2019 legislative agenda: Medicare for all?
The idea of expanding the Medicare program to cover Americans younger than the age of 65 has been around for a long time – it was referred to as the “single payer option” during the run-up to passage of the Affordable Care Act in 2010 and proved to be a divisive political issue at the time. Now, with Democrats seizing control of the House of Representatives and a presidential election year looming in 2020, the single payer option is getting another look and another slogan: “Medicare-for-all.”
It’s worth examining two “Medicare-for-all” plans currently circulating in Washington, both introduced by Democratic lawmakers eager to draw a contrast between their ideas on healthcare and that of both the Trump administration and their Republican counterparts.
These new proposals are distinct from the “Medicare-for-all” proposal introduced by former presidential hopeful Bernie Sanders (I-Vt.) in 2016.
A generous but incomplete ‘single-payer’ option
The “Medicare for All Act of 2019,” introduced by Reps. Pramila Jayapal (D-Wash.) and Debbie Dingell (D-Mich.) is in many ways a more progressive version of the original 2016 plan from Sen. Sanders, but it does leave a role for private, commercial insurers.
Key provisions of this bill are as follows:
- The federal government would create a healthcare insurance program that would cover most types of medical care for all U.S. citizens, with no cost sharing.
- Unlike Medicare, the new program would cover long-term care, such as nursing homes and assisted living, making it more generous than any previous proposal
- Commercial payers would not be allowed to compete with the new government plan, but they could offer private plans to cover medical services not already covered by the government plan.
- Healthcare providers could choose not to participate with the new plan and charge patients under their own fee schedule.
- The plan allows for a two-year transition (the Sanders plan allowed for four years) during which Medicare and Medicaid beneficiaries would move to the new plan.
- Veterans Affairs and Indian Health Services would continue to operate without impact.
- The new plan would have the ability to negotiate directly with drug manufacturers, and the power to strip away drug patents if negotiations failed to produce acceptable pricing, a policy sometimes referred to as “compulsory licensing.”
The bill’s authors don’t have much to offer yet when it comes to financing their proposal, with Sen. Jayapal stating that additional taxes on the wealthy or a repeal of the Trump administration’s 2017 tax cut could be options.
A Medicare ‘buy-in’ option
On the other end of the spectrum from a generous single-payer option is the Medicare “buy-in” plan, which would allow patients 50 and older to purchase Medicare coverage through the existing Affordable Care Act (ACA) exchanges. The most current incarnation is a bill called “Medicare at 50,” introduced by Sens. Sherrod Brown (D-Ohio), Debbie Stabenow (D-Mich.), and Tammy Baldwin (D-Wis.), with co-sponsors in the House, including Reps. Joe Courtney (D-Conn.), Brian Higgins (D-N.Y.), and John Larson, also a Democrat from Connecticut.
Here’s how their bill would work:
- Any person aged 50-64 (the current Medicare eligibility age is 65) would be able to buy Medicare coverage on the ACA exchanges, with the ability to use the ACA’s tax credits to purchase that coverage.
- The cost of the premiums would be set so the overall effect is budget-neutral, which is being touted as a benefit of this plan.
- Though there are no specific numbers in the bill, the premium could be about $7,600 a year per beneficiary for the federal government to break even, according to a 2008 estimate by the Congressional Budget Office. The average ACA exchange premium for a 64-year-old can be as high as $15,300 per year, according to a CBO estimate.
Democratic ambitions in 2020 and beyond
Polls suggest that a Medicare buy-in option would be popular with most Americans, with 8 in 10 saying it would be a good idea, including nearly 7 in 10 Republicans, according to polling by the Kaiser Family Foundation. However, reenergized Democrats in Congress want to shoot for more than the buy-in option, which they see as being too incremental. Some believe bigger opportunity exists to sell voters on a much larger reform along the lines of Medicare-for-all, with affordable healthcare likely to be a top issue in the 2020 presidential election.