Hadley Heath Manning joins the podcast to discuss this month’s policy focus: The Public Option for Health Coverage. We focus on what a public option would mean, how the idea continues to pop up in bills at both the federal and state levels, and why competition is a good thing when it comes to health coverage.

Hadley Heath Manning is director of policy at Independent Women’s Forum and Independent Women’s Voice, and is a Senior Blankley Fellow at the Steamboat Institute. Hadley has testified before Congress and state legislatures on various policy issues. She also appears frequently in radio and TV outlets across the country and is a regular guest on the Fox Business Network. Her work has been featured in publications such as The Wall Street Journal, Forbes, POLITICO, and many others.


Beverly Hallberg:

Welcome to She Thinks, a podcast where you’re allowed to think for yourself. I’m your host Beverly Hallberg, and on today’s episode, we delve into our November policy focus, the public option for health coverage. We’ll discuss what public option means, how the idea continues to pop up in bills on both the federal and state levels and why competition is a good thing when it comes to health coverage.

Hadley Heath Manning, the author of the Policy Focus is with us today. But, before we bring her on, a reminder for our podcast listeners that we’ve expanded to video. Go to Independent Women’s Forums YouTube channel and subscribe. Of course, you can still listen to the podcast on iTunes, Google Play, Spotify, and Acast.

Now you can see our guest, Hadley Heath Manning. Those who know us, know that she is a director of policy at Independent Women’s Forum, and Independent Women’s Voice, and a senior Blankley fellow at the Steamboat Institute. She has testified before Congress and state legislatures on various policy issues.

She also appears frequently in radio and TV outlets across the country and is a regular guest on the Fox Business Network. Her work has been featured in publications, such as the Wall Street Journal forums, Politico, and many others. Hadley, always a pleasure to have you on She Thinks.

Hadley Heath Manning:

Yeah, thanks for having me. It’s great to be back.

Beverly Hallberg:

You wrote this policy focus and I want to let people know they can go to iwf.org to read all about it, even though you’re going to detail it for us here. I thought we would start by, first of all, defining what that term, the Public Option, means. We often hear of Medicare For All. Is there a difference between Medicare For All, and what you refer to as the Public Option?

Hadley Heath Manning:

Right. When I think of Medicare For All, and what I think advocates for Medicare For All really want is, a public health plan for all, for everyone. Meaning, private health plans would no longer exist, and so the difference really between a fully socialized medical system or a fully socialized health insurance system and a public option is that I think advocates of the public option would say it would coexist with private options.

There would be a national health plan people could sign up for, pay the premiums for it, and it would operate alongside other existing plans, whether those are offered in the private sector or employers, or whether they’re the existing public health plans we have today which are Medicare, Medicaid, and a couple others.

Beverly Hallberg:

Of course, on paper, this always sounds great. It sounds great to have a public option, everybody gets the same thing, everybody can be covered regardless of any underlying health conditions. But, what is your main concern of a public option being instituted?

Hadley Heath Manning:

It’s interesting that you started with a question contrasting the Public Option with Medicare For All because really, I see these two things as ultimately the same direction and the same policy. When you introduce a public option, a national health plan, you’re putting a public competitor into the mix where most working-age, non-disabled Americans have to obtain health insurance on our own.

If we make the income requirements for Medicaid, maybe we qualify for that program for low-income people. But, most people are looking at a set of options. Maybe they’re not very many options today, not a lot of competition in the health insurance sector when you talk about why that is.

When you’re talking about a public competitor and private competitors, that’s not really fair competition. When the government gets involved… The government’s really supposed to be the referee when it comes to markets for different goods and services. When the referee enters the game, what you have is, subsidies and savor and the government smiling upon the public option. Where private options continue to face regulations, taxations. They don’t get the same treatment so ultimately, my fear about the Public Option is that it would become the only option.

It would make it so that the existing private health insurance companies that are offering plans would cease to do that. Then people would not have a public option, they would just have the public health plan because it wouldn’t be optional. When you have one entity paying all the bills for everybody’s healthcare, then you do have a single-payer. That’s the definition of single-payer.

