The question of single-payor healthcare continues to linger in the policy sphere in a sort of malaise. Even before the Trumpian era, Republicans have unanimously opposed it, and since the 90’s, even the concept of insurance mandates are no-go’s for Republicans. One solution, however, proffers a unique compromise between those who believe that healthcare is a fundamental right and those who believe its none of the government’s business: have it both ways. 

In a “Medicare For All (Who Want It)”-style plan, private insurance markets would exist alongside a government-sponsored option, and individuals would choose which to pay into (either via premiums or taxes), if either at all. The only catch? If you don’t choose the public option by age 26, you’ve made that decision for life. Making patients stick with their choices, a key tenant that helps distinguish this plan from current Medicare, isn’t just about teaching responsibility–it keeps older and sicker patients from switching the burden their care when it becomes too expensive to finance themselves. 

Though a seemingly harsh determination, the idea is far from new. In 2009, one of Clinton’s former healthcare advisors suggested that Democrats drop the individual insurance mandate from Obamacare, and instead stipulate that those who opted out of the exchange would be barred from participating in it for 5 years thereafter. If adversaries of Obamacare disliked it so much, the thinking went, they would have no issue finding insurance without it. Health economist Uwe Reinhardt, writing a few years later, took the idea a step further: give us both extremes of health insurance administration (pure public and pure private) and lock in our choices forever. 

The plan seems highly appealing: Republicans and Libertarians have the full freedom of the private sector, paying actuarially-fair premiums without having to subsidize their neighbors (or not buying insurance at all), and Democrats have a community-backed single-payor system that prevents patients from going flat broke in the event of emergency. A win-win situation. 

The longer we look, however, the more apparent it is that the Republicans get the short end of the stick. Take, for example, the term “actuarially fair.” A more apt term, perhaps, would be medically underwritten: you pay for exactly how healthy you are. At age 26, when joining the plan, this is undoubtedly a good deal. Premiums for a healthy young person would be extremely low, if that person even chose to buy insurance. Unfortunately, such premiums do not stay long. Smoking, drinking, driving, and other forms of risk taking each add to your bill, and even the perfect patient will see their premiums rise exponentially as they age. By 65, when citizens normally join Medicare, private insurance premiums will be unsustainably high, and proponents of private insurance will soon learn why insurance is often pooled as it would be in the public option: though a seemingly unfair “subsidization” of strangers when you are young, it becomes a saving grace in ones own old age and sickness. Hospitals and private insurance plans would, of course, be authorized to use tough collection measures to prevent freeloading (the bane of rugged individualists’ existence), seizing assets and garnishing wages to cover the cost of care and prevent moochers from raising the cost for other, healthier individualists. 

Republicans are not likely to support this plan, however. Could it be its shortsighted nature? Its total disregard for the wellbeing of our fellow countrymen? Probably not. As RFK testified during his confirmation hearings, he believes we “need to focus more on making [patients] more accountable for their own healthcare,” and this solution, though morbid in its pauperization of the sick and elderly who opted for private insurance, would do just that. No, the Republican Party would likely oppose this plan because it would implement a government-sponsored system. Ignoring the issue of purely actuarially-fair determinations, as RFK and Trump would be likely to do, any plan that involves a concession towards “socialist” healthcare would be an affront to the GOP. Though an elegant solution, Trumpian Republicanism seems impervious to compromise, and it seems this proposal will have to go dormant yet again, returning to its status as a thought exercise as it did during the first Trump era.