medicare for all

Do Americans Want Choice, or Do They Just Want Health Care?

Photo: Erik McGregor/LightRocket via Getty Images

The ad is slick; the actors, suitably concerned. “We can’t afford one-size-fits-all plans,” a woman protests. Her complaint, written for her by the Partnership for America’s Healthcare Future — a front group for private insurers, hospitals, and pharmaceutical companies — is a simple one to grasp. She doesn’t want Medicare for All. She wants choice: the choice to keep her private health-insurance plans, to tell the government to butt out. It is not a novel presentation. The woman in the ad revives fears once given life by opponents of the Affordable Care Act. Though the ACA, even in its most liberal version, introduced a public option while keeping the private insurance industry intact, critics in both parties warned that it would sacrifice choice on the altar of big scary government. Then and now, the implication is consistent: Americans are hardy and independent creatures, and they value free will above all else.

Pete Buttigieg expressed those exact sentiments at a campaign event this week:

But Buttigieg and his fellow travelers might be wrong, according to a new report from Axios, based in part on research by the Kaiser Family Foundation. When people have choice in health care, they don’t often exercise it. People “rarely switch” health insurance plans “even if they could have gotten a better deal,” Axios reports — and the tendency is widespread. Workers who get insurance through their employers usually keep whichever option they initially picked, no matter what alternatives are available to them. “You’re more likely to stick with the choice you’ve already made if you’re not sure you’re going to benefit from switching,” economist Benjamin Handel told the New York Times back in 2014. Handel’s research, as cited by the Times, found that workers lost “as much as $2,000 a year by staying in their insurance plans.” Though the ACA’s marketplaces were designed to protect choice and to encourage competitive pricing from insurers, they also aren’t working as intended. Most people don’t shop around for better coverage, according to data provided by the Centers for Medicare and Medicaid Services; the Trump administration’s decision to cut funding for insurance navigators, who help consumers choose the best plan for their needs, is at least partially responsible for the trend.

But another reason for all this inertia, a Kaiser Family Foundation expert told Axios, is that the process of shopping for insurance is complicated. Plans themselves are expensive and confusing, which encourages a sense of fatalism. “It’s just too hard,” a Kaiser Family Foundation expert explained to the news outlet last year. With all the uncertainty caused by potentially catastrophic costs, and the innate difficulty of predicting medical needs a full year in advance, many consumers decided to stick with what they know. Despite the ACA’s subsidies or an employer’s contribution to a benefits package, insurance, as Axios points out, is one of the most expensive purchases an average household makes.

The data highlighted by Axios offers a strong counterargument to Medicare for All skeptics like Buttigieg, who seem to think that Americans treasure the notion of consumer choice. In fact, they might value it far less than they claim, or certainly less than Buttigieg, the Partnership for America’s Healthcare Future, and the insurance industry itself all claim. Choice isn’t everything. Applied to health care, it creates work: work that we have to do in order to get basic care, work that we pay for the privilege of doing. It doesn’t look much like freedom at all.

Opponents of Medicare for All often cite polling data that suggests most people have a preference for private insurance. But the polls aren’t really that straightforward. Scrutinize them a little further, and a dilemma reveals itself: A preference for choice is only one element in a bigger, and more complicated, set of public opinions. One Gallup poll, published in 2018, does show that 69 percent of the American population says they’re pleased with their current coverage, while 80 percent said they also like the quality of the care they receive. But they’re less cheerful about the overall state of the nation’s care: In the same poll, only 34 percent rated the nation’s health-care coverage as excellent or good. As of this August, only 38 percent told Gallup that they have a very or somewhat positive view of the American health-care industry. Meanwhile, 57 percent said they believed the government had some responsibility to make sure all Americans had insurance — not exactly an enthusiastic public endorsement of choice at all costs.

In another poll, conducted by CBS News in October, about 60 percent said they wanted a national health insurance plan to compete with the private market. Moderates like Buttigieg take this and polls like it as proof that voters do not want Medicare for All, which would eliminate private insurance. While it’s certainly true that Medicare for All’s supporters have yet to completely sell the public on such a radical transformation of the American health-care system, organizations like the Partnership for America’s Healthcare Future — the group behind that sleek ad against Medicare for All — should still be worried. Americans might say they like their coverage when they have it. But if they aren’t shopping around, or comparing prices, and they’re deeply unhappy with the health-care system overall, then they are open to alternatives. The polls offer no reason to think that Americans are so committed to private insurance that choice matters more to them more than affordability, or a guarantee of care.

The gap between what Americans say they want, and what they actually do, sets up a series of important questions for opponents and skeptics of Medicare for All. If it’s too difficult and too expensive for most people to exercise the choices they technically have, why is the private market so preferable to a government-run alternative? How much can the government really do to make private insurance less complicated and more affordable to use? And why should the government prioritize that project over one that guarantees an equal level of health-care coverage to everyone?

Opponents of Medicare for All should answer these questions. They haven’t, perhaps because no one with any power has asked them to try. In primary debate after primary debate, health care has topped the agenda. But moderators have reserved most of their scrutiny for Bernie Sanders and Elizabeth Warren, the two candidates most publicly associated with Medicare for All. Advocates of a system based around consumer choice — a quality that Buttigieg and Biden both play up in their plans — are well overdue for a similar level of scrutiny. So is the concept of choice itself. It ought to imply freedom, or at least flexibility. But applied to health care, the concept of choice for most Americans is so vague as to be meaningless. That kind of choice is an abstract notion. It’s not reality.

In Health Care, Choice Isn’t Everything