Some Democrats and some progressives have been forthcoming about the fact that when they say they want a public option, they want to do that as a stepping stone to get to single-payer. Some people aren’t quite as honest about it, and they say, “We can get on this rollercoaster and stop halfway through and have Public Option without Medicare For All.” I don’t think that’s politically feasible and I don’t think it’s realistic.

Beverly Hallberg:

I’m glad you mentioned Medicare and Medicaid because I often hear a Public Option or a Medicare For All being sold as, people love Medicare, so we’re going to expand that. So, if you’re older and currently on Medicare, you’re on Medicare advantage, let’s say, then you’re going to love this. When it’s sold that way, what do you say to people? Those Americans who say I like my Medicare, why wouldn’t I want other people to be on a similar type of program?

Hadley Heath Manning:

Yeah, sure, I get it. I feel like some people are counting down the days until they’re 65 and they’re Medicare eligible, in part because of the problems with our private health insurance system, for people who aren’t quite age-eligible yet for Medicare. We should focus on fixing those problems first of all, for those of us who are not so close to being 65.

I understand why people like Medicare. I’ve got grandparents on Medicare, they love it. They’ve got Medicare advantage plans, which ironically are the private’s piece of Medicare. When it comes to Medicare, really the problems lie beneath the surface. When you start to look at this from a public policy perspective, you see that Medicare is something we pay into for our entire working lives.

Everybody pays a payroll tax to put dollars into the Medicaid, Medicare trust fund. But, when we reach retirement age, because we are living longer and because healthcare is so expensive at the end of life, because typically, by that point in our lives, we have some kind of chronic conditions that we’re managing, or we need expensive medications.

Those dollars coming out of Medicare do not match the dollars that are currently going into the program. We’ve got about three dollars going out for every one dollar going in, in terms of the average couple. Over your working years, if you put 100,000 dollars in Medicare, you’d get 300,000 dollars in benefits.

That’s not a sustainable path, and it’s not something that we could scale up for the entire population without making significant changes to the way that Medicare pays doctors and hospitals, and that’s going to have serious repercussions.

It’s already starting to have some repercussions for Medicare beneficiaries today. Certainly, we see this phenomenon much more so in Medicaid. It’s a problem when you start to pay doctors and hospitals less for their services, especially in the world where they can’t pass those costs onto private insurance companies.

Beverly Hallberg:

I feel like something that we used to hear about, say five years ago, was the fact that we need entitlement reforms. That you would hear lumped into that, social security reform, Medicare, being part of that Medicaid. I don’t hear as much anymore, there isn’t that narrative that we are headed towards bankruptcy with these programs. Is it because we have so many other problems that this has been ignored? I don’t feel like it’s been a focus.

Hadley Heath Manning:

When we did talk about entitlement reform, people used to use this expression about it. They’d say, “It’s the third rail of American politics.” It’s really not a popular thing to talk about. People don’t even like to talk about Medicare as an entitlement, but that’s technically what it is in the public policy sense.

People think that if you are a beneficiary of an entitlement that somehow you have some entitled attitude. You don’t have to have an entitled attitude just because you’re legally due some benefits. It’s not bad to participate in an entitlement program.

But, I think that the way that we should approach reforming these programs is giving those beneficiaries who are already in the program, more choice over how their dollars are spent. Choice and competition really are the keys to holding costs down. We have real choice and real competition among private sectors and marketplace, that is fair. That’s really the direction we’d ought to go with entitlement reform.

To answer your question Beverly, I think it’s just not politically popular to talk about entitlement reform. Republicans used to talk about it more, Paul Ryan used to talk about it, he got no thanks for that. He got depicted throwing Grandma off a cliff in a political ad. When Republicans started talking about entitlement reform less, nobody was talking about it. That’s where we are today.

Beverly Hallberg:

Let’s pick up on that word, competition. Some people claim that having any type of competition within something as serious as medical coverage as health coverage is wrong. That there are winners and losers when it comes to competition, and we shouldn’t be instituting that into a place where it concerns people’s health. What do you say in reference to the idea of competition?

Hadley Heath Manning:

I think this question really gets at the heart of the debate. People who believe in Medicare For All typically come to the health policy discussion with a principle that healthcare is a human right, and therefore they believe that the government should be responsible for providing healthcare to everyone. On the other side of the debate, you have people like me who say, “Healthcare is not a right. It is a service, it is a commodity, it is the term that we use to refer to any treatment, drug, doctors visit, that we consume. We’re consuming it.

