Skyrocketing medical bills. Overflowing hospitals with limited staff and lack of equipment. Confusion over what specific insurance plans will cover and what they won’t.
These are only a few of the factors that are currently fueling uncertainty and fear surrounding how the United States’ healthcare infrastructure is handling the unprecedented demands brought on by the COVID-19 pandemic, further driving the debate over how best to reform our system.
Throughout the Democratic presidential primary, former Vice President Joe Biden has championed the idea that “a public option” — which would be added to the current Affordable Care Act (ACA), or “Obamacare” — would greatly improve healthcare in America.
In early June, Biden secured enough pledged delegates in the Democratic Party presidential primary to be considered the presumptive nominee. He won’t officially be nominated by his party until they hold their convention in August.
While the general election fight with President Donald Trump is only just shaping up, two starkly different approaches to healthcare will be on the ballot.
If Biden is elected president in November and he’s able to get a public option passed as part of a healthcare reform package, would our healthcare system be better equipped to handle pandemics and public health crises like COVID-19?
Healthline spoke with several health policy experts to get their opinions on how effective a public option could be, what’s wrong with our current system, and where we should go from here.
What is a ‘public option?’
Generally, a public option is the idea that a government-controlled health insurance plan would exist in competition with private health insurance plans.
It’s different from Medicare for All, which Senators Bernie Sanders and Elizabeth Warren advocated for throughout the Democratic primary.
“A public option is not a 0-1 choice — it has many shades and variations,” said John McDonough, DrPH, MPA, a professor of public health practice in the department of health policy and management at the Harvard T.H. Chan School of Public Health and director of executive and continuing professional education.
McDonough worked on the development and passage of the ACA as a senior advisor on national health reform to the U.S. Senate Committee on Health, Education, Labor, and Pensions.
He told Healthline that if a non-watered down public option was developed at the national level that “attracts far more people into coverage,” then it “would enhance the country’s ability to respond to epidemics like COVID-19.”
Karen Pollitz, a senior fellow at the Kaiser Family Foundation (KFF), said discussions about a “public option” are complicated because it’s a broad term and there’s no one-size-fits-all approach.
“When it comes to ‘public option’ proposals, there are a bunch of them and we have a bunch of public options,” Pollitz, who works on the Program for the Study of Health Reform and Private Insurance at KFF, told Healthline.
She said Medicare (available to everyone 65 and over) and Medicaid, are examples of current “public options,” with the latter providing complications given “it’s a different ‘public option’ for different states, under the ACA,” leaving no universal standard for who qualifies state-to-state.
Pictured above: Luis Mora stands in front of the closed offices of the New York State Department of Labor on May 7, 2020 in the Brooklyn borough in New York City. He’s one of millions of Americans who have filed for unemployment insurance and are worried about the cost of continued healthcare coverage. Photo by Stephanie Keith/Getty Images
How a national public option might help during a pandemic
If a national public option were to pass and be signed into law, McDonough said the nation’s healthcare system would see significant change.
“If a public option were created in the more aggressive direction, it could create some significantly lower cost health insurance options for consumers that do not limit benefits or eligibility. Depending how aggressive, it could also create disruption in hospital and physician markets,” he explained.
However, he said any final version of a public option-containing health plan would likely be “awfully watered down from the full-strength formula,” due to Republican opposition and some queasiness from Democrats whose seats would be on the line.
Pollitz said that if there was a government-supported nationalized system like Medicare for All or a national public option like the one Biden is proposing, any move toward universal coverage would be transformative in the time of a crisis.
If all patients had access to government-funded insurance, they wouldn’t be charged exorbitant fees anymore. Also, fears over whether a given facility would accept one’s insurance would no longer be a problem either.
Nevertheless, she said this wouldn’t mean all problems would be solved. For instance, with the current pandemic, competing COVID-19 tests are being developed.
Under a national public option, would the federal government cover tests from private entities as well as those from the Centers for Disease Control and Prevention (CDC)? Would it just cover some?
“I’m sure some of the manufacturers would say, ‘well, I’m not going to invest in this right now if I’m only going to be paid 50 dollars. I want to be paid 500 dollars,’ for instance,” she added.
Beyond this, public option proposals are also complicated in that they don’t necessarily solve the issue of doctors and hospitals who might reject the government-provided coverage.
In other words, just because a public option would provide more access to affordable coverage, it doesn’t necessarily mean that all physicians would accept that coverage.
Why wouldn’t doctors and hospitals accept a public insurance option?
Pollitz and four of her KFF colleagues explored this and other topics in an analysis of the potential national impacts that Democratic Party public option proposals could have.
In their paper, the healthcare researchers point out that some healthcare providers are currently against public option proposals over concerns of being paid less than they’ve been accustomed to through private insurance plans.
The current Medicare program, for instance, offers people a broad network of participating providers. If a public option instituted through a new presidential administration is enacted — and isn’t tied to the Medicare system at all — it could result in a much smaller selection of participating providers throughout the country.
If participation was voluntary, it could also potentially prevent the U.S. government from establishing lower payment rates across the board.
