What Is a Public Option for Health Insurance?

As the healthcare debate rages on, interest in a public option is springing up among proponents of the Affordable Care Act, who would rather refine the law than repeal it.

Republicans argue that the recently passed American Health Care Act (their current replacement bill for the ACA) would increase coverage, yet initial analysis from the Congressional Budget Office and other independent organizations find that millions fewer people would actually be covered.

So if universal, or near universal, coverage is the goal, what's an alternative to the Republican alternative?

Some Democrats, notably Vermont Senator Bernie Sanders, have endorsed a "public option" within the ACA exchange framework. Here's what that means.

What Is a Public Option?

There are primarily two types of public options discussed in the healthcare debate: The first is the expansion of existing government programs, like Medicare and Medicaid. The second is the creation of a new government-run plan for those under 65, that would compete against private insurers in the individual market exchanges. We're focusing on the latter, since that's more easily implemented.

An increasing number of counties in the U.S. (around 20-25%) had just one insurer option in the ACA exchanges this year, and the number of counties will likely grow in 2018. The creation of a new public healthcare plan would intentionally fill the gaps in counties where insurance options are limited, offering consumers choice and competitive pricing. The point is to ensure that all Americans in the individual market have access to an affordable healthcare plan, even if private insurers raise rates or exit the market.

Ideally, the public plan would offer the same coverage and benefits nationwide, with price varying depending on region. But with Republicans in control of Congress and the White House, it would likely need to be introduced state-by-state to be implemented soon.

It's not a new idea: It was first embraced by John Edwards in 2008, and subsequent Democratic presidential candidates have also promoted the idea. When the ACA was written, a public option was included in draft versions of the bill, but it was ultimately omitted, due to steadfast opposition from Republicans and withdrawal of support from moderate Democrats.

Though a public option and single payer system are often discussed in tandem, they are very different. A public option is a single plan that would exist alongside private plans, while single payer refers to an entire public healthcare system. Think of the public option as Medicare for More, whereas single payer is often called Medicare for All.

Helen Halpin, a professor at the U.C. Berkley School of Public Health, says the introduction of a public option could help transition the U.S. to a single-payer program down the road. "The premium will be less expensive and the coverage will probably be better," she says.

Benefits of a Public Option

Proponents argue that a public option modeled after Medicare would increase coverage while lowering costs for consumers, and would be far easier to implement than a complete overhaul of the current system.

This is partly because administrative and billing costs would decrease significantly, and partly because the government would be able to bargain more aggressively with drugmakers, medical device manufacturers, hospitals, etc., like it does for those enrolled in Medicare. Plus, public plans don't have to worry about turning a profit like private plans do. Add that all together, and the Congressional Budget Office has estimated that premiums for the public option plan would be at least 7 to 8% less expensive than private plans offered in the marketplace (that could be a conservative estimate: other reports put the savings higher).

Ultimately, Halpin says, it comes down to choice. "What’s more American than giving everyone the choice? It doesn’t force anyone into anything," she says. "If you want private insurance, you can have that, and if you want public insurance, you can have that."

Criticisms of a Public Option

The public option has critics on both sides of the aisle. Conservatives argue it is incompatible with a free market and lets the government interfere too much in an individual's healthcare. Some Democrats, on the other hand, believe it does not go far enough, and promote the single-payer system instead.

For conservatives, getting the federal government more involved in the healthcare system is loathed. And some care providers worry that government involvement would lead to lower payment rates and increased government control over healthcare more generally. Some economists worry that a public option plan would lead to reduced access to care, as physicians might be unwilling to accept the lower payments. Insurance companies, naturally, detest the idea of a public plan competing against them that can offer lower premiums.

There's also the question as to whether there should be one standard national plan, or if the states should design their own program and designate rates.

Like single payer, the biggest disadvantage the public option faces is public opinion about how involved the federal government should be in Americans' healthcare.