That said, it’s not just any commodity. It’s not a widget, it’s not a TV screen, it’s not something that I believe the government should have no role. I think we should have a guarantee in a society as rich as ours that people who have no means of obtaining healthcare on their own. We should have safety net programs for those people. But, when you start to expand those safety net programs to include more and more people, who could otherwise pay for these services on their own.

You’re not only lowering the quality ultimately of goods and services that are available, but you’re weakening the safety net because you’re overloading it and you’ve lost the whole concept of a safety net at that point. That I think is really where there’s a lot of tension and that’s really where the philosophical debate is when it comes to healthcare policy.

Beverly Hallberg:

Let’s talk about what Covid has meant for our health coverage system. I think there have been a lot of pros as far as some regulations being rolled back. We have seen with telemedicine more ability for people to be able to visit their doctor virtually versus going into the offices, are positive changes.

But, has there also been a push since this has been a global pandemic, this has impacted everybody, everybody’s had to deal with the fear or the reality of Covid. Has there been a bigger push to have some type of Medicare For All, or Public Option for the entire country? Based on the fact that they can point to Covid and say, “It affects everyone, so we do need a one size fits all policy.”

Hadley Heath Manning:

What we’re seeing in terms of the push right now, the Affordable Care Act was passed in 2010, and there was a lot of discussion around that time, was there going to be a public option included in the Affordable Care Act? Even among the democrats who voted for that law in 2010, there wasn’t enough consensus around a national health plan or public option.

That was abandoned some 11 years ago. It’s popped up here and there in national debates. Now what we’re seeing instead, is there’s the Affordable Care Act did include a big expansion of the Medicaid program. Some states are doing what they call Medicaid buy-ins, which is essentially opening up a public option, that public option being named Medicaid.

Someone like me might go and pay a premium and I could join Medicaid even though I don’t qualify in terms of my income. There are three states who have passed explicit public option plans. Some of the political debate has devolved to the state level. Some of it is also around expanding, for example, Medicare eligibility age down to the age of 60, which would usher in millions of beneficiaries a little bit earlier than age 65.

Those three states that I mentioned… Washington State, Colorado, where I live, and the state of Nevada, which is out west. The only one of those states that has really implemented their public option, and it was in its first year in 2020, the year of the pandemic. Washington state has not been a successful first year for the public option there.

Globally, in terms of the impact of the pandemic on healthcare policy, I think it revealed a lot about our healthcare system. Some good, some bad. I’ve always said that our problem in the U.S. is not healthcare. Our problem in the U.S. is how we pay for it. It’s health coverage, it’s health costs, it’s health choices, but it’s not healthcare.

The quality of healthcare available in the United States is actually some of the best in the world. We actually have the highest per capita, ICU beds available in the world. When something terrible, like a novel coronavirus, ravages humankind, I’d rather be in the United States. I’d rather be here than any other country in the world. That said, of course, it’s posed new challenges for us and of course it’s changed the political debate, some about who pays for what.

Ultimately, that debate is going to come back to that philosophical debate that I mentioned earlier. Do you believe that this is a right, that the government should pay for for everyone? And are you willing to accept the trade-offs that come with that approach? Or, do you believe that it’s something where we can see market competition? We can give people and doctors more choices at the most local level?

Beverly Hallberg:

We know certain lawmakers do believe that healthcare is a right, and they push for policies in that direction. You just mentioned Washington state… A new law that they had instituted there. But are we seeing whether, on the state level or the federal level, that there have been laws or policies that are instituted and they go under the radar, we don’t even know they’re being implemented? They are pushing our healthcare system or health coverage system more to a public option.

Hadley Heath Manning:

Yes, I think so. For example, we talked a little bit about the Affordable Care Act. When the Affordable Care Act was passed, the previous to its passage, there were 50 different state-level health insurance commissions that regulated health insurance, and they regulated what every health plan had to cover. If you were selling that insurance plan in that state, you had to comply with the insurance commission in that state.

The idea that we had some kind of Wild Wild West in health insurance, that it was unregulated prior to the Affordable Care Act, simply isn’t right. We added a layer of federal regulation to health plans when the ACA passed. What we saw as a result of that was that many smaller health insurance companies dropped out of the market all together.

