Medicare-for-All and Public Plan Buy-In Proposals: Overview and Key Issues

By Tricia Neuman, Karen Pollitz, and Jennifer Tolbert
KFF, October 2018

As policymakers debate next steps for expanding health insurance coverage and lowering health costs, some have introduced legislation that would broaden the role of public programs, such as Medicare and Medicaid. During the 115th Congress, eight such proposals were introduced, ranging from bills that would create a new national health insurance program for all U.S. residents, replacing virtually all other sources of public and private insurance (Medicare-for-All), to more incremental approaches that would create a new public plan option, as a supplement to private sources of coverage and public programs.

These eight legislative proposals differ in ways that have important implications for consumers, health care providers and payers, including employers, states, the federal government, and taxpayers. Key policy differences relate to eligibility, the size and scope of the public plan, covered benefits and cost sharing, premiums, subsidies for premium and cost sharing, cost containment strategies, and the likely interactions with current public programs and private sources of coverage. They also vary in their level of detail; some bills, according to their sponsors, are intended to serve as blueprints for reform, and are expected to include greater specificity over time. Given the timing of the legislative calendar, these bills are unlikely to advance in the current Congressional session; however, they illustrate the range of options that will likely serve as prototypes for legislation that may be introduced in the next session of Congress.

Greatly simplified, these public plan proposals fall into four general categories:

* Two proposals would create Medicare-For-All, a single national health insurance program for all U.S. residents (Senator Sanders, S.1804; Rep. Ellison, H.R. 676);

* Three proposals would create a new public plan option, based on Medicare, that would be offered to individuals and some or all employers through the ACA marketplace (The Choice Act by Rep. Schakowsky, H.R. 635, and Sen. Whitehouse, S. 194); The Medicare-X Choice Act by Sen. Bennett, S. 1970, and Rep. Higgins, H.R.4094; and the Choose Medicare Act by Sen. Merkley, S. 2708 and Rep. Richmond, H.R. 6117)

* Two proposals would create a Medicare buy-in option for older individuals not yet eligible for the current Medicare program (Sen. Stabenow, S. 1742; Rep. Higgins, H.R. 3748); and

* One proposal would create a Medicaid buy-in option that states can elect to offer to individuals through the ACA marketplace. (Sen Schatz, S. 2001 and Rep. Luján, H.R. 4129).

This policy brief summarizes key features of these proposals, highlights similarities and differences, and discusses key questions, trade-offs and potential implications.

Issue Brief (16 pages):
http://files.kff.org…

Side-by-Side Comparison of Medicare-for-All and Public Plan Proposals (12 pages):
http://files.kff.org…

Interactive for comparing proposals:
https://www.kff.org…

The enthusiasm for Medicare for All continues to increase so much so that it has now become part of our national parlance. Until recently, the meaning of the term has been quite specific, referring to a single payer national health program based on an improved version of our traditional Medicare program that would include everyone and which would be publicly-financed and publicly-administered.

Now advocates of various models of incremental reform want to get in on the action, and they are doing so usually by using the Medicare label. So we not only have two Medicare for All bills, but we also have the labels of Medicare public option (Choice, Medicare-X Choice, Choose Medicare), Medicare Buy-in (Medicare at 55, Medicare Buy-in and Health Care Stabilization), and even a Medicaid buy-in option. Needless to say, this has caused confusion which particularly has been a problem with distinguishing true single payer from merely adding a public option to our current inefficient, fragmented financing system.

This report, authored by the policy experts at KFF, is timely and welcome since it describes the eight leading legislative proposals and discusses some of the key issues that distinguish them. The authors do set apart Medicare for All as a single, federal, government-administered program that would provide coverage to all U.S. residents, replacing virtually all other sources of private health coverage (employment-sponsored plans and insurance offered inside and outside ACA marketplaces) and most public programs, including Medicare, Medicaid and CHIP. All of these other programs – public option, Medicare buy-in, and state Medicaid buy-in – keep intact our administratively inefficient, expensive, fragmented, dysfunctional health care financing system while merely adding administratively complex options.

The difference is night and day. There should be no confusion between an improved Medicare for All that would fix our health care financing problems, and the other proposals that merely add to the complexity and waste while failing to adequately address the inequities and deficiencies inherent in our current system.

This is why the Issue Brief and Side-by-Side comparison produced by KFF are so pertinent. They can be used to educate others on the stark differences between the two approaches to reform – single payer versus adding an option – not to mention that they can be used to sharpen your communication skills as you attempt to educate others on these crucial differences.

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