Public health insurance option
The public health insurance option, also known as the public insurance option or the public option, was a proposal to create a government-run health insurance agency which would compete with other health insurance companies within the United States. The public option is not the same as publicly funded health care, but was proposed as an alternative health insurance plan offered by the government. The proposal was initially part of the debates surrounding the Patient Protection and Affordable Care Act, but was not passed in the final reconciled bill.
The public option was featured in three bills considered by the United States House of Representatives in 2009: the proposed Affordable Health Care for America Act (H.R. 3962), which was passed by the House in 2009, its predecessor, the proposed America's Affordable Health Choices Act (H.R. 3200), and a third bill, the Public Option Act, also referred to as the "Medicare You Can Buy Into Act", (H.R. 4789). In the first two bills, the public option took the form of a Qualified Health Benefit Plan competing with similar private insurance plans in an internet-based exchange or marketplace, enabling citizens and small businesses to purchase health insurance meeting a minimum federal standard. The Public Option Act, in contrast, would have allowed all citizens and permanent residents to buy into a public option by participating in the public Medicare program. Persons covered by other employer plans or by state insurance plans such as Medicare would have not been eligible to obtain coverage from the exchange. The federal government's health insurance plan would have been financed entirely by premiums without subsidy from the Federal government, although some plans called for government seed money to get the programs started.
President Barack Obama promoted the idea of the public option while running for election in 2008. Following his election, Obama downplayed the need for a public health insurance option, including calling it a "sliver" of health care reform, but still campaigned for the option up until the health care reform was passed.
Ultimately, the public option was removed from the final bill. While the United States House of Representatives passed a public option in their version of the bill, the public option was voted down in the Senate Finance Committee and the public option was never included in the final Senate bill, instead opting for state-directed health insurance exchanges. Critics of the removal of the public option accused President Obama of making an agreement to drop the public option from the final plan, but other journalists pointed out that the agreement was probably based more on vote counts than backroom deals, as substantiated by the final vote in the Senate.
The purpose behind the public option was to make more affordable health insurance for uninsured citizens who are either unable to afford the rates of or are rejected by private health insurers. Supporters argued that a government insurance company could successfully lower its rates by using greater leverage than private industry when negotiating with hospitals and doctors, as well as paying the employees of the public option insurance company salaries as opposed to paying based on individual medical procedures.
Supporters of a public plan, such as Washington Post columnist E. J. Dionne, argue that many places in the United States have monopolies in which one company, or a small set of companies, control the local market for health insurance. Economist and New York Times columnist Paul Krugman also asserted that local insurance monopolies exist in many of the smaller states, accusing those who oppose the idea of a public insurance plan as defenders of local monopolies. He also argued that traditional ideas of beneficial market competition do not apply to the insurance industry given that insurers mainly compete by risk selection, claiming that "[t]he most successful companies are those that do the best job of denying coverage to those who need it most."
Economist and former US Secretary of Labor Robert Reich argued that only a "big, national, public option" can force insurance companies to cooperate, share information, and reduce costs while accusing insurance and pharmaceutical companies of leading the campaign against the public option.
Many Democratic politicians were publicly in favor of the public option for a variety of reasons. President Obama continued campaigning for the public option during the debate. In a public rally in Cincinnati on September 7, 2009, President Obama said: "I continue to believe that a public option within the basket of insurance choices would help improve quality and bring down costs." The President also addressed a Joint Session of Congress on September 9, 2009, reiterating his call for a public insurance option, saying that he had "no interest in putting insurance companies out of business" while asserting that the public option would "have to be self-sufficient" and succeed by reducing overhead costs and profit motives. Democratic Representative Sheila Jackson-Lee, who represents the 18th congressional district in Houston, believed that a "vigorous public option" would be included in the final bill and would "benefit the state of Texas."