Sometimes insurance companies sell more than one type of product. They might sell health insurance, they might also sell property and causality insurance. Some of them looked at the Affordable Care Act, all the regulations, and all the things that had to do to comply with that law, and they said, “I give up. I’m not going to participate in this”

We saw some 90 percent decrease in the number of insurance carriers that were competing in the states on average. If you were someone who buys your health insurance outside of your employer, many people were faced with only one carrier operating in their exchange, which the ACA established for people to buy health insurance.

If you’ve only got one private company offering you health insurance, you can’t really say that competition is working out well for you. I would say, the whole reason that we got there in the first place, was because the Affordable Care Act made it so difficult for, especially small insurance carriers, to continue to operate and continue to provide that accountability to some of the bigger players in the market and hold prices down.

Beverly Hallberg:

In this policy focus, you talk a lot about what we don’t want to do, which is go towards a public option, but you also talk about what we should do. You’ve used some of that language here. We need lower costs, we need more choice, we need that through competition.

The question is, what is the answer? We know the last time there was a push to try to get reforms in our healthcare system, trying to repeal and replace the Affordable Care Act, it failed. It failed in the Senate. A lot of people are fearful to dip their toe in again because that was such a major loss for those who thought we needed healthcare reform in a different direction. What do you see as possible and feasible solutions if the Public Option is the opposite of what we need to do?

Hadley Heath Manning:

Going back to that philosophical debate. If you do believe that healthcare is something that somebody’s got to pay for, and that’s the reality, then the question becomes, what’s the most effective way to pay for this so that the number of people who can get the best, highest quality of healthcare is maximized?

We all want our neighbors to have healthcare. It’s just a question of, how do we do it? I think one of the biggest hurdles to good health policy in the U.S. is not just the political system, but it’s actually our cultural expectations around healthcare and around how we pay for it. Many people have private health insurance, and since the Affordable Care Act, we’ve seen a reduction, for example, in some of the copays that we make around birth control, as one example.

Now people have first ever coverage for their birth control pills and when they go to the pharmacy and they pick up some medicine, they don’t have to pay anything at the point of consumption. That probably feels really good, it feels like a benefit, but the reality is, we’re still paying for those things in our health insurance premiums, which skyrocketed after the passage of the Affordable Care Act.

I would say, if we’re really going to talk seriously about reforming healthcare, we have to talk about what we want health insurance to be. Do we want it to be insurance? Like something that we pay for as a backstop against unexpected financial losses? That’s what insurance is in every other context. That’s not really how we treat health insurance in the U.S.

We treat health insurance like a third party that’s supposed to show up anytime we go to the doctor’s office, or show up anytime we purchase any kind of medicine and pay for what we consume. When we think of it that way, we’re actually including a middle man and a lot of transactions where he’s not necessary.

We’re starting to see some changes around the margins and our healthcare system where people are starting to do things like healthcare sharing ministry or a direct primary care arrangement, where you pay your doctor directly, and he or she doesn’t have to fiddle with getting the health insurance company or Medicare or Medicaid to reimburse them.

It’s a direct arrangement between you and a doctor, and I think a lot of our solutions lie on that path of innovation, and they lie in the cultural and private creativity and innovation that Americans are known for throughout time. You can’t really cast one big, behemoth policy that’s going to fit every person’s individual needs and preferences.

While I think that we’ve made some serious mistakes in federal health policy, I think it’s also a mistake to expect that the federal government is ever going to solve this problem for all of us. The federal government can get out of the way for some of those other innovative solutions. But ultimately, I think we have to change our thinking around how we expect our healthcare system to work.

These are doctors and nurses who are working very hard. They’ve worked very hard throughout this whole pandemic. Many of them are feeling burned out, but their services have great value. Somebody got to pay them. We can’t say that we have a right to their services. We have to pay them. The question is, how are we going to do it?

Beverly Hallberg:

Because their school bills were very expensive. And they should be, based on what they do for us. It’s a really important piece. Healthcare is still one of the most important issues that people in this country care about. They should go to iwf.org to see this policy focus on a Public Option. Always great to have you on She Thinks. Hadley Heath Manning, thank you for joining us.