has been one of his hallmark issues for decades.  

Tom Steyer: Bringing nothing new to a crowded table.

I’m not going to spend a lot time on this one.  I’ve followed Tom Steyer’s work over the years – he’s been an important Democratic fundraiser and he led an effort to push for the current President’s impeachment.  He’s also a billionaire who has pledged to give away half of his money prior to his death to good causes around the world.  I suspect he’s a decent fellow.

steyerHe brings nothing new to this Democratic field of candidates, as far as I can tell.  Steyer’s announcement video rehashes the same things the other candidates have already been talking about for months.

If you wait this long to get into the race, you are doing so because you either have an ego to feed, or you feel that you have something critical to the country’s future that other candidates are lacking.  I can’t see any evidence of the latter.

Kamala Harris: I just…yes.

kamalaI am not sure why my blog post about Kamala Harris has been so difficult to put together.  The honest truth is that I’m not totally sure why I like her so much.  I don’t even agree with many of her policy positions.  But she’s a bad ass woman who I can see leading this country in the right direction.  While Buttigieg still holds the top spot for me, my thoughts about Kamala Harris have evolved.

I had originally put Harris further down on my list, because her record on criminal justice has been … mixed.  But after her CNN Town Hall, I thought she did a reasonable job of defending that record.  I think she understands the issues of criminal justice reform better than almost any of the other candidates.

I am not a big fan of her flagship idea to raise teachers’ salaries.  I agree that we need to invest in education, including doing significant work to increase teachers’ salaries.  My dad, my sister, and so many of my friends were or are teachers; I deeply feel that they are all underpaid.  I just don’t know that this is the best way to spend dollars on education improvements.

Harris is also a supporter of a full stop Medicare-for-All program, with the virtual elimination of private insurance, except as supplemental insurance.  While I think that we are headed in this direction, I again think that it is too simple to say that we’re just going to jump here.  I believe we need a slower trajectory to this end goal, with a public option.

Even as I write my thoughts up in this post, I recognize that Harris in my second spot is not totally rational – but I like her.  I trust her. If a zombie apocalypse were upon us, I would be entirely comfortable with her in charge.

Buttigieg still has my vote, but if Harris is the nominee, I will happily sport a Kamala Harris For the People tee, put up a yard sign, and talk to my neighbors and friends about her.

Joe Biden: Crazy Uncle Joe

bidenJoe Biden is a known commodity.  His political career is older than I am – and I’m not exactly young.  He knows what is required of the office of the President through first hand, albeit not direct, experience.  Perhaps most importantly for many people, Biden can very likely beat the sitting President in the general election.

I don’t think any of those are good enough reasons to give him my vote in the primary.  Here are some reasons why I won’t:

  1. Biden voted for the Violent Crime and Law Enforcement Act of 1994 – a bill that has, in retrospect, been a disaster for this country.  A bad vote doesn’t have to be a deal breaker, if the candidate also sees it as a bad vote.  I can find no information that indicates that Biden sees this as the disastrous legislation that it was.
  2. Biden’s treatment of Anita Hill is, by now, an old story.  What’s not an old story is that he attempted to apologize to her for that treatment only weeks (maybe days) before formally announcing his 2020 candidacy.  It’s never too late to apologize, but sometimes it is the wrong time to apologize if you want anyone to believe that you were sincere.
  3. Last year, he was captured at a speaking event saying that he had no empathy for millennials.  In addition to be a really stupid thing for any politician to say, he used the Kent State shooting as an example of why things were hard for his generation – ignoring the epidemic of school shootings over the past twenty years.
  4. Biden’s attempt to be the bipartisan healer could be admirable, except that it has lead to him indicating (just today) that he would seek middle ground solutions on climate change.  The actual policy is a bit unclear in the details – two different sources seem to be provided slightly different accounts – but it’s the idea of “middle ground” when it comes to something as catastrophic as climate change.  You can talk about solutions that work well for the economy and the climate without seeking “middle ground”.  I am usually all for looking for middle ground, except that in this situation, it seems to undermine the sense of urgency that we absolutely need to be pushing when it comes to action on the climate.
  5. Biden has a habit of saying stupid shit and then laughing it off.  Crazy Uncle Joe.  He’s a gaffe machine.  Ha ha ha.  Except that words matter, and when a leader can’t be bothered to recognize that what he says has the power to hurt or heal, I can’t be bothered to listen to him.
  6. While I have absolutely no reason to believe that Joe Biden has ever crossed a line into sexual assault, his complete disregard for the fact that his handsy behavior makes people – mostly women and girls – incredibly uncomfortable is flat out inexcusable.  It’s been laughed off for years, but when he was finally forced to address multiple accounts of women saying that he made them uncomfortable, he took his normal path of a half-assed non-apology.  Within a week, he’d used the situation as a punchline at an event.

