We’ve long known this: A health care system hinged on employer-sponsored insurance is unequal, inefficient, and ill-equipped for an employment crisis.
Amid a global pandemic and unprecedented job loss, no one can argue this: The US’s patchwork health insurance system has needlessly imperiled the lives and economic security of many, especially our nation’s most vulnerable.
Per this month’s Journal of General Internal Medicine, “18 million adults at increased risk of severe COVID-19 were inadequately insured and hence at risk of delay in seeking care because of cost concerns and of financial toxicity if hospitalized . . . 5.7 million Americans at high risk for severe COVID-19 are uninsured.” Black, Latinx, and Indigenous people—and those with low incomes—are disproportionately represented in that at-risk group.
This moment demands bolder, more inclusive, and more humane health care policy. As Roosevelt Fellow Naomi Zewde and Lafayette College’s Adam Biener describe in a new report, written before COVID-19 struck, some states had already begun exploring better options—including a public option. In the process, they’re encountering substantial constraints.
Ten years after passage of the Affordable Care Act (ACA), and after the legislative failure of a Medicare public option bill, public option proposals now draw majority support, as do broader single-payer overhauls. But with this Congress unlikely to act on either, Zewde and Biener explain, states are experimenting with public options of their own, navigating the trade-offs inherent in lowering plan costs and expanding access without compromising market stability or the breadth of provider networks.
As the report notes, there’s no one way to do it.
The New Mexico legislature, for example, has paid particular attention to a targeted Medicaid buy-in among the possible forms of state public options they studied. By contrast, Colorado and Washington—the latter is the only state to have passed a public option bill into law thus far—will contract with existing private insurance companies to implement a public option much more similar to private insurance, for which consumers can apply ACA subsidies.
These state public options would mark an improvement over the status quo, but they could constrict provider networks in ways that a federal public option wouldn’t. “Whereas nearly as many physicians and facilities accept patients with Medicare as with private insurance, far fewer providers accept Medicaid patients,” Zewde and Biener write. Moreover, any public option must contend with the dual charge not to destabilize the competing private market. That can inherently limit the potential to offer a high-quality, low-cost alternative to private insurance, especially when private insurers are the ones assigned the task.
To that end, many state legislatures—including New York’s—were thinking (if not yet voting) bigger: universal single-payer coverage, with “no narrow networks, no eligibility rules, [and] no ‘churning’ in and out of coverage when you change jobs,” as Zewde wrote in a blog post last year.
COVID-19 has both complicated these efforts and exacerbated the consequences of earlier inaction. Several states, including New York, have proposed Medicaid cuts to balance strained budgets. Meanwhile, 14 states have still not adopted the Medicaid expansions embedded in the ACA, depriving lower-income people of health care they desperately need and disproportionately harming Black people, who are more likely to live in these predominantly Southern states.
Nevertheless, the state level is where some of the boldest health policymaking is happening—and has to happen—right now.
During a conference call earlier this year, President Trump advised the nation’s governors not to wait for the federal government to supply respirators—“try getting it yourselves.” When it comes to more affordable and accessible health care, states have been following that advice for years. The insights of their policy experiments will be invaluable whenever the federal government is willing to build the equitable, efficient, and resilient national health care system we all deserve and need.