U.S. House of Representatives, Committee on the Budget
January 8, 2019
Dr. Keith Hall
Congressional Budget Office
Washington, DC 20515
Dear Dr. Hall:
The Affordable Care Act substantially increased the number of Americans who have health insurance and created important consumer protections, such as caps on out-of-pocket costs and prohibiting discrimination against people with pre-existing conditions. However, millions of Americans remain uninsured, and millions more – even though they have insurance – struggle to afford their health care costs. Many members of Congress are considering new approaches to achieve the goal of affordable, high-quality coverage available to everyone. There are several possible pathways toward this goal, ranging from incremental improvements to the Affordable Care Act to a more comprehensive overhaul of the nation’s health care system. One approach that has garnered considerable interest is a single-payer system. Supporters often point to the experience of other countries that have achieved near-universal coverage through single-payer systems. The single-payer systems in other countries differ in important respects, however, and do not necessarily provide a clear blueprint as to how such a system in this country would be designed. Members of Congress developing proposals to establish a single-payer system will face many important decisions that could have major implications for federal spending, national health care spending, and access to care.
To assist Congress with that work, I request that the Congressional Budget Office provide a report on the design considerations that policymakers would confront in developing proposals to establish a single-payer system in the United States. The report would cover the following issues: how the system would be administered; who would be eligible for coverage and how they would be enrolled; what services would be covered and what cos-sharing requirements, if any, would be imposed; what role, if any, private insurers would play; whether other public programs (such as Medicaid, the Veterans Health Administration, the Indian Health Service, and the Military Health System) would continue to exist; how provider payment rates would be established; what participation rules would be established for providers; what methods would be used to contain costs; and how the system would be financed. The report would not necessarily provide CBO’s estimate of the effects of any particular proposal for a single-payer system on federal spending to national health care spending but would, to the extent feasible, provide a qualitative assessment of how the choices with respect to major design issues would affect such spending. The staff contact for this request is Erika Appel, who can be reached at (number omitted to avoid a deluge of calls – DMc).
John A. Yarmuth
By Don McCanne, M.D.
Speaker of the House Nancy Pelosi has already stated that the Budget Committee would be holding hearings on Medicare for All. This letter indicates that the process has already begun since the committee does need basic information on what a single payer system is, and the nonpartisan Congressional Budget Office (CBO) serves as an impartial resource for such information. The fact that single payer Medicare for All is now receiving formal consideration in Congress is an important milestone in our journey toward health care justice for all.
Concerns are already being expressed over the background of Keith Hall, the Director of the CBO, who is a Republican and was the chief economist for the White House Council of Economic Advisers under George W. Bush, and was a senior research fellow at the Mercatus Center at George Mason University – a free-market oriented institution that recently released a report critical of Sen. Bernie Sanders’ Medicare for All legislation.
The probability is that the report will be credible since the CBO staff has continued to demonstrate professional integrity and impartiality regardless of the political inclinations of the director. Prior CBO controversies such as the application of dynamic scoring likely will not play a role here. In the unlikely event that they digress and redefine single payer as a more conservative or libertarian model, or if they distort socialist features as being a nefarious route to totalitarianism, the uprising by Medicare for All activists would put their report to rest. But that won’t happen. Likely, at the very worst, we might have to correct some minor distortions or errors, and we do have the credibility to do that. Furthermore, this is only a report and not legislation. The real test comes when the final, definitive legislative is crafted.
Whether or not the report turns out to be useful, we already have a plethora of health policy data that can guide Congress as they create the design and transform it into legislative language. Whatever bill(s) may be produced will have plenty of exposure during this session of Congress, allowing for our input to perfect them for the next session of Congress when we may finally have a real chance of achieving our goal of Medicare for All.
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