Biden does not have my vote in the primary, and it would take something pretty major to change my mind on that.  If he is the Democratic candidate, I will vote for him against the current President, but I can’t imagine myself as an enthusiastic campaign supporter.

Julián Castro: Struggling to stand out

castroJulián Castro had been mentioned as a possible Vice Presidential pick by Hilary Clinton in 2016, and I remember that I really wanted him to be the choice.  I am not sure now why I was so interested in Castro for the VP spot.  I wish I could recapture some of that enthusiasm for him.

I have no reason not to like Castro as a Democratic Presidential nominee.  I think there’s a good perspective coming into the race as a former cabinet Secretary, and Castro was the Secretary of Housing and Urban Development under Obama.  

Castro’s views on immigration align pretty well with my own, with a focus on our need to not only reform our immigration system, but also to recognize that we need to provide critical aid to Central America (among other places) to help families stay safely in their own countries.

I just wish Castro wasn’t quite so boring in interviews.  I’m as tired of writing the same thing as you guys are probably tired of reading it, but Julián Castro inspires zero excitement or interest in me.  

I really want someone to tell me I’m wrong.  Tell me what to watch to get inspired.  

Michael Bennet: I did not expect to like him

bennett_michael_senatorMichael Bennet was a surprise.  If I’m not mistaken, he’s the most recent entry into the Democratic primary race, and the very fact that anyone is choosing to get into the race at this point is annoying me.  (Mostly because I’m tired of sounding like a broken record in these blog posts.) And so I did not expect that I would be very interested in what he had to say.

Honestly, I really just like the way that he comes across.  He is very calm and reasoned.  There’s so many candidates right now, just the fact that I like his voice is enough to make me pay more attention.  I also like that in interviews I’ve seen with him so far, he makes a point of speaking well of other candidates in the race.  

My only minor negative on Bennet is that he seems to put climate change as a third priority behind the economy and democratic reform.  I honestly don’t know yet if that means he takes it any less seriously than others – it’s just that he talks about the other two as the top priorities.

I’m going to make a point to keep listening.  I might even donate to his campaign if he gets close to making it to the debates.  

Has anyone been following Bennet at all?  Anything I need to know that I haven’t found yet?


Seth Moulton: Meh, part deux.

I watched the WMUR Conversation with the Candidate for both Seth Moulton and Tim Ryan on the same day.  Moulton may have benefited from this comparison.  Overall, I found him to be reasonable, relatively intelligent, and a bit overly sincere.  (The guy has a heart-tugging story for everything.)

I generally like Moulton’s position on healthcare, where he is on the side of a strong public option.  (The “Medicare for all who want it” position.)

On education, he also does not believe that four year universities should be free, but rather suggests investing in high school and vocational schools to ensure that everyone can get a good education with skills necessary for the workforce.  

sethmoultonOn climate, Moulton is on board with the Green New Deal and he supports a carbon tax.  He also proposes a CCC-like service opportunity to provide jobs and implement infrastructure changes that would be more climate friendly.  Moulton also talked a bit about tax incentives for individuals and businesses who implement green energy sources.

Moulton is okay.  He’s middle of the pack for me. I could support him in the general election, but I have a hard time imagining that he’s going to capture enough attention to get there.

Any other opinions I should hear?  Interviews I should watch?


Tim Ryan: I’m not a fan

ryanIn such a crowded field of Democratic hopefuls, I do not have a lot of time to spend on each candidate.  First impressions matter.  After about 40 minutes with Tim Ryan, my first impression is that I am not at all a fan.

Substance-wise, Tim Ryan is hyper-focused on economic issues.  That’s not a terrible thing, but when he is given a chance to talk about his priorities, climate doesn’t get mentioned.  If you aren’t mentioning climate as a priority, I’m not really interested in your candidacy.

Personality-wise, I find Ryan to be a bit insufferable.  Honestly, this is based on a single set of interviews.  (WMUR Conversation with the Candidate.)  Maybe Tim Ryan was having a bad day.  Maybe *I* was having a bad day.  But with a large field, I’m not interested in spending more time with him.

