Dr. Abdul El-Sayed is the Democratic candidate for Senate in Michigan. A public health physician and former director of the Wayne County Department of Health, Human & Veterans Services, he has long been an advocate for universal health care program with a single payer, such as Medicare for All, for which I too am a strong proponent (see IMPROVED and Expanded Medicare for ALL. Now. The people want it!, Sept 27, 2026). But recently he added what seems like a “little nuance”. In his debate with Republican Mike Rogers, the Michigan Daily coverage says
El-Sayed has long advocated for expanding Medicare. Most Medicare for All proposals would replace or phase out private insurers, but El-Sayed said families would be able to keep private insurance under his plan if they chose to.
It also quotes him as saying “I want to guarantee every single person in this country, cradle to grave, coverage — without premiums, co-pays, deductibles,” which is good, right? That’s what I advocate for right? Why would I make a big deal about him saying people could keep private insurance? It plays well with the voters, right? It’s kind of what Barack Obama said about the ACA, right? And it passed, right? And it helped lots of people, right?
Yes. But that line about people “keeping their private insurance if they choose to” is really important. It is not a “little nuance”. If he, and others, are serious about that, it will make single payer, Improved Medicare for All, fail. I don’t think that is what Dr. El-Sayed wants, but it is the truth. If people can keep their health insurance, then whatever single-payer plan may be created becomes just one option, the “public option”, a concept that has been long the darling of many “mainstream” Democratic leaders and policy wonks from Obama on down. If you believe in the whole premise of universal, single-payer health insurance, then that is what it has to be, a single payer, not be simply a “public option”. A recent Health Justice Monitor piece quotes from an article by Robert Kuttner from The American Prospect that advocates for such a public option. Then Jim Kahn and Hank Abrons proceed to debunk the arguments Kuttner makes, with 3 key points:
(1) The public option creates a serious risk of adverse selection. Private insurers have strong incentives to make their plans less attractive to very sick, expensive patients, nudging them toward the public option. If the public plan thus attracts a sicker population, its costs — and, if it must be self-financing, its premiums — will rise. That in turn makes private mainly job-based insurance more attractive to healthier people, likely worsening the selection problem. Meanwhile, because the public option remains embedded in a multi-payer system, we get very little of single payer’s administrative savings. This “cost spiral” will be portrayed by opponents of Medicare for All as proof that it can’t work.
(2) Neither providers nor patients will experience what it’s actually like to give or receive care in a single-payer system. The public option would be grafted onto our incredibly cumbersome insurance system. Providers would still deal with multiple payers, rules, networks and billing systems. And patients would still encounter the complexities of today’s Medicare: Traditional Medicare has substantial cost-sharing and often requires supplemental Medigap coverage, while Medicare Advantage puts beneficiaries back in the hands of private insurers.
(3) The public option doesn’t even begin to address other critical failings of our health system, such as gaps in coverage for essential services (e.g., vision, hearing, and dental), high drug prices, and major access inequities (e.g., lack of coverage for non-working families).
These are all true and important points. While I don’t think that I can say it better, I can say it in different words, emphasizing some aspects while not in any way disagreeing with Kahn and Abrons.
Their point (1) is about adverse selection. This is an essential problem with all public option plans, and is a strong argument against them. The health insurance industry is all about making profit, this does not require them to cover more people, or to cover them well. It can often be by covering fewer people, a method explained in detail in Wendell Potter’s recent Health Care Uncovered, “Q3 2026: UnitedHealth’s Profits Soar as it Covers Fewer People, Pays Less for Care.” As Kahn and Abrons point out, this is especially true if the people cut off are those who are sick and cost a lot; the wet dream for insurance companies is to have all healthy people who pay premiums (or whose employers pay premiums for them) who never use any health care or cost the company any money. Having the public option as a “safety net” encourages them to divest themselves of the sick, and puts the burden on the public option, which now has lots of high-cost sick people without the low-cost healthy people to balance them out. The key principle of all insurance is that everybody pays in, and their premiums pay the cost of the minority of people who need to collect because they are sick that year. Remember this graphic from Red, Blue, and Purple: The Math of Health Care Spending, October 20, 2009 and still true today: in any given year, 5% of the people are responsible for 50% of health care spending. If we let a bunch of those “blue” people, the 50% who are responsible for only3% of costs, opt out, the system fails. And also remember: those 5% next year will not be the same people as they were this year.
Kahn and Abrons’ point (2) really includes two important concepts. The public option keeps the grab-bag, complex, pay for some things but not others, different kinds of programs for different people (poor, rich, employed, old) and many different plans within each. It continues prior authorization and the right of insurance companies to deny your care, and keeps people completely confused. It won’t really be better than the current non-system because it keeps that and then grafts the public option on. The second part is that, without everybody being in the same universal payer system, organized like Medicare but with Improved and Enhanced coverage for all health needs, then most people are not experiencing the benefits of such a system.
The key flaw that all “public option” plans have is that they keep the insurance companies in the game, and allow them to keep making money by denying people the healthcare that they need. For Medicare for All, or any comprehensive universal single-payer system, to be affordable (and, in fact, cost less than the US spends on “healthcare” now) is the enormous savings on administrative costs, including insurance company profit. That is the enemy. A good, affordable health plan requires the elimination of for-profit insurance companies that are motivated to cover less care for fewer people so they can make more money.* But keeping the enormously expensive, inefficient, and bad-for-the-public’s-health for profit insurance industry is exactly what “public option” advocates are trying to do! Why? You guess. It’s almost as if they get lots of political contributions from that industry…
Kahn and Abrons point (3) is critical, and speaks for itself. Universal single-payer coverage doesn’t solve all the problems of our health care chaos. It is, however, a necessary, if not sufficient, characteristic. With single-payer Medicare for All those other problems have can be addressed; with our current system, or the version of it that includes the public option, they cannot and will not be, not in any kind of comprehensive way.
Finally, I emphasize the most important moral point: Everybody In, Nobody Out. Every single person is in the same health insurance plan. No one gets to buy their way out. This is horrifying to the very wealthy, and to those middle-class people who like to identify with the wealthy (until they face the stark reality of not being wealthy when their health care coverage is denied). But it is central. When those who are poor and disempowered are in the same system as those who are well-to-do and empowered, the former will get better care because the latter will make sure it works.
This is the moral imperative.
*Unless, of course, they are very tightly regulated, as in Switzerland. They all have to deliver the same coverage to everyone, and charge the same amount in premiums, and not be for-profit. I can go with that; it means that the only thing that they can compete on is customer service! Imagine that!
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