The final bill, the Patient Protection and Affordable Care Act, included provisions to open health insurance exchanges in each state by October 1, 2013. As the Act requires Americans to purchase health insurance, the federal government will offer subsidies to Americans with income levels up to four times the federal poverty level.
An alternative proposal is to subsidize private, non-profit health insurance cooperatives to get them to become large and established enough to possibly provide cost savings Democratic politicians such as Howard Dean were critical of abandoning a public option in favor of co-ops, raising questions about the ability of the cooperatives to compete with existing private insurers. Paul Krugman also questioned the ability of cooperatives to compete.
While politically difficult, some politicians and observers have argued for a single-payer system. A bill, the United States National Health Care Act, was first proposed by Representative John Conyers in 2003 and has been perennially proposed since, including during the debate on the public option and the Patient Protection and Affordable Care Act. President Obama has come out against a single-payer reform at this time, stating in the joint session of Congress that "it makes more sense to build on what works and fix what doesn't, rather than try to build an entirely new system from scratch." Obama had previously expressed that he is a proponent of a single payer universal health care program during an AFL-CIO conference in 2003.
A number of alternatives to the public option were proposed in the Senate. Instead of creating a network of statewide public plans, Senator Olympia Snowe proposed a "trigger" in which a plan would be put into place at some point in the future in states that do not have more than a certain number of private insurance competitors. Senator Tom Carper has proposed an "opt-in" system in which state governments choose for themselves whether or not to institute a public plan. Senator Chuck Schumer has proposed an "opt-out" system in which state governments would initially be part of the network but could choose to avoid offering a public plan.
In January 2013, Representative Jan Schakowsky and 44 other U.S. House of Representatives Democrats introduced H.R. 261, the "Public Option Deficit Reduction Act" which would amend the 2010 Affordable Care Act to create a public option. The bill would set up a government-run health insurance plan with premiums 5% to 7% percent lower than private insurance, with the Congressional Budget Office estimating a reduction in the United States public debt by $104 billion over 10 years.
Opposition and criticism
Both before and after passage in the House, significant controversy surrounded the Stupak–Pitts Amendment, added to the bill to prohibit coverage of abortions – with limited exceptions – in the public option or in any of the health insurance exchange's private plans sold to customers receiving federal subsidies. In mid-November, it was reported that 40 House Democrats would not support a final bill containing the Amendment's provisions. The Amendment was abandoned after a deal was struck between Representative Bart Stupak and his voting bloc would vote for the bill as written in exchange for the signing of Executive Order 13535.
Michael F. Cannon, a senior fellow of the libertarian CATO Institute, has argued that the federal government can hide inefficiencies in its administration and draw away consumers from private insurance even if the government offers an inferior product. A study by the Congressional Budget Office found that profits accounted for less than 3% of private health insurance premiums, and Cannon argued that the lack of a profit motive reduces incentives to eliminate wasteful administrative costs.
Dr. Robert E. Moffit of the Heritage Foundation has argued that a public plan in competition in private plans would likely be used as a "dumping ground" for families and individuals with higher than average health risks. This, in his view, would lead to costs that business should pay being passed onto the taxpayer.
Marcia Angell, M. D., Senior Lecturer in the Department of Social Medicine at Harvard Medical School and former Editor-in-Chief of the New England Journal of Medicine, believes that the result of a public option would be more "under-55's" opting to pay the fine rather than purchase insurance under a public option scenario, instead advocating lowering the Medicare age to 55.
The chief executive of Aetna, Ron Williams, argued against the public option based on issues of fairness. On the News Hour with Jim Lehrer, Williams noted that a public option creates a situation where "you have in essence a player in the industry who is a participant in the market, but also is a regulator and a referee in the game". He said, "we think that those two roles really don't work well."
