2020 OPEN ENROLLMENT ENDS (most states)

Time: D H M S

UPDATE: Bernie rolls out his NEW Medicare for All bill...what's different this time?

In September 2017, Sen. Bernie Sanders introduced his "official" Medicare for All, universal single payer bill to much fanfare. At the time, it garnered a lot of attention, but it also had some gaping holes...most notably the lack of any actual funding mechanism or specifics, as well as a big coverage gap which could be found in both the "Medicare for America" bill which I'm a big fan of as well as the House MFA version.

Today, Sanders launched a revised version of the bill which supposedly addresses both of those issues along with others. Let's take a look.

First of all, who's co-sponsoring it? In 2017, it was cosponsored by 16 Democratic Senators:

Mr. Sanders (for himself, Ms. Baldwin, Mr. Blumenthal, Mr. Booker, Mr. Franken, Mrs. Gillibrand, Ms. Harris, Mr. Heinrich, Ms. Hirono, Mr. Leahy, Mr. Markey, Mr. Merkley, Mr.Schatz, Mrs. Shaheen, Mr. Udall, Ms. Warren, and Mr. Whitehouse) introduced the following bill; which was read twice and referred to the Committee on Finance

In 2019, it's down to 13. One of those doesn't count since Al Franken resigned, but it looks like Martin Heinrich (NM) and Jeanne Shaheen (NH) have bailed:

Mr. SANDERS (for himself, Ms. BALDWIN, Mr. BLUMENTHAL, Mr. BOOKER, Mrs. GILLIBRAND, Ms. HARRIS, Mr. LEAHY, Mr. MARKEY, Mr. MERKLEY, Mr. SCHATZ, Mr. UDALL, Ms. WARREN, Mr. WHITEHOUSE, and Ms. HIRONO

UPDATE: Hmmmm...thanks to Colin Seeberger for calling my attention to this: Apparently Martin Heinrich is still cosponsoring the new bill after all...his name isn't listed on it, but it's listed in Sanders' press release:

Sanders introduced the bill along with Sens. Tammy Baldwin (D-Wis.), Richard Blumenthal (D-Conn.), Cory Booker (D-N.J.), Kirsten Gillibrand (D-N.Y.), Kamala Harris (D-Calif.), Mazie Hirono (Hawaii), Martin Heinrich (D-N.M.), Patrick Leahy (D-Vt.), Edward Markey (D-Mass.), Jeff Merkley (D-Ore.), Brian Schatz (D-Hawaii), Tom Udall (D-N.M.), Elizabeth Warren (D-Mass.) and Sheldon Whitehouse (D-R.I.).

OK, fair enough.

First, a few tidbits from reporter Sahil Kapur:

.@BernieSanders lays out some “options” to finance single payer health insurance—4% fee on income >$29k for family of four; 7.5% payroll tax above $2 million; ending health tax breaks; taxing estates, upper income, wealth; a fee on big banks, targeting corp accounting “gimmicks.”

— Sahil Kapur (@sahilkapur) April 10, 2019

OK, I do give Sanders credit for finally baking in actual funding mechanisms into the legislative text!

Wait, what's that?

It’s in a financing white paper released by his office

— Sahil Kapur (@sahilkapur) April 10, 2019

Oh. Um...never mind.

100% of the Federal Poverty Line for a family of 4 is $25,750 this year. $29,000/year is 116% of the poverty line. A family of 4 earning, say, $40,000/year (155% FPL) would pay $440/year. If they earned $60,000/year (233% FPL), they'd pay $1,240/year. At $100,000 (388% FPL), they'd pay $2,840.

The "ending health tax breaks" bit is cute, since, as Kapur notes...

Notable that Bernie Sanders’ plan ends the tax break for employer-based coverage, which single payer would hollow out anyway. It’s currently the most expensive tax expenditure and costs the Treasury $172.8 billion per year (JCT FY2019 est).

— Sahil Kapur (@sahilkapur) April 10, 2019

Nothing wrong with this, actually: Both Sanders and Kapur are correct that employer-sponsored insurance tax breaks heavily subsidize the ~155 million who currently are covered that way...although very few realize that.

