Popular…to a Point: The Enduring Political Challenges of the Public Option

Health Insurance US Health Care Reform

Policy Points:

  • A decade after failing to make it into the Affordable Care Act, the public option reemerged as a health reform goal at both the national and state levels, with polls reporting strong, bipartisan support.
  • A 2020 poll that probed both support for one public option approach (Medicare “buy-in”) and attitudes toward government suggests that differences in these attitudes could plague reform advocates’ efforts.
  • Although the COVID-19 pandemic viscerally highlighted the need for a more coherent health care system—including universal coverage—other recent evolutions in the broader US political context could undermine reform.

In an increasingly polarized era, one health reform policy stands out for its apparent popularity among both Democrats and Republicans: a public health insurance plan intended to compete alongside private health insurance products (the so-called “public option”).1 Depending on the structure of the policy—whether and how monthly premiums are constrained—a public option could promote more vigorous price competition on the individual market for health insurance. Though the health insurance marketplaces created by the Affordable Care Act (ACA) were intended to promote this type of competition and expand insurance access for people who didn’t receive coverage through an employer or a public program, affordability and inadequate insurance have been persistent concerns (notwithstanding recent expansions of financial assistance under the American Recovery Plan Act and Inflation Reduction Act).2 A nationally representative survey conducted in 2022 found that nearly one-quarter of working-age adults had coverage for a full year but were underinsured, meaning their coverage did not provide affordable access to care (based on deductible size or out-of-pocket medical expenses over the prior year).3 Among those who were uninsured at the time of the survey or had experienced a gap in coverage in the prior year, 46% reported that affordability challenges were the main reason they lacked coverage.



  1. Singh R, Palosky C. Poll: Democrats like both the public option and Medicare-for-all, but overall more people support the public option, including a significant share of Republicans. KFF. January 30, 2020. https://www.kff.org/health-reform/press-release/polldemocrats-like-public-option-medicare-for-all-but-overallmore-people-support-public-option-including-significant-shareof-republicans/
  2. Collins SR, Gunja MZ, Aboulafia GN. U.S. health insurance coverage in 2020: a looming crisis in affordability — findings from the Commonwealth Fund Biennial Health Insurance Survey, 2020. August 19, 2020. https://doi.org/10.26099/6AJ3-N655
  3. Collins SR, Haynes LA, Masitha R. The state of U.S. health insurance in 2022: findings from the Commonwealth Fund Biennial Health Insurance Survey. September 29 2022. https://doi.org/10.26099/73ZG-3432

McIntyre A, Blendon R, Benson J, Findling M, Schneider E. Popular… to a Point: The Enduring Political Challenges of the Public Option. Milbank Q. 2023;101(1):0124.