Physicians for a National Health Program (PNHP), April 10, 2019
Today is another important day in the movement towards improved Medicare for All. This morning, Sen. Bernie Sanders introduced the Medicare for All Act of 2019 in the Senate, along with 14 co-sponsors. Sen. Sanders has long been a strong voice for health care justice in the U.S., and we welcome his continued advocacy and leadership for single-payer reform.
What’s in the bill?
The Medicare for All Act of 2019 mostly follows the Senator’s 2017 bill, with one notable addition. Here’s a summary of what’s in the bill:
- Eligibility: Covers everyone residing in the U.S.
- Benefits: Covers medically-necessary services including primary and preventive care, mental health care, reproductive care (bans the Hyde Amendment), vision and dental care, and prescription drugs. This bill also provides home- and community-based long-term services and supports, which were not covered in the 2017 Medicare for All Act.
- Patient Choice: Provides full choice of any participating doctor or hospital. Providers may not dual-practice within and outside the Medicare system.
- Patient Costs: Provides first-dollar coverage without premiums, deductibles or copays for medical services, and prohibits balance billing. Copays for some brand-name prescription drugs.
- Cost Controls: Prohibits duplicative coverage. Drug prices negotiated with manufacturers.
- Timeline: Provides for a four-year transition. In year one, improves Medicare by adding dental, vision and hearing benefits and lowering out-of-pocket costs for Parts A & B; also lowers eligibility age to 55 and allows anyone to buy into the Medicare program. In year two, lowers eligibility to 45, and to 35 in year three.
How can the bill be improved?
Similar to the 2017 bill, the launch of this bill is a major step forward in the fight for Medicare for All. At the same time, PNHP again recommends ways that this bill can be improved:
Fund hospitals through global budgets, with separate funding for capital projects: A “global budget” is a lump sum paid to hospitals and similar institutions to cover operating expenses, eliminating wasteful per-patient billing. Global budgets could not be used for capital projects like expansion or modernization (which would be funded separately), advertising, profit, or bonuses. Global budgeting minimizes hospitals’ incentives to avoid (or seek out) particular patients or services, inflate volumes, or upcode. Funding capital projects separately, in turn, allows us to ensure that new hospitals and facilities are built where they are needed, not simply where profits are highest. They also allow us to control long term cost growth.
End “value-based” payment systems and other pay-for-performance schemes: This bill continues current flawed Medicare payment methods, including alternative payment models (including Accountable Care Organizations) established under the ACA, and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Studies show these payment programs fail to improve quality or reduce costs, while penalizing hospitals and doctors that care for the poorest and sickest patients.
Establish a national long-term care program: This bill includes home- and community-based long-term services and supports, a laudable improvement from the 2017 bill. However, institutional long-term care coverage for seniors and people with disabilities will continue to be covered under state-based Medicaid plans, complete with a maintenance of effort provision. PNHP recommends that Sen. Sanders include institutional long-term care in the national Medicare program, as it is in Rep. Pramila Jayapal?s single-payer bill, H.R. 1384.
Ban investor-owned health facilities: For-profit health care facilities and agencies provide lower-quality care at higher costs than nonprofits, resulting in worse outcomes and higher costs compared to not-for-profit providers. Medicare for All should provide a path for the orderly conversion of investor-owned, for-profit health-care providers to not-for-profit status.
Fully cover all medications, without copayment: Sen. Sanders’ bill excludes cost-sharing for health care services. However, it does require small patient copays (up to $200 annually) on certain non-preventive prescription drugs. Research shows that copays of any kind discourage patients from seeking needed medical care, increasing sickness and long-term costs. Experience in other nations prove that they are not needed for cost control.
Single-payer opponents, including deep-pocketed lobbying groups like the Partnership for America’s Health Care Future that represent corporate health care interests, will certainly attack this bill and its co-sponsors. At the same time, a slew of alternative proposals that fall short of what is needed, like a public option, could confuse the public.
Let’s remind our members of Congress that a majority of Americans (including a growing majority of physicians) support real single-payer reform. So please consider calling both of your U.S. Senators at (202) 224-3121 and request that they co-sponsor the Medicare for All Act of 2019. If they are already a co-sponsor, thank them and ask them to work towards improving this bill, educating their colleagues, and amplifying the work of grassroots organizers.
The fight for a just health care system for all is moving forward. Together, it’s a fight we can win.
Adam Gaffney, M.D., M.P.H
By Don McCanne, M.D.
Single payer Medicare for All bills have now been introduced in both the House and the Senate. They are both named Medicare for All Act of 2019, although there are significant differences in the bills. What do we do with them?
In this session of Congress, neither bill can clear the Senate, and they would certainly face a veto by President Trump. But that is true of other reform measures, especially those that offer a Medicare-like public option. So our goal during this session of Congress is to use the two single payer Medicare for All bills to educate, not only the public at large, but also present and potential future members of Congress and potential presidential candidates. But remember, the politicians need to hear it from their constituents. The public leads, politicians follow, unless corrupted.
The most important message is why the single payer model of Medicare for All is the only model that will achieve the goal of truly affordable and equitable health care for absolutely everyone. There is a surge in popularity for reform that protects private employer-sponsored plans and the private Medicare Advantage plans, reflecting the fact that the public and many politicians do not realize the profound differences in the efficiency, affordability, and equity of the two models of reform: single payer Medicare for All versus public option Medicare for some. Tweaks to the Affordable Care Act do not even qualify as a game changer.
For those who do understand the single payer model, it is important to educate them on the policy details that are important, such as those concerns listed in the PNHP message above. Time is short. Potential presidential candidates are already refining their policy positions, as are members and candidates for Congress. Their positions should be clear before the election, and the policy details of the legislation should be carefully defined before the next session of Congress begins. This work has to be done now. Relying on a drawn-out, legislative sausage-making process could be disastrous. Human lives depend on getting it right.
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