The latest health care legislative compromise being floated is one in which states would be allowed to opt out of offering a public option. Chris Bowers lists the problems with the proposal here. Ezra’s more sanguine.

I suppose if someone put a gun to my head and the options were no public option or an opt-out compromise, I’d opt for the latter. (I should point out we’re not at the gun-at-the-head stage yet). But it’s also important to point out just how perverse the results of this compromise would be.

Red, rural states would almost all probably opt out and yet it’s rural America that needs the public option the most. As the Center for Community Change points out in a new report [PDF] people who live in rural areas are a) more likely to be underinsured, because fewer people receive insurance from their employers and b) live in markets where there is essentially no competition. In Alabama one health insurance company has 90% market share, in South Dakota, it’s two companies. It’s under these circumstances where the public option is most needed. In fact, I was talking about this issue with a health care wonk (who works for the government and so can’t go on record) and she went so far as to put it this way:


My point is that the public option is probably valuable in this debate, but not for the people fighting for it–precisely for the people not fighting for it. This is important for rural areas where there is little or no managed care in the health insurance exchange (since the public option would be offered within the exchange anyway).


Would be nice if folks like Kent Conrad, Ben Nelson and Max Baucus could be made to understand this.