Public polling consistently showed majority support for a public option. A July survey by the Quinnipiac University Polling Institute found that 28% of Americans would like to purchase a public plan while 53% would prefer to have a private plan. It also stated that 69% would support its creation in the first place. Survey USA estimated that the majority of Americans (77%) feel that it is either "Quite Important" or "Extremely Important" to "give people a choice of both a public plan administered by the federal government and a private plan for their health insurance" in August 2009. A Rasmussen Reports poll taken on August 17–18 stated that 57% of Americans did not support the current health care bill being considered by Congress that did not include a public option, a change from their findings in July 2009. A NBC News/Wall Street Journal poll, conducted August 15–17, found that 47% of Americans opposed the idea of a public option and 43% expressed support. A Pew Research Center report published on October 8, 2009 stated that 55% of Americans favor a government health insurance plan to compete with private plans. The results were very similar to their polling from July, which found 52% support. An October 2009 Washington Post/ABC poll showed 57% support, a USA Today/Gallup survey described by a USA Today article on October 27 found that 50% of Americans supported a government plan proposal, and a poll from November 10 and 11 by Angus Reid Public Opinion found that 52% of Americans supported a public plan. On October 27, journalist Ray Suarez of The News Hour with Jim Lehrer noted that "public opinion researchers say the tide has been shifting over the last several weeks, and now is not spectacularly, but solidly in favor of a public option."
Between October 28 and November 13, 2009, Democratic Senator Dick Durbin's campaign organization polled Americans to rank their support for various forms of the "public option" currently under consideration by Congress for inclusion in the final health care reform bill. The 83,954 respondents assigned rankings of 0 to 10. A full national option had the most support, with an 8.56 average, while no public option was least favored, with a 1.10 average.
A survey designed and conducted by Drs. Salomeh Keyhani and Alex Federman of Mount Sinai School of Medicine done over the summer of 2009 found that 73% of doctors supported a public option. A survey reported by the New England Journal of Medicine in September, based on a random sample of 6,000 physicians from the American Medical Association, stated that "it seems clear that the majority of U.S. physicians support using both public and private insurance options to expand coverage."
Conversely, an IBD/TIPP poll of 1,376 physicians showed that 45% of doctors "would consider leaving or taking early retirement" if Congress passes the health care plan wanted by the White House and Democrats. This poll also found that 65% of physicians oppose the White House and Democratic version of health reform. Statistician and polling expert Nate Silver has criticized that IBD/TIPP poll for what he calls its unusual methodology and bias and for the fact that it was incomplete when published as responses were still coming in.
- Why We Need a Public Health-Care Plan Robert Reich The Wall Street Journal
- e.g. House Bill H.R.3962 Section 322 (b)2(B) "AMORTIZATION OF START-UP FUNDING- The Secretary shall provide for the repayment of the startup funding provided under subparagraph (A) to the Treasury in an amortized manner over the 10-year period beginning with Y1". The Senate HLP Committee bill contains a similar clause in § 3106 "A Health Benefit Plan Start-up Fund will be created to provide loans for initial operations, which the plan will be required to pay back no later than 10 years after the payment is made."
- Wangsness, Lisa (June 21, 2009). "Health debate shifting to public vs. private". Boston Globe. Retrieved September 21, 2009.
- Kranish, Michael (August 19, 2009). "Health co-ops’ fans like cost and care: But successful models still rare nationwide". The Boston Globe.
- Obama, Congress easing debate on public option - Beaver County Times
- CNN: Senate panel votes down public option for health care bill. September 29, 2009.
- Bankrate: Key details of health reform bills.
- David D. Kirkpatrick, August 12, 2009, "Obama is taking an active role in talks on health care plan," New York Times, http://www.nytimes.com/2009/08/13/health/policy/13health.html
- Washington Post: Obama never secretly killed the public option. It’s a myth.. November 17, 2011.
- Gauvey Herbert, David (January 2, 2011) "Public Option", National Journal.
- Washington Post: 8 Questions About Health-Care Reform.
- Paul Krugman (2009-06-22). "Competition, redefined". The New York Times. Retrieved 2009-10-10.
