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.  

Pete Buttigieg: For so many reasons


Photo from Vogue, April 2019.

It’s no secret that Mayor Pete Buttigieg has my vote in the primary.  I could happily support most of the candidates currently running in the general election if he does not end up being the candidate, but I believe with every fiber of my being that Buttigieg is the person that we need in the Oval Office in 2021.

There’s no shortage of media coverage to try to explain why Buttigieg has captured people’s attention, but I still think it is worth explaining why he’s captured MY attention.

  • Demeanor and personality

The person who sits in the office of the US President leads the nation – and the world – by personal example.  It’s not entirely about what the individual does in terms of policies; it’s also about what that person does in terms of how they speak about other people, what they choose to focus attention on, and where they show up literally and figuratively.  Personality matters.  Personal integrity matters.

Buttigieg has a calm, thoughtful presence, with a humility and integrity that seems to be fully genuine.  He is also, however, incredibly confident and at ease with himself.  It’s the combination of those things that make him so compelling.

  • Allow and invite people to evolve

Of all of the things that Buttigieg has articulated that seem to have been pulled from my own brain, his understanding that “bad habits and bad instincts are not the same as people being bad people”.  (Time, May 2, 2019.)  This is a fundamental truth that guides the way that I personally try to engage with people, and while it might sound obvious, it is also very often misunderstood.

The pace of social change has been pretty swift over the past few decades.  Not everyone is able to keep pace with that change; people come around to important social changes at different speeds.  When Barack Obama was elected to the Presidency, he did not necessarily support full marriage equality.  However, through the engagement and advocacy of any number of LGBT leaders, he evolved in his understanding and we now give him the grace to consider him an LGBT ally.  Someone who, today, is still struggling to complete that same evolution is not likely to be engaged in compassionate dialogue about their view, rather they may be criticized and preached to about their wrong-headedness.  Shame and condemnation isn’t likely to bring about an evolution to the right side of history.  People need to be invited to evolve.

Buttigieg tells a story in his book and often on the campaign trail about an older, conservative woman in South Bend who met his then-boyfriend Chasten, and later told the Mayor that his “friend” was wonderful.  Rather than be critical of this woman coming up short on using the word “boyfriend”, he recognized her effort to move in the right direction and simply accepted the compliment.

  • Fairness versus Mercy

One of the other subtleties that Buttigieg seems to understand and articulate better than anyone I’ve ever heard before is the difference – and the battle – between what is fair and what is merciful.  (It’s similar, albeit from a different perspective, of the difference between equality and equity.)

There is already some concept of fairness versus mercy built into our system.  A woman who kills a violently abusive husband is likely to serve a lesser sentence than a woman who might kill her husband because she finds out he’s cheating.  (I recognize that our criminal justice system lacks both fairness and mercy in so many other ways.)

Governing means creating a system (criminal justice, immigration, foreign policy, etc) that is fair, but that allows for mercy when necessary.

  • Technical Problems versus Moral Problems

Similar to the challenges of fairness versus mercy, Buttigieg explains his understanding that governing requires the ability to solve both technical problems and moral problems.  The technical problems have a solution that can be defined and implemented.  Often, however, a technical problem can have more than one possible solution – none of which is without negative consequences.

It then becomes a moral problem.  Which solution provides the best positive result with the least negative impact?  Those are answers that cannot be quantified, but rather require a leader who is able to gather the right input, evaluate the options, and make and implement the best decision.  And, perhaps most importantly, takes personal responsibility for that decision whether it ultimately proves to be the right one or not.

If I can point to a single leadership trait that is most important to me, it is this – and the fact that Buttigieg not only displays this type of leadership, but is able to be self-aware enough to TALK about it… That says a lot to me.

  • Campaign versus Reality

Buttigieg is not entirely alone in his willingness to articulate that the policies that are laid out on the campaign are not always possible to translate into governing reality.  Most voters know this at some level, but we still look for candidates to tell us what they plan to do, because it highlights their priorities.  What I appreciate about Buttigieg’s approach to the campaign, though, is that he wants voters to understand his priorities in terms of values and moral compass before he creates the policy detail that often then becomes a distraction.  (I’m planning to talk about this a little bit more in another blog post.)

  • Reclamation of Faith, Freedom, Security and Democracy

This is at the bottom of my list, not because it is the least important to me, but because it is the most understood by those following the campaign.  Buttigieg ran for DNC chair in 2017 for much the same reason – he recognizes that conservatives have done a great job of continuous framing traditional American values in conservative terms.  Even the concepts of patriotism and the American flag have become more recognized in terms of conservative messaging than progressive messaging.

I believe – and there might be another blog post coming about this, too – that Buttigieg’s primary purpose in entering the Democratic primary was to get this message in front of the Democratic party and its leaders.  As Democrats, we believe in freedom, security and democracy.  Our party is made of many people of many faiths.  Our values align with these core ideas.  It’s time that we started helping a larger audience understand it.

This is the first of a planned six part series of blog posts on why Buttigieg is my candidate in the primary, so stay tuned for more.  Eventually.