Here's Sarah Kliff on the funding issue:

The big question Sanders doesn’t answer: How do you pay for it?

The Sanders plan goes into great detail on what kind of coverage a universal plan ought to offer. But it does significantly less work explaining how this would be paid for. Instead, Sanders’s office released a paper that included this bullet-point list of possible options:

  • Creating a 4 percent income-based premium paid by employees, exempting the first $29,000 in income for a family of four
  • Imposing a 7.5 percent income-based premium paid by employers, exempting the first $2 million in payroll
  • Eliminating health tax expenditures
  • Making the federal income tax more progressive, including a marginal tax rate of up to 70 percent on those making above $10 million
  • Making the estate tax more progressive, including a 77 percent top rate on an inheritance above $1 billion
  • Establishing a tax on extreme wealth
  • Closing a tax-loophole that allows self-employed people to avoid paying certain taxes by creating an S corporation
  • Imposing a fee on large financial institution
  • Repealing corporate accounting gimmicks

The items on this list could no doubt be used to finance a national health care system. But eventually, someone is going to have to pick which items on this list become law — and that’s where things get tough.

Instead of reading through the exact text of the bill, for now let's take a look at the summary:

TITLE I—ESTABLISHMENT OF THE UNIVERSAL MEDICARE PROGRAM
Establishes a national health insurance program for every resident of the United States, including the District of Columbia and the territories. Provides for patient freedom of choice among providers. Creates an enrollment mechanism and provides for issuance of health insurance cards. Effective date of benefits: four years after the date of enactment (starting January 1 of that year)

TITLE II—COMPREHENSIVE BENEFITS
Requires coverage of the following benefits: hospital services, including emergency services and inpatient drugs; ambulatory patient services; primary and preventive services, including disease management; prescription drugs, medical devices, and biological products; mental health and substance abuse treatment services, including inpatient care; laboratory and diagnostic services; reproductive, maternity, and newborn care; pediatrics; oral health and vision; rehabilitative and habilitative services and devices; emergency services and transportation; home- and community based long-term services and supports; other items as deemed necessary.

States may provide additional benefits at their expense.

Institutional long-term care coverage for seniors and people with disabilities will continue as it is currently covered under Medicaid, complete with a maintenance of effort provision; no one receiving benefits through Medicaid or any other federal or state health program will lose support. Separating home-and-community-based services from institutional services will allow us to erase the current institutional bias and ensure people are allowed to choose the setting which suits them best.

There it is: He's indeed added LTSS into the mix, matching both Medicare for America and the House version of the MFA bill.

TITLE III—PROVIDER PARTICIPATION
Requires all providers to sign a participation agreement
, which includes nondiscrimination on the basis of race, color, national origin, income, religion, age, sex or sexual orientation, gender identity, disability, handicapping condition, or illness (subject to the provider’s scope of practice). Participation agreements may be terminated by the agency for cause, or by the provider for any reason. Providers shall be considered qualified if they are properly licensed and certified under State and federal law to provide such services. The agency shall establish and maintain national minimum provider standards. Allows providers to enter into private contracts with individuals for services otherwise covered by this Act as long as the individual pays fully out of pocket.

I'm not sure whether this last bit is new or not, but it basically just means that doctors who refuse to participate in the program at all (which I admit to being a bit confused by given the first sentence) are allowed to provide healthcare services as long as the patient is willing to pay 100% cash. In other words, concierge medicine for the rich will indeed be allowed.

TITLE IV—ADMINISTRATION
Establishes a Universal Medicare Agency to oversee and administer this Act, within the Department of Health and Human Services. The agency shall be headed by the Secretary of HHS and 6 other individuals, subject to Senate confirmation. Requires the agency to consult with all relevant stakeholders when formulating guidelines and regulations. Provides for regional and state administration. Provides for a Beneficiary Ombudsman to assist individuals enrolled in the Act, and an Inspector General for the Board. Applies all current Medicaid fraud provisions to this Act.

