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)1;
- 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. LujƔn, 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.
Key Policy Considerations
- HOW WOULD THE PROPOSALS PROVIDE AND EXPAND COVERAGE?
- HOW WOULD THE PROPOSALS AFFECT THE AFFORDABILITY OF COVERAGE FOR CONSUMERS?
- HOW WOULD THE PROPOSALS AFFECT MARKETPLACE COVERAGE?
- HOW WOULD THE PROPOSALS AFFECT PRIVATE EMPLOYER-SPONSORED HEALTH COVERAGE?
- WOULD THE NEW PUBLIC PLAN OPTIONS BE THE SAME AS THE CURRENT MEDICARE PROGRAM?
- HOW WOULD THE PROPOSALS AFFECT THE CURRENT MEDICARE PROGRAM?
- HOW WOULD THE PROPOSALS AFFECT THE CURRENT MEDICAID AND CHIP PROGRAMS?
- HOW WOULD THE PROPOSALS ADDRESS THE NEEDS OF SPECIFIC POPULATIONS?
- HOW WOULD THE PROPOSALS AFFECT PAYMENTS TO PROVIDERS?
- WHAT COST CONTAINMENT FEATURES ARE IN THE PROPOSALS?
- WHAT ARE THE COSTS AND POTENTIAL TRADE-OFFS?
- HOW WOULD THE PROPOSALS BE FINANCED?
From the Discussion
With health care reemerging as an issue for voters in the mid-term elections, the debate over the role of public programs in our health care system appears to be intensifying. Current proposals offer a range of approaches from those that would transform the existing system by creating a new national, Medicare-for-All plan to more incremental approaches that would offer a new public plan option alongside existing private coverage and public programs. With many details yet to be provided, these proposals raise a number of questions, the answers to which will have important implications for consumers, health care professionals, and health care payers, including employers, states, and the federal government.
Comment:
By Don McCanne, M.D.
This 16 page KFF issue brief summarizes various legislative proposals that would expand public coverage of health care. Because they vary in their impact, the authors have suggested questions that should be asked in evaluating each proposal. Single Payer Medicare for All supporters can certainly come up with several other important questions.
Some in the legislative and policy communities would consider these proposals to be on a level paying field, and that choices would be based on various policy trade-offs that might be preferred by a majority of legislators and policy wonks. Although that process could bring us to an optimal system, it very well might not. It risks neglecting fundamental goals that should be a moral imperative such as universality, equity, accessibility, comprehensiveness, efficiency and affordability.
The proposed and other pertinent questions should be asked not only regarding the Medicare for All, public option and buy-in proposals, but they should also be asked about the state versus federal proposals, especially Single Payer Medicare for All. Under any circumstances would it ever be right to leave out certain socioeconomic sectors in states other than yours?
By asking the right questions, we can identify the policy pathway to health care nirvana. That would be either a national health service or Single Payer Medicare for All. The latter would not only be more feasible, it would also align more closely with perceived American cultural values, even if the former might actually be a superior model.
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