By NextBestFitLosing the choice of health plan and insurer competition
With one public payer, people can't switch plans if they dislike how their coverage is run, and insurers no longer compete on service, care management, or extra benefits.
Evidence
- 80% of adults with employer coverage rate their insurance excellent or good.Sources: KFF (2023)
Is it really a cost?
The arguments on each side, with sources. Whether it matters depends on whom you ask.
- 80% of adults with employer coverage rate it excellent or good, and they lose the option to keep it.Sources: KFF (2023)
- With one payer, there is no competitor to move to if service is poor, so service depends on public accountability alone.
- Choosing an insurer today largely means choosing a network. With one payer, every provider is covered.
- Choice can survive in other forms: in Australia, 45.2% of people add private hospital cover to the public system.
Who's affected
- People with employer coverage: They can't keep or pick a plan they like, or switch if service is poor.
None identified.
Under your mix of paths
- A single payer has no competitors
Open questions
- How can a single payer be held to good service without competition?
Caused or worsened by these paths
This problem only matters if one of these paths is chosen.
There is no other insurer to switch to if the public plan is run poorly.
Ending private Medicare plans moves enrollees into the universal public plan and removes their private-plan options.
Solution paths (3)
Open a path for what it fixes, what it creates or worsens, who gains and who loses, precedents, and how it connects to other paths. See all paths as a decision tree.
Publish service metrics (call wait, claim time, appeal outcomes), give an ombudsman power to order fixes, and let patients choose any provider.
- +Losing the choice of health plan and insurer competition
- +Narrow networks and out-of-network surprises
- −Depends on other changes to work
- −Targets and quality metrics invite gaming
People can buy private plans for things outside the public benefit (private rooms, extra therapies), keeping some insurer choice.
- +Losing the choice of health plan and insurer competition
- +Transition disruption: jobs, companies, and familiar coverage
- −Two-tier care: a private fast lane for those who can pay
- −Raises spending or loosens control over it
- −Copays keep billing systems alive and still deter poorer patients
One public payer, but people pick among competing integrated care organizations (e.g., Kaiser-style groups) paid by capitation.
- +Losing the choice of health plan and insurer competition
- −Paying a fixed amount per patient rewards doing less
- −Solves only part of the problem
Also addressed by paths for other problems
Competing regulated plans retain insurer choice and competition on service.
Income-based premiums retain the ability to choose a health plan.
Reforming payments while retaining private Medicare plans preserves plan choice and extra benefits.
Premium-spending requirements and nonprofit status preserve multiple plans.
Standardizing insurer rules retains multiple payers rather than replacing them with a single payer.