In other words, there would still be bureaucrats deciding the limits of what is or isn't covered...it's just that they'd be government bureaucrats instead of insurance company bureaucrats. I don't mean this as either an attack or defense of "bureaucratic meddling", just noting that it'd still be a thing.

TITLE V—QUALITY ASSESSMENT
Creates an American Health Quality Council to review and evaluate all practice guidelines, profile practices and patterns of health care, conduct quality reviews, and report to the agency on outcomes research. Requires the Council to evaluate and address health care disparities.

Again: Coverage and practices would still be up for review and modification.

TITLE VI—BUDGET AND COST CONTAINMENT
Requires the agency to create an annual budget, which shall include the cost of covered health services; quality assessment activities; health professional education expenditures; administrative costs; innovation; operating and other expenditures; capital expenditures; and public health activities. For the first five years following the date of enactment, the budget may also provide transition assistance to health insurance administration workers who may be displaced because of the implementation of this Act. Provides for a reserve fund to anticipate natural disasters or other such public health emergencies. Continues current Medicare payment methods, including alternative payment models established under ACA and MACRA. Requires the agency to negotiate the price of prescription drugs and establish a formulary. Gives patients and providers the right to petition to have drugs placed on or off the formulary. Provides a means of access for patients who need off-formulary medications.

The "5 years for displaced workers" bit refers to the 2.7 million people currently employed directly or indirectly in the health insurance industry today, of whom half a million work directly for health insurance companies.

The 2.7 million figure includes other types of insurance (life, auto, homeowners), but many insurance companies sell more than one type of insurance, so 2-3 million seems like a good estimate when you include related businesses.

TITLE VII—UNIVERSAL HEALTH INSURANCE TRUST FUND
Creates a trust fund for this Act. Includes all current federal health insurance program receipts, as well as all extra dollars attributed to changes in the Internal Revenue Code (for example, removing the employer health insurance premium exclusion). Bans the Hyde Amendment.

This is the closest that the bill apparently comes to actually stating how it would be funded:

  • 100% of all current federal healthcare funding (i.e., all current spending on Medicare, Medicaid, CHIP, the ACA, the FEHBP, TRICARE, etc), plus
  • "all extra dollars attributed to changes in the Internal Revenue Code"...otherwise known as "whatever additional taxes we come up with from the list at the top of this blog entry"

"Bans the Hyde Amendment" is a pretty dismissive way of referring to what will no doubt be an epic Battle Royale no matter what universal coverage plan we eventually end up with.

TITLE VIII—ERISA CONFORMING AMENDMENTS

Hmmm...this section is completely blank in the summary for some reason. Here's the actual legislative text for Title 8...make of it what you will:

SEC. 801. PROHIBITION OF EMPLOYEE BENEFITS DUPLICATIVE OF BENEFITS UNDER THE UNIVERSAL MEDICARE PROGRAM; COORDINATION IN CASE OF WORKERS’ COMPENSATION.

(a) IN GENERAL.—Part 5 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1131 et seq.) is amended by adding at the end the following new section:

‘‘SEC. 522. PROHIBITION OF EMPLOYEE BENEFITS DUPLICATIVE OF UNIVERSAL MEDICARE PROGRAM BENEFITS; COORDINATION IN CASE OF WORKERS’ COMPENSATION.

‘‘(a) IN GENERAL.—Subject to subsection (b), no employee benefit plan may provide benefits that duplicate payment for any items or services for which payment may be made under the Medicare for All Act of 2019.

‘‘(b) REIMBURSEMENT.—Each workers compensation 25 carrier that is liable for payment for workers compensa- 61 TAM19490 S.L.C. 1 tion services furnished in a State shall reimburse the Uni2 versal Medicare Program for the cost of such services.

‘‘(c) DEFINITIONS.—In this subsection—

‘‘(1) the term ‘workers compensation carrier’ means an insurance company that underwrite workers compensation medical benefits with respect to 1 or more employers and includes an employer or fund that is financially at risk for the provision of work9 ers compensation medical benefits; 10 ‘‘(2) the term ‘workers compensation medical 11 benefits’ means, with respect to an enrollee who is an employee subject to the workers compensation laws of a State, the comprehensive medical benefits for work-related injuries and illnesses provided for under such laws with respect to such an employee; and

‘‘(3) the term ‘workers compensation services’ 18 means items and services included in workers com19 pensation medical benefits and includes items and 20 services (including rehabilitation services and long term-care services) commonly used for treatment of work-related injuries and illnesses.’’.

