Opt-in and Opt-out

By Merrill Ring

The idea of what role individual choice plays and should play in public policy making is at the heart of the discussion of Medicare for All, but is not being explicitly examined.

In the Democratic’ arguments about health insurance, there has been a little noticed difference of possibility on one point.

Some candidates, those opposing a single payer system (Medicare for All) and supporting an expansion of the existing Affordable Care Act (Obamacare) have nonetheless made an obeisance to the promise of their opponents’ idea by allowing those who are signing up for health insurance to opt-in to the ongoing Medicare program. They argue that that provision (rejected by Obama in creation of the ACA) is a great thing because it expands the range of choice for Americans. You could not only have a choice between different private insurance plans, but could also opt to join the public plan.

That justification for having an opt-in to Medicare provision rests not only on the assumption that having more choices is always the better thing, but also on the assumption that only individual choices should count in the creation of public policy.

Of course, that is not what policies we accept are always based on. We cannot opt-in to paying taxes and we (at crucial times) do draft people (men at least) into military service regardless of what an individual might choose to do.

Julian Castro, when he was still in the race, had a quite different scheme. He supported Medicare for All, a program which if instituted would put Americans into the public plan without a choice. However, he recognized that Americans do like the idea of choice, so he had in his scheme the possibility of opting-out if an individual so chooses. If you don’t want (for whatever reason, say hatred of government) to be enrolled in the public plan, a person on Castro’s plan could opt-out - if they can show that they have an equally good private plan. (Whether there would actually be such insurance on the market under a universal single-payer system is quite problematic.)

Our public programs often do have that feature. You might opt-out of being drafted into military service if you choose to be a medic. Parents might opt-out of the law that their child must be vaccinated by having a doctor state that vaccinating that particular child would be harmful to her/him.

We are a country that does prize individual choices. However, the idea that all public policy must make central the notion of individual choice, no matter how appealing the idea is to conservatives, is not what our practice is. We also recognize the value and importance of the common good and of community and sometimes adopt policies that make those concerns outweigh individual choice.
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Would it be best to require everyone to join a single health insurance pool (as single payer advocates hold) or would it be best to rest the policy on letting people have a choice as to what insurance they will have (as Buttigieg wants)? While that matter is being debated, the broader issues of when policy should be based on individualism and on what individuals choose and when that should not be the aim of policy is not being talked about in our current discussions.