Heads Up! Major House Universal Coverage Hearings on Tuesday, 12/10!

 

Tuesday, December 10th, is gonna be a pretty big day for federal healthcare policy, especially in the U.S. House of Representatives.

For one thing, it's my understanding that the big Prescription Drug Bill (H.R. 3, the Lower Drug Costs Now Act) is scheduled for a floor vote on Tuesday, although it's possible that it'll be bumped until later in the week given the grumbling by the Congressional Progressive Caucus.

For another, the House Energy & Commerce Committee is holding what I'm assuming are all-day hearings on not one, not two, but nine different Universal Coverage bills, including the Big Ones: Medicare for All and Medicare for America:

HEARING ON "PROPOSALS TO ACHIEVE UNIVERSAL HEALTH CARE COVERAGE"

Date: Tuesday, December 10, 2019 - 10:30am

Location: 2322 Rayburn House Office Building

Subcommittees: 116th Congress, Energy and Commerce (116th Congress), Health (116th Congress)

The Subcommittee on Health of the Committee on Energy and Commerce will hold a legislative hearing on Tuesday, December 10, 2019, at 10:30 a.m. in room 2322 of the Rayburn House Office Building.  The hearing is entitled, "Proposals to Achieve Universal Health Care Coverage."

Key Documents: Memorandum from Chairman Pallone to the Subcommittee on Health

Legislation:

• H.R. 1277, the "State Public Option Act"
• H.R. 1346, the "Medicare Buy-In and Health Care Stabilization Act of 2019"
• H.R. 1384, the "Medicare for All Act of 2019"
• H.R. 2000, the "Medicare-X Choice Act of 2019"
• H.R. 2452, the "Medicare for America Act of 2019"
• H.R. 2463, the "Choose Medicare Act"
• H.R. 4527, the "Expanding Health Care Options for Early Retirees Act"
• H.R. 584, the "Incentivizing Medicaid Expansion Act of 2019"
• H.R. 2085, the "Consumer Health Options and Insurance Competition Enhancement Act" or the "CHOICE Act"

Here's Chair Pallone's memo summarizing all nine bills and the witnesses...many of whom are members of Congress themselves:

• To: Subcommittee on Health Members and Staff
• Fr: Committee on Energy and Commerce Staff
• Re: Hearing on “Proposals to Achieve Universal Health Care Coverage”

On Tuesday, December 10, 2019, at 10:30 a.m. in room 2322 of the Rayburn House Office Building, the Subcommittee on Health will hold a legislative hearing entitled, “Proposals to Achieve Universal Health Care Coverage.”

I. BACKGROUND

In 2018, approximately 150 million individuals had employer sponsored health insurance, 13 million purchased health insurance through the individual health insurance market, 2 and about 120 million received their health insurance through either Medicare, Medicaid or Children’s Health Insurance Program (CHIP).

The passage of the Affordable Care Act (ACA) has led to historic reductions in the uninsured rate and provided health insurance to more than 20 million individuals. The number of uninsured Americans decreased from about 44 million in 2013, before the ACA’s major coverage provisions took effect, to 27.5 million in 2018. More than half of those who remain uninsured are either eligible for the ACA’s Medicaid expansion or subsidies.

II. LEGISLATION

A. H.R. 1277, State Public Option Act

H.R. 1277, the “State Public Option Act”, introduced by Rep. Lujan (D-NM), would authorize states to offer a Medicaid buy-in on the ACA Marketplace that would cover the 10 essential health benefits. States would be authorized to charge premiums, deductibles, and costsharing, and beneficiaries would be eligible for the advance premium tax credits and cost-sharing subsidies, subject to the same limitations as exist for a qualified health plan (QHP) currently offered on the ACA Marketplace. States would receive a 90 percent Federal medical assistance percentage (FMAP) for the administrative costs of establishing and operating the buy-in.

This is the House companion bill to Senator Brian Schatz's similarly-titled Medicaid buy-in public option bill.

B. H.R. 1346, Medicare Buy-In and Health Care Stabilization Act of 2019

H.R. 1346, the “Medicare Buy-In and Health Care Stabilization Act of 2019”, introduced by Rep. Higgins (D-NY), would allow for individuals ages 50-64 to buy-in to Medicare. The coverage would be treated as coverage provided by a QHP offered on the ACA Marketplace and individuals would be eligible for the advance premium tax credits and cost-sharing subsidies. The bill would enhance cost-sharing subsidies for all ACA Marketplace enrollees. States would be prohibited from purchasing Medicare buy-in coverage on behalf of Medicaid eligible individuals ages 50-64. H.R. 1346 would also permit the Secretary of Health and Human Services (HHS) to negotiate drug prices for Medicare and for the buy-in plan, create a new voluntary public Medigap option, establish a reinsurance program for the individual market, and reinstate the ACA’s risk corridor program through 2024.