- "Robert Reich Public Option Video".
- "How Pharma and Insurance Intend to Kill the Public Option, And What Obama and the Rest of Us Must Do".
- "Obama: Public option should be part of reform". MSNBC.com. 2009-09-07.
- Weiner, Rachel (September 9, 2009). "Obama Health Care Speech: FULL VIDEO, TEXT". Huffington Post.
- Houston Chronicle: Jackson Lee predicts “vigorous public option” on health care. July 31, 2009
- CNN: The marketing of Obamacare exchanges begins. June 21, 2013.
- Kranish, Michael (August 19, 2009). "Health co-ops’ fans like cost and care: But successful models still rare nationwide". The Boston Globe.
- Are health care co-ops the answer for reforming the system? - Kansas City Star
- New York Times: Baucus and the Threshold, Paul Krugman, September 17, 2009
- Colliver, Victoria (May 30, 2009). "Health care activists lament single-payer snub". San Francisco Chronicle. Retrieved October 10, 2009.
- H.R. 676
- "House Reps Introduce Medicare-for-All Bill" Becker's Hospital Review, Feb. 14, 2013
- Remarks by the President to a joint session of Congress on health care
- Obama on single payer health insurance - Youtube
- Ezra Klein. "A guide to the public option compromises in the Senate". The Washington Post.
- "House Dems push again for creation of government-run health insurance option" The Hill, January 16, 2013
- Alec MacGillis, "Health-care reform and abortion coverage: Questions and answers", Washington Post, November 14, 2009.
- Molly Hooper, "Cantor: Public option poll 'skewed'", Blog Briefing Room, 10/21/09
- Michael F. Cannon (August 6, 2009). "Fannie Med? Why a "Public Option" Is Hazardous to Your Health" (PDF). CATO Institute. Retrieved October 10, 2009.
- "Government as "Competitor": The Latest Prescription for Government Control of Health Care". Heritage Foundation. August 14, 2008.
- The Huffington Post: "Is the House Health Care Bill Better than Nothing?" Marcia Angell, M. D., November 9, 2009.
- "Aetna CEO: Public Insurance Option 'Wrong Way to Go'". News Hour with Jim Lehrer. August 18, 2009.
- "U.S. Voters Back Public Insurance 2-1, But Won't Use It". Quinnipiac University. July 1, 2009. Retrieved September 4, 2009.
- "News Poll #15699 "Health Care Data Gathered Using NBC News Wall Street Journal Questions" on 8/19/09". SurveyUSA. August 20, 2009.
- "57% oppose reforming healthcare without including the public option". Rasmussen Reports.
- "50% Oppose Government Health Insurance Company". Rasmussen Reports. July 17, 2009. Retrieved August 28, 2009.
- Murray, Mark (August 18, 2009). "NBC poll: Plurality opposes public option". MSNBC.com. Retrieved August 27, 2009.
- "Mixed Views of Economic Policies and Health Care Reform Persist". Pew Research Center. October 8, 2009. Retrieved October 9, 2009.
- Washington Post: Public option gains support. October 20, 2009.
- Fritze, John (October 27, 2009). "Dems Advance opt-out 'public option'". USA Today.
- Connelly, Joel (November 20, 2009). "New Poll: Voters back, but also fear, health reform". Seattle Post-Intelligencer.
- Dick Durbin Public Option Poll Results GetActive Software, Inc., 16-Nov-2009
- Shapiro, Joseph (September 14, 2009). "Poll Finds Most Doctors Support Public Option". National Public Radio. Retrieved October 10, 2009.
- Salomeh Keyhani, M.D., M.P.H., and Alex Federman, M.D., M.P.H. "Doctors on Coverage — Physicians’ Views on a New Public Insurance Option and Medicare Expansion" NEJM • September 14th, 2009.
- IBD/TIPP doctors poll is not trustworthy