Biden’s Public Option is a BFD—and a Super-Popular One
By Jacob S. Hacker
Long, long ago, in a galaxy far, far away, former Vice President Joe Biden, Senator Bernie Sanders, and Senator Elizabeth Warren were in a fierce debate over health care reform. The eventual victor, Biden, initially supported a comparatively modest plan to build on the Affordable Care Act (ACA) with a Medicare-like public option. Sanders, of course, demanded Medicare for All with no cost-sharing. And Warren ended up in between, eventually backing a generous public option as a major step toward a universal Medicare program.
But even as Biden clinched the nomination, Sanders and Warren continued to push him. Since effectively securing the nomination, Biden’s public option—indeed, his entire health plan—has become more ambitious and expansive. Biden’s first plan was a big deal. Among other key features, it would have allowed workers dissatisfied with their employment-based insurance to enroll in the public option. Still, it wasn’t a “big fucking deal”—to quote the memorable three-word assessment that Biden blurted out at the signing of the ACA.
It is now. Biden’s public option has become the centerpiece of an ambitious approach that involves automatic enrollment of less affluent Americans and a commitment to build on Medicare’s affordable prices and broad provider network, as well as much more generous coverage than previously envisioned. Not only is this approach bold, as new polling by Data for Progress shows, it is also extremely popular, with large bipartisan majorities supporting even the most robust possible incarnations of the public option.
Biden’s Ambitious Turn
A big reason for the increased boldness, of course, is the pandemic. As part of his proposed emergency response, Biden says he would create a public option with no deductible at the ACA’s “platinum” level (meaning it would cover at least 90 percent of patients’ cost on average). Lower-income Americans would be automatically enrolled in this generous public option. The public option would also become the default for those whose COBRA benefits run out. (Like most Democrats, Biden wants to subsidize continued workplace coverage for the unemployed—in part because they may regain their former jobs). Since all of Biden’s emergency measures would be tied to objective health and economic conditions, they’d not only stay in place as long as we face the current crisis; they’d kick in again if a similar one occured in the future.
But the pressure of the pandemic isn’t the only reason Biden’s public option has muscled up; progressives have also successfully pushed for an approach that’s closer to Warren’s and Sanders’, with a generous public option that could become the foundation for universal coverage in the future. The big upgrades in Biden’s plan are contained in the so-called Unity Task Force Recommendations, which emerged out of negotiations between the Biden and Sanders camps. These include a promise to provide a no-deductible public option that would cover all primary care visits without cost-sharing. and a commitment to ensuring that the federal government will directly administer this public option. Many campaign watchers have missed these shifts, which bring his plan much closer to his more progressive campaign rivals’.
Opponents of the public option have certainly noticed Biden’s bolder approach, and they’re gearing up to trash it. We know what these attacks will look like. Conservatives will call it a backdoor route to Medicare for All that will hike taxes and destroy good private plans. Medical-industry interests—especially drug manufacturers and consolidated hospital systems—will say that shifting toward Medicare payment levels will bankrupt providers and destroy innovation. All these opponents will try to scare the public, knowing full well that Americans will like a plan based on Medicare unless they’re bombarded with horror stories.
Americans to Biden: Go For It
That’s why this new survey from Data for Progress is so important. For the first time, a top-flight polling team looked at how Americans think about the kind of public option Biden is heading towards. Previous surveys asked about a generic public option, and it’s always enjoyed strong supermajority support. But never has a poll delved so deeply into the mechanics of how a public option would actually operate.
And the mechanics are crucial. When I first argued for the public option more than a decade ago, I said it should be embedded in a system in which Americans without coverage were automatically enrolled in the public option and employers were required to contribute to its cost if they didn’t provide good coverage on their own. I also argued that the public option had to be generous to make it a secure and popular foundation for expanding coverage over time. Fortunately, the ACA put in place an employer penalty that could be easily converted into a contribution. Now, thanks to the Unity Task Force, Biden is saying the public option should have a no-deductible choice covering a broad range of benefits, with no copayments for primary care.
What this new polling shows is that voters like this approach—a lot. Not only do they support a generic public option by overwhelming margins; they support a public option without a deductible by a commanding margin of 37-percentage-points. Even voters who self-identify as Republican support this proposal by a 20-point margin. Still more striking, by a margin almost as large (27 points), voters support automatically enrolling every uninsured person into this generous public option and having this coverage be paid for through taxes rather than individual or family premiums.
Perhaps most important, Americans aren’t worried about the public option evolving into Medicare for All. To the contrary, the biggest plurality of voters think it should be a stepping stone to universal Medicare or something similar. Another large block think a system in which the public option competes with private plans would be a good outcome. Together, these two groups vastly outnumber those who don’t support a public option, even among Republicans.
This is exactly what you’d expect and want if you believe in the logic of the public option. Some Americans seem to think that with increased competition, private plans will rise to the occasion and offer plans equal, if not better, to that of the public option. Others think the public option will evolve into some kind of a universal system. The beauty is that a well-designed public option might go either way, depending on how many Americans wanted to enroll in it—and most of the public seems down with that.
BFD=SFP
To be sure, many design and political questions remain. But based on the results Data for Progress offers here, Biden’s move toward a more robust public option is a political winner. Warren faced real difficulties defending her Medicare for All plan, which eventually caused her to embrace the public option as an interim step. Still, it’s remained an open question whether more robust versions of the public option would face their own special liabilities.
Now, thanks to Data for Progress’s innovative polling, we know the answer: Biden’s public option should take the boldest possible form to be consistent with what large majorities of Americans want. That means generous coverage without a deductible, automatic enrollment, and a willingness to rely on tax financing, rather than premiums. Above all, it means truly building on Medicare, with its broad provider network and its proven capacity to restrain prices.
In a nutshell, these survey responses indicate that Americans don’t want the public option to be like existing private plans. They want it to be distinctive, and distinctively better. A BFD would be super fucking popular, too.
Jacob Hacker (@Jacob_S_Hacker) is a professor of political science at Yale University. He is the coauthor of the new book, “Let Them Eat Tweets: How the Right Rules in an Age of Extreme Inequality.”