(b) CONFORMING AMENDMENT.—Section 4(b) of the Employee Retirement Income Security Act of 1974 (29 25 U.S.C. 1003(b)) is amended by adding at the end the following: ‘‘Paragraph (3) shall apply subject to section 2 522(b) (relating to reimbursement of the Universal Medicare Program by workers compensation carriers).’’

(c) CLERICAL AMENDMENT.—The table of contents in section 1 of such Act is amended by inserting after the item relating to section 521 the following new item: ‘‘Sec 522. Prohibition of employee benefits duplicative of Universal Medicare Program benefits; coordination in case of workers’ compensation.’’.

SEC. 802. REPEAL OF CONTINUATION COVERAGE REQUIREMENTS UNDER ERISA AND CERTAIN OTHER REQUIREMENTS RELATING TO GROUP HEALTH PLANS.

(a) IN GENERAL.—Part 6 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1161 et seq.) is repealed.

(b) CONFORMING AMENDMENTS.—

(1) Section 502(a) of such Act (29 U.S.C. 16 1132(a)) is amended—

(A) by striking paragraph (7); and (B) by redesignating paragraphs (8), (9), and (10) as paragraphs (7), (8), and (9), respectively.

(2) Section 502(c)(1) of such Act (29 U.S.C. 22 1132(c)(1)) is amended by striking ‘‘paragraph (1) or (4) of section 606,’’.

(3) Section 514(b) of such Act (29 U.S.C. 2 1144(b)) is amended—

(A) in paragraph (7), by striking ‘‘section 4 206(d)(3)(B)(i)).’’; and (B) by striking paragraph (8).

(4) The table of contents in section 1 of the Employee Retirement Income Security Act of 1974 is amended by striking the items relating to part 6 of subtitle B of title I of such Act.

SEC. 803. EFFECTIVE DATE OF TITLE. The amendments made by this title shall take effect on effective date of benefits under section 106(a).

TITLE IX—RELATIONSHIP TO EXISTING FEDERAL HEALTH PROGRAMS
Provides for a transition from Medicare, Medicaid, FEHB, SCHIP, and any other federal health insurance program into the Universal Medicare Program. Requires VA and IHS to stay independent for the first ten years of the program, with an evaluation at the end to determine if the systems need to stay independent. Requires HHS to consult with tribal leaders and stakeholders before making any determination with respect to the Indian Health Service.

I think the "ten year" part is a change from the prior version, which just left the VA and IHS exactly as is permanently. It's worth noting that both the old and new Senate versions of the bill are not technically "universal", in that they leave roughly 2.2 million people enrolled in the IHS and 9 million covered by the VA out of the program.

Yes, this may be splitting hairs given that both the IHS and VA are still taxpayer funded, but the point is that even Sanders recognizes that not every population's healthcare service needs are exactly the same.

TITLE X—TRANSITION
Provides for a four-year phase-in. Establishes a Medicare Transition Plan to allow Americans to buy into the Medicare program during the transition. Lowers the Medicare age to 55 in year one, 45 in year two, and 35 in year three. Adds new dental, vision, and hearing benefits to Medicare in year one. Lowers Medicare out-of-pocket costs in year one and eliminates the Part A and Part B deductibles. Eliminates the two-year waiting period for Medicare coverage for individuals with disabilities. Provides for continuity of care for persons with private health coverage to ensure a smooth transition.

He's sticking with the 4-year, age-based transition period. This is one of the biggest differences between MFA and Medicare for America, which is phased in based on type of current coverage instead of age.

TITLE XI—MISCELLANEOUS
Updates the resource limits under Social Security to current dollars and indexes for inflation going forward. Provides definitions of certain terms.

Honestly, while I'm sure there are some other differences between the old and new Senate version, it looks like the LTSS addition is by far the biggest one.