A more uniform system would be possible if all providers participated in a public option system, according to the KFF researchers.
What Biden’s healthcare plan proposes
If Biden wins the presidency, McDonough said it’s “fairly certain” his administration would prioritize “improving and expanding coverage and protections within the ACA structure, including lower premiums and cost sharing, prescription drug pricing controls, and other mechanisms to expand coverage to lower the number of uninsured.”
He said this would likely be at the top of the new administration’s to-do list in the aftermath of the unprecedented COVID-19 pandemic.
The Biden campaign did not respond to Healthline’s request for comments. However, on Biden’s official campaign website, the public option factors heavily in his healthcare messaging.
“The Biden Plan will give you the choice to purchase a public health insurance option like Medicare. As in Medicare, the Biden public option will reduce costs for patients by negotiating lower prices from hospitals and other health care providers," the site reads. “It also will better coordinate among all of a patient’s doctors to improve the efficacy and quality of their care, and cover primary care without any co-payments. And it will bring relief to small businesses struggling to afford coverage for their employees."
How COVID-19 has exposed our current system’s flaws
As more people contract the virus and seek care, Pollitz explained that they will keep running into brick walls blocking access to affordable care.
While the Families First Coronavirus Response Act signed into law has the provision ensuring free COVID-19 testing, Pollitz said loopholes exist over just how “free” coronavirus-related care is.
For example, she pointed out that you could visit a drive-thru testing site or visit an in-network urgent care center that could send the test to be processed at an out-of-network lab, resulting in you being billed by that lab.
She said that while Congress “took a bold step in this first act to make sure free testing is available to everyone, you still have to find the test which is a big challenge and then make sure that everybody involved in that test is in-network.”
You could also visit a healthcare facility because you’re experiencing a fever or cough and not be administered a test and end up being diagnosed with the flu. Then “you could be charged for that visit,” Pollitz said.
The major risk of these barriers baked into our current system is that they could dissuade people from seeking care in the first place.
If an individual is unclear if a hospital near them would even take their insurance, they might not go at all.
“There’s tremendous uncertainty for people. You might be sitting at home and not sure if you have it. Your chest is going tight and your fever is going up but you don’t know if you should go in to pursue a test because you aren’t 100 percent sure you won’t be charged,” she explained.
This has a domino effect, generating uneasiness around cost that can extend to not even seeking remote telemedicine services or stopping by the local clinic.
The result? People potentially at risk are scared away from COVID-19 treatments because they’re more wary of their medical bills than the deadly virus itself.
For his part, McDonough said the gaps in our health system exposed by the pandemic are “many and widespread.”
“On coverage, we don’t have as many people insured as we should, and that creates financial hardships for patients and providers. On the provider system, we are sorely lacking in surge capacity and in sufficient reserves of life-essential equipment such as masks and gowns and ventilators,” he said.
Beyond this, he stressed the federal government was simply “sorely unprepared,” especially since it dismantled “key offices created in the wake of the Zika crisis.”
“This was a staggering bungle by the Trump Administration, and no one in the Administration has had the integrity to explain how and why this was done,” McDonough added.
How COVID-19 has highlighted systemic racism in healthcare
Right in the middle of this current debate over healthcare reform that’s been front-and-center in the presidential election, a separate, but crucially related issue has emerged — racial justice.
Around the time that Biden was zooming to clinch the needed number of delegates to be the presumptive nominee, multiple tragedies of violence against Black people in America made headlines.
Breonna Taylor, a 26-year-old medical technician, was fatally shot by police officers who entered her Louisville, Kentucky apartment on March 13.
Two months later, on May 23, George Floyd was gruesomely murdered in Minneapolis during a police arrest — a white officer knelt on his neck for 8 minutes and 46 seconds, ultimately killing him. Footage went viral, and Black Lives Matter protests surged throughout the country, held in all 50 states and around the world, demanding change.
This movement isn’t disconnected from the healthcare debate — in fact, they're intertwined.
Floyd himself had lost his security job during the COVID-19 health crisis, and it was revealed he actually tested positive for the coronavirus in early April, a health issue unrelated to his death.
As the protests and demonstrations called into question the way institutions of all kinds have perpetuated systemic racism and inequality, healthcare disparities for Black Americans have been put under a microscope.
New research published in the Journal of General Internal Medicine shows that 18.2 million people in the United States who are at increased risk of severe COVID-19 are either uninsured or underinsured. This of course impacts racial minorities at high rates.
Black people were 42 percent more likely to be at risk for more serious COVID-19, while 51 percent of Black people who are high risk were more likely to have worse health coverage than white people who are also at high risk.
Native Americans were another group to experience higher COVID-19 risk as well as poor healthcare coverage and access. The study found 90 percent of Native Americans had a high chance of being at risk for severe COVID-19 while 53 percent of those who are high risk had insufficient health coverage.
Many people in these communities might not even have access to a primary care physician to call to seek, not just testing, but basic medical care — a huge problem, especially at the height of the pandemic in the spring.