Anyone have a reason I should reconsider?  Feel free to point me to resources that might change my mind.

John Hickenlooper: Déjà vu

hickenlooperI spent about an hour listening to the WMUR interview and town hall with 2020 Democratic candidate and former Governor John Hickenlooper on my drive to work.  After arriving to work, I wrote down three notes:

– Okay ideas on policing and education

– Foreign policy?

– Painful to listen to.

The last note is self-explanatory.  In the interview I watched, there were no foreign policy questions asked of Hickenlooper, so I noted that I had no perspective on where he stands.  And I can only barely remember what he said about policing and education.

Clearly, Hickenlooper did not come across as inspirational or even memorable.

In an effort for fairness, I looked up a few other articles that might be able to tell me why I should consider a vote for Hickenlooper, including this one from Vox and this one from FiveThirtyEight.  They were not particularly compelling.

Final verdict?

Hickenlooper is a moderate Democrat who describes himself as a “do-er” – and his record as Governor of Colorado is pretty decent.  However, he doesn’t strike me as any level of inspirational, at a time when we are in desperate need of inspiration.

Anyone feel differently about Hickenlooper?  There’s obviously a lot I don’t know about the guy – and with so many candidates, I’m not going to bother to do too much more research without a compelling reason.  Let me know if you think there is a compelling reason. 

Eric Swalwell: Meh.

swalwellFirst let me apologize to Representative Swalwell, as I’ve been spelling his name incorrectly for over a month now.  Something about the fact that it took me this long to notice says a lot about how I feel about his candidacy.  Meh.

I took the time this morning to pull together a YouTube playlist to listen to on my way to work of interviews with Eric Swalwell.  I tried to make sure I was pulling things from the last month, so that they represented his Presidential campaign. With so many candidates, I really just can’t spend hours on each one – so I admit that I’m coming to you with my opinion after only about an hour of assorted video clips.  As always, I welcome any feedback on what I’ve missed or where you think I’ve gotten something wrong.

Go Big. Be Bold. Do Good.

I actually really like his slogan.  It does seem to translate into some of the ideas that he’s ideas that he has.  Here are a few things I’ve heard that I like:

  • “Team of Rivals”

This was my favorite thing that I heard from him.  Swalwell has committed to a cabinet made up of both Democrats and Republicans.  He doesn’t seem naive enough to believe that this will be easy; he said that he may have to search high and low for Republicans willing to put country over party.  This also might turn out to be a colossally terrible idea. I love it because it appeals to my desire to see real bipartisan cooperation and conversation, but I am not the one who would have to implement it.  So I love the idea, and I’m highly skeptical of it’s efficacy.

  • “Medicare for all who want it”

He’s obviously aligned with Buttigieg on this one.  I’m assuming he’s also using Pete’s words, although it isn’t like it’s a phrase that’s been copyrighted.  Basically, Swalwell is for a robust public option. I have not heard him specifically spell out whether he means that to be a means to a full “Medicare for all” system eventually, or if he sees the public option as a long-term solution.

And then there are questions

Swalwell started out as a candidate focused on gun control – and he has big ideas here.  He wants universal background checks, as most of the country does. Swalwell also wants to make assault weapons illegal for private ownership, including proposing a buy back program for those that are already in private ownership.  I agree in principle, but I find myself questioning whether the buy back part of that is worth how contentious it might become.

I also love Swalwell’s commitment to “modernizing all public schools” in all communities, but I’m not clear on how much falls into federal versus state authority, how we would pay for those modernizations, and what programs we wouldn’t be able to fund if we did it.  It sounds like a great campaign promise, but I need more detail.

Finally, I have been surprised by how little I’ve heard about climate change from Swalwell.  He supports the Green New Deal, but doesn’t seem to talk a lot about specifics. Maybe it’s because he’s trying to focus on the things that others aren’t?  The unfortunate thing about such a large pool of candidates is that a.) I don’t have time (and they don’t have the media attention) to focus on every issue, and b.) if a candidate is going to focus on policy ideas, I’m going to assume that the candidate’s priorities fall on the policies they talk about the most.  

So in summary…

I’m not opposed to a Swalwell candidacy, but I still have questions and I’m generally uninspired.  I do not feel like his priorities align that well with mine, I don’t think he’s compelling enough to make it to the end of this primary, and I probably won’t spend a ton of time learning more about him.

What did I miss?  What am I wrong about?