Huh. This is interesting...the first part simply mirrors Senator Debbie Stabenow's "Medicare 50+" Act, which lets people age 50-64 buy into Medicare...but the other provisions are an interesting hodge-podge of good ideas from other bills. Enhancing CSRs is part of Senator Warren's CHIPA "ACA 2.0" bill. Reinstating the federal reinsurance program is part of the House ACA 2.0 bill (H.R. 1884). Negotiating drug prices for Medicare is obviously a major goal of just about every Democratic universal coverage bill, as well as the H.R. 3 being voted on this week itself. The public Medigap option is the only provision I haven't heard discussed before. And I'm surprised to see someone wanting to reinstate the ACA risk corridor program after the mess it turned into after the GOP torpedoed it back in the 2014 CRomnibus bill.

C. H.R. 1384, Medicare for All Act of 2019

H.R. 1384, the “Medicare for All Act of 2019”, introduced by Reps. Jayapal (D-WA) and Dingell (D-MI), would create a national health insurance program for all U.S. residents. The national program would replace the current Medicare program, Medicaid, CHIP and private health insurance for covered services. The bill would not change coverage provided by the Indian Health Service or Department of Veterans Affairs. Individuals would pay no premiums or cost sharing for covered services. One year after enactment, individuals over the age of 55 and under 19 would be eligible to enroll and two years after enactment all U.S. residents would be eligible to enroll. H.R. 1384 would also permit the Secretary of HHS to negotiate drug prices and issue compulsory licenses to allow generic production if negotiation fails.

Ah, yes. This is The Big Kahuna: The House version of Bernie Sanders' identically-titled bill. I don't think I need to say any more about this here.

D. H.R. 2000, Medicare-X Choice Act of 2019

H.R. 2000, the “Medicare-X Choice Act of 2019”, introduced by Rep. Delgado (D-NY), would establish a Federal public option plan on the ACA Marketplace. Under H.R. 2000, the public plan option would be subject to the same requirements that apply to other QHPs offered on the Marketplace, and would be available to all individuals who are eligible for QHPs. The bill would require HHS to offer the plan at two different benefit levels and to set premiums to cover 100 percent of benefits and administrative costs of the public option. H.R. 2000 would also expand the ACA’s premium tax credit eligibility to individuals with income above 400 percent of federal poverty level (FPL) by capping their required contribution to 13 percent of their income. Lastly, the legislation would establish a temporary reinsurance program and provide $10 billion annually over three years.

This is the House companion to Senators Michael Bennett & Tim Kaine's Medicare X public option bill.

E. H.R. 2452, Medicare for America Act of 2019

H.R. 2452, the “Medicare for America Act of 2019”, introduced by Reps. DeLauro (DCT) and Schakowsky (D-IL), would create a national health insurance program for all U.S. residents with an option to opt out if an individual has qualifying coverage. Individuals currently enrolled in Medicare, Medicaid, or CHIP would over time be enrolled in the Medicare for America plan while individuals enrolled in qualifying employer-sponsored plans, coverage provided by the Indian Health Service or Veterans Administration, TRICARE, or the Federal Employees Health Benefits Program would be able to keep their current coverage if they choose to opt out. A qualifying employer-sponsored plan is defined as a governmental plan or any other employer plan that includes vision, dental, and hearing benefits, with an actuarial value equivalent to at least 80 percent of Medicare for America coverage, and that the employer contributes at least 70 percent toward the premium of such plan. Individuals below 200 percent of the FPL would not pay premiums or cost sharing. The Secretary of HHS would establish premiums that would be no greater than 8 percent of an individual’s or household’s monthly income. The bill would also permit the Secretary of HHS to negotiate drug prices and ban the use of prior authorization or step therapy in any form of health insurance.

Woo-hoo! At long last, my own preferred long-term Universal Coverage heatlhcare bill is getting a full hearing! This is also the bill that Beto O'Rourke was touting during his ill-fated Presidential campaign, and Julian Castro's healthcare plan sounds an awful lot like it as well. I don't think it has a Senate companion version as of yet, unfortunately.

F. H.R. 2463, Choose Medicare Act H.R.

2463, the “Choose Medicare Act”, introduced by Rep. Richmond (D-LA), would establish a public option (‘Medicare part E’) to be available on the ACA Marketplace. The bill 4 would also require HHS to establish a process to allow individuals to enroll in the public option on a voluntary basis for the small and large group markets. H.R. 2463 would subject the public option to the same requirements that apply to other QHPs offered on the Marketplace. H.R. 2463 would enhance the ACA’s tax credits and increase the eligibility threshold from 400 percent of FPL to 600 percent of FPL. Lastly, the legislation would enhance the ACA’s cost-sharing subsidies and establish a three-year reinsurance program at $10 billion annually.

Choose Medicare is the House version of Senators Chris Murphy, Jeff Merkley and Dianne Feinstein's public option bill (I didn't realize Feinstein was a primary sponsor of it until today). 