The authors cite coverage of a report from Rubix Life Sciences, a Boston-based biotech data firm. It looked at hospital billing data from several states, finding Black patients with reported symptoms like fever or cough were less likely to be administered a coronavirus test than white counterparts.
So, what will be done to tackle these inequalities? The Biden campaign released “Lift Every Voice: The Biden Plan for Black America," which addresses how COVID-19 has shed a spotlight and exacerbated these economic, social, and health inequities in Black communities.
“While there’s a lot we don’t yet know about COVID-19, we do know that equitable distribution of resources, like testing and medical equipment, can make a difference in fighting the virus. Biden believes this should be a priority and action must be taken now,” the plan reads on Biden’s campaign website.
Improving healthcare in the U.S. will take more than a public insurance option
The huge inefficiencies in our healthcare system and the nation’s lack of preparedness point to problems that aren’t just fixed by the creation of a public option, said Sara Rosenbaum, the Harold and Jane Hirsh Professor of Health Law and Policy and founding chair of the Department of Health Policy at the Milken Institute School of Public Health at George Washington University.
“I’m not in the camp of people who believe single payer would solve this problem,” Rosenbaum told Healthline. “It certainly would have made it possible to pay for care, but one of the big problems right now is that the healthcare system is dysfunctional and insurance alone doesn’t fix it.”
From her perspective, Rosenbaum said the big issue is money. She said there needs to be funding that’s shot directly into the arm of the system, so to speak. That way, more equipment can be bought, more supplies can be stocked, and more personnel staffed.
“We don’t think of it that way, but the system is a little clumsy. A person has to show up, get covered for services, a claim submitted — clearly hospital systems need a lot of frontline money just to keep themselves afloat right now, from hospitals to community health centers,” she added. “Right now, the biggest problem they got is all non-COVID-related care revenue has disappeared.”
She said current grants from Washington are “okay,” but isn’t enough money to sustain the massive demands placed on the system.
“The model of a hospital or the model of a health center or the model of a physician’s office, for that matter, most of their revenue comes from insurance payments. If most revenue stops, you’re like the... restaurant down the street that is now completely closed with no business,” Rosenbaum said.
It’s important to note that a public option is still separate from “universal healthcare” seen in European countries or even a standardized single-payer system that was proposed by other Democratic candidates earlier in the current election.
It wouldn’t guarantee coverage for everyone across the board. Instead, it offers an alternative to the current healthcare system, giving more people the chance to access coverage.
Inequalities and gaps in access would remain — it wouldn’t be a magical fix for all our current system’s problems.
Not all providers would opt into this system, realities like increased taxation would need to be adopted to achieve reform, and the funding issues Rosenbaum cites wouldn’t be fixed with just a public option.
All of that being said, it would still be meaningful reform from what exists today.
In addition to improving insurance access and coverage for individuals, experts say hospitals need to be better funded with more equipment, supplies, and staff to truly improve healthcare in the United States. Photo by Mario Tama/Getty Images
A “teachable moment” for America’s current (and future) healthcare system
Regardless of whether discussing how the healthcare system sustains itself or how insurance reform is achieved, it’s clear that COVID-19 has provided the United States with an extreme “teachable moment,” Pollitz said.
She said whether a public option is put in place or a move toward a single-payer system is made, something needs to happen to expand access to care throughout the population at large.
“Up until the outbreak, there was the fact that maybe every candidate in the Democratic side agreed there needed to be improvements,” Pollitz explained. “Everyone agreed public plans have to be a piece of the solution if not the solution.”
On the opposite end of the spectrum, the Trump administration is currently pursuing a lawsuit “to strip the Affordable Care Act, which would mean more gaps in coverage for people, no real option at all for them,” she added.
Even now, as the pandemic starts to reach its height and millions of Americans are losing their insurance due to job layoffs, the Trump administration announced it would not reopen the Affordable Care Act’s online marketplaces to new possible customers.
This comes as experts assert the number of actual cases could be much higher than currently reported given the low level of testing and the government’s dangerously stalled response during the first few months of the pandemic.
While the nation’s largest densely populated urban area, New York City, was at one point the "epicenter" of the outbreak, other large cities like Los Angeles and Seattle are also being hit, while more remote rural areas with significantly less access to resources and large health facilities could be next.
It seems the need for increased healthcare access would be greater than ever. There might be political resistance in conservative corners to healthcare reform, but Pollitz believes public headwinds are changing.
“People like the idea of a public plan being in place during these crises, especially with impossible prices for any given service,” she said.
Brian Mastroianni is a New York–based science and health journalist. Brian’s work has been published by The Atlantic, The Paris Review, CBS News, The TODAY Show, and Engadget, among others. When not following the news, Brian is an actor who’s studied at The Barrow Group in NYC. He sometimes blogs about fashionable dogs. Yes. Really. Brian graduated from Brown University and has a Master of Arts from the Columbia University Graduate School of Journalism. Check out his website https://brianmastroianni.com/ or follow him on Twitter.
Fact-checked by Jennifer Chesak.