Skip to main content

Some Presumed 'Opt-Outers' May Spite Themselves

A public option for U.S. health care has been refashioned as a decision for individual states. Might some states most in need spurn the offer?
  • Author:
  • Updated:

As the health care debate shifts now to the Senate, following the narrow passage this weekend of a bill in the House, a new buzz phrase is poised for the front page. We've moved past "death panels,""Gang of Six" and even "you lie." The new slogan of the moment, summing up in so few words all of the conflict inherent in overhauling the massive health care industry, is "opt out."

Sen. Harry Reid two weeks ago proposed a twist on the public plan progressives love but conservatives fear as the sneaky first step toward universal health care. The Senate version of the bill, Reid declared, would include a public plan, but one that individual states could "opt out" of if they chose.

The concept lends some sense of local control to an initiative frequently billed as a "government takeover" of health care, but it also prompts a whole new set of problematic questions: Wouldn't states that opt out of the benefits still have to pay in with taxpayers' money? Who would get to decide which way to opt? Voters in a referendum? A state legislative body or a lone governor? Might the disparity prompt internal migrations in the same way professional athletes are drawn to states with no income tax?

Above all, any such "opt out" plan could magnify a picture the Commonwealth Fund revealed in a state-by-state health care scorecard released this fall. Where you happen to live (or are born), the report concluded, makes a big difference in the quality of the health care you receive.

In a state-by-state ranking, 12 of the 13 states in the top quartile offering the best care were all in the upper Midwest or Northeast (the lone outlier, at No. 2, was Hawaii).

Meanwhile, the lowest ranking states were, starting at the bottom: Mississippi, Oklahoma, Louisiana, Arkansas, Nevada, Texas, Kentucky, Florida and New Mexico.

"Clearly poverty and economic circumstances are a very important driver here," said Joel Cantor, director of the Center for State Health Policy at Rutgers and one of the Commonwealth report's authors. "They're big contributors to determining peoples' health and ability to pay for the care they need, and also the revenue and resources a state would have to invest in coverage and improvements in the system. Poor people live in states that have a hard time raising revenue, and it's a whole cascade of things."

The study, which measured states on 38 indicators of access, quality, cost and health outcomes, suggests in today's political climate that the states most likely to opt out of a public plan — or with the elected officials that have been the staunchest opponents of reform legislation — are the ones that need help the most.

"That's not health policy, that's political philosophy," Cantor said. "Very frankly, the only way to really broaden coverage in this country is by having the government playing a bigger role in paying for it. And if you're against government helping to pay for coverage, then sort of 'game over,' you're not going to solve the coverage gap."

Southern states opposed to reform legislation are also, in effect, opposing a redistribution of resources in their favor. The states with the highest number of uninsured — nearly a third of the populations in both Texas and New Mexico — would disproportionately benefit from taxpayer dollars funneling out of states like Massachusetts, where well over 90 percent of people already have insurance.

If every state could match the benchmarks of the best-performing ones (Vermont was ranked No. 1 overall), the report estimates 29 million more people in America would be insured — and nearly 78,000 fewer would die prematurely.

Sign up for our free e-newsletter.

Are you on Facebook? Become our fan.

Follow us on Twitter.

Add our news to your site.