G. H.R. 4527, Expanding Health Care Options for Early Retirees Act

H.R. 4527, the “Expanding Health Care Options for Early Retirees Act”, introduced by Rep. Malinowski (D-NJ), would allow qualified first responders age 50 to 64 to buy-in to Medicare. A qualified first responder is defined as a first responder, such as a law enforcement officer or firefighter, who is separated from service due to retirement or disability. The Secretary of HHS would determine a monthly premium for individual first responders who enroll under this buy-in program. The coverage would be treated as coverage provided by a QHP offered on the Marketplace and individuals would be eligible for the ACA’s tax credits and cost-sharing subsidies. The bill would also allow for first responders to utilize defined contributions from retiree plans to help purchase coverage. However, first responders would not be eligible for any cost sharing assistance provided by the Medicare program. States would be prohibited from purchasing Medicare buy-in coverage on behalf of Medicaid eligible individuals age 50 to 64.

This is a new one, and it's kind of interesting...it's a very limited version of the "Medicare 50+" bills, but limited to retired/disabled first responders only. Huh. It sounds like a pretty good idea to me, but I'm not sure why it's being bundled in with this particular group of bills...it sounds way too limited to be justified as being part of a "Universal Coverage" hearing.

H. H.R. 584, Incentivizing Medicaid Expansion Act of 2019

H.R. 584, the “Incentivizing Medicaid Expansion Act of 2019”, introduced by Rep. Veasey (D-TX), would provide 100 percent FMAP for Medicaid expansion beneficiaries for the first three years after a state expands Medicaid, and then scales down to 95 percent FMAP, 94 percent FMAP, and 93 percent FMAP, for, respectively, years four, five, and six that has Medicaid expansion. In year seven and beyond, the FMAP for the expansion population would be 90 percent. This enhanced FMAP schedule was available to states that expanded Medicaid beginning in 2014. The bill would provide parity to states that chose to expand Medicaid subsequent to 2014

Again, I'm not sure why this bill, which I support, is included in this particular hearing. It really should have been included as part of the ACA 2.0 umbrella bill (HR 1884). Under the ACA, states which expanded Medicaid out of the gate in 2014 got a free ride for 3 years: The federal government covered 100% of the cost of Medicaid expansion. Starting in 2017, the states had to start paying 5% of the cost, which rose gradually to 10% starting in 2020, where it stays. The states which have refused to expand Medicaid until now would have to hit the ground running by paying 10% of the cost if they do so, since the 3-year freebie was tied to specific dates (2014, 2015, 2016). All this bill does is make that timeline open ended, so if Florida or Texas were to expand Medicaid starting in 2021, they'd pay nothing until 2024.

It's a good idea to help incentivize more states to jump onboard. My only question is how it handles the states which didn't expand Medicaid until after 2014 but did so before this bill theoretically takes effect. For instance, Louisiana expanded Medicaid starting July 1, 2016. According to the original timetable, the feds only covered 100% of the cost for six months; the state then had to pay 5% in 2017, 6% in 2018, 7% in 2019 and 10% in 2020 and beyond.

...except that a state which hasn't expanded Medicaid yet would get a full 3 years of not paying anything under this bill, and would then get an extra 3-5% covered after that for the next 3 years. That effectively amounts to punishing the states which did the right thing while rewarding the states which didn't. Would Louisiana get compensated for the other 2 1/2 years and so forth? Not according to the legislative text. Ah, well, it's still a good idea.

 I. H.R. 2085, Consumer Health Options and Insurance Competition Enhancement Act

H.R. 2085, the “Consumer Health Options and Insurance Competition Enhancement Act” or the “CHOICE Act”, introduced by Rep. Schakowsky (D-IL), would create a Federal public option plan on the ACA Marketplace. Under H.R. 2085, the public plan option would be subject to the same requirements that apply to other QHPs offered on the Marketplace, and would be available to all individuals who are eligible for QHPs.

The CHOICE Act is a fourth public option/buy-in program, in the same arena as CHOOSE Medicare and Medicare X (the State Public Option Act is in a slightly different category since it leaves both the decision and administration of the public option up to the states, as it's based on Medicaid instead of Medicare). This is the companion version of Senator Whitehouse's bill.

I plan on liveblogging the hearing as much as possible tomorrow, so tune into the YouTube link above!

Here's the list of witnesses:

Panel I

• Hon. Brian Higgins (D-NY): Member of Congress
• Hon. Pramila Jayapal (D-WA): Member of Congress
• Hon. Antonio Delgado (D-NY): Member of Congress
• Hon. Rosa L. DeLauro (D-CT): Member of Congress
• Hon. Tom Malinowski (D-NJ): Member of Congress
• Hon. Cedric L. Richmond (D-LA): Member of Congress

Panel II

• Sara Rosenbaum, J.D.
• Harold and Jane Hirsh Professor of Health Law and Policy
• George Washington University Milken Institute School of Public Health
• Testimony

• Peter Morley
• Patient Advocate
• Testimony

I should note that Peter Morley is basically a healthcare hero to patient advocates nationally. 

• Jean Ross, RN
• President
• National Nurses United
• Testimony

• Douglas Holtz-Eakin, Ph.D.
• President
• American Action Forum
• Testimony

• Scott W. Atlas, M.D.
• David and Joan Traitel Senior Fellow
• Hoover Institution, Stanford University
• Testimony