Greetings Daily Kos readers! This is my first foray into your diary system, so of course I had to choose a topic that everyone will love to see broken down, right? Right. I know many people are supporters of #MedicareforAll, but did you know the House actually has a proposed bill on this very subject? Yup, HR 676, the Expanded & Improved Medicare for All Act, introduced by Rep. John Convers Jr (D-MI) and co-sponsored by 93 Democrats, almost half the current Democratic Party in the House.
Since I work in Healthcare and have become a bit of a policy wonk since last year, I decided to dive in and see what Sen. Sanders, Mark Ruffalo, and other supporters were talking about. Below are what I thought are the Pros and Cons of the bill, as well as some final thoughts on its feasibility and where it’s going. (I apologize for the length, but given the topic it’s still fairly short).
Pros
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Regarding Coverage
- Expanded Coverage. Unlike our current Medicare, this plan expands services to include Vision, Dental, and Prescription coverage. Also included that is not always in current medical policies is Substance Abuse and Chiropractic Services.
- Territorial Coverage. While Puerto Rico, Virgin Islands, et al do get Medicare and Medicaid funding, it’s more limited than what the states currently get. This dramatically expands their healthcare coverage.
- Full Program Integration. Both the Veterans Affairs (VA) and Indian Health Services (IHS) will be integrated over the course of a decade. That means the best parts of both programs can be assimilated and eventually there won’t be confusion on which doctors to see for which program.
- Low Patient Cost. This plan requires no deductible, coinsurance, copay, or any cost-sharing that almost all plans require today, including Medicare.
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Regarding Finances
- Equal Mental Reimbursement. This Act requires not only the coverage of mental healthcare, but increases their reimbursement rate to be commiserate with the medical reimbursement rate. For those of you unaware, Medicare and most private insurances reimburse mental health at a reduced amount compared to physical health.
- Expanded Budget. This Act calls for a part of the budget specifically for “the construction or renovation of health facilities.” This is a bit of infrastructure budget in a healthcare bill and is drastically needed in some parts of the nation.
- International Cooperation. This requires Secretary of Health (Secretary) to negotiate reimbursement rates for those that come to the US for non-emergency services. That means Canada’s medical procedure and pharmaceutical pricing could influence our own in a positive way.
- Uniform Costs. This Act requires all medical procedures to have the same cost (fee for service) across the nation. No more discrepancy costs between hospital to hospital, state to state.
- Tax Reform. In order to fund this Act, some tax reform is included: an increase on taxation for the top 5% of earners in the nation, an increased tax on bond and stock transactions, a new payroll taxation model, and a tax on unearned income
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Regarding Administration
- Easy Application. This Act requires that the application to enter the program be no more than 2 pages. This will undoubtedly be online, so easy access and easy application. It also states that if you haven’t applied or got your card and go to a participating doctor’s office/hospital for treatment, you can do so right there. Same-day registration written into the law.
- National Electronic Database. This Act calls not only for a national electronic patient database, but also a uniform billing submission guideline. No more fifty forms to fill to be seen by a new doctor or get a service paid.
- National Evaluation. This Act creates a 15-member board of national appointees to evaluate the system twice a year and provide recommendations and updates. This is faster than the current annual Medicare procedures evaluation, but slower than the quarterly Medicare drug pricing reports, a good middle ground.
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Regarding Transitioning
- Employment Transition Benefits. That invisible economic price of diminishing jobs by transitioning to a single-payer system is addressed. This Act requires retraining and job placement assistance for job loss as a result of this proposed transition, including wage reimbursement (up to $100k).
- Public and Non-Profit Promotion. The only doctors able to participate and get reimbursed for this program must be part of public health facilities (i.e. city and state hospitals) or Non-Profit facilities (i.e., clinics, Planned Parenthood). It also offers private healthcare officials and companies the chance to convert to non-profits to enroll in this program.
- Deconstruction of Insurance Companies. This bill makes it illegal for healthcare insurance companies to duplicate any services and/or provisions (of the expanded coverage) required under this healthcare law. This isn’t dissimilar to laws in Canada and other state-sponsored single payer. In fact, this Act recommends Insurance companies move to cover cosmetic, acupuncture, and other services not covered by this law.
Cons
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Regarding Coverage
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FDA Guidelines. Though not specified in this Act, it states the Secretary of Health will be directing and dictating the usage guidelines. If the Secretary follows the Food & Drug Administration’s (FDA) approved guidelines for covered services, there are unfortunately many of these currently in dispute.
- Mental Health: some people in the nation don’t believe in depression and other mental afflictions, some believe the only treatment should be religion, some believe homosexuality is a mental affliction that should be treated. The FDA disagrees with all of these, and has proper guidelines for treatment (i.e. depression) and what’s not allowed (i.e. conversion therapy).
- Vaccines: the FDA is very clear that vaccines are safe and should be provided to all children. Since this Act must “stress the importance of good public health through the prevention of diseases” vaccines will thus be, if not mandatory, pushed harder than they are now. There is a whole segment of the population that will disagree.
- Abortions: this is a legal medical procedure, in fact there are multiple legal procedures addressing contraception. All allowed and must be provided according to current Medicare guidelines. You can queue up the conservatives and religious groups easily to object to this.
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Regarding Finances
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Physician & Administrators Reimbursement. This Act requires not only State Directors, but Regional Directors to help formulate and recommend annual reimbursement rates for everyone (doctor to nurse to secretary to janitor) based on needs and services. However, this is contravened by the Fee for Service pay model, in which this Act requires not only “a uniform national standard” but to “be compensated at a rate...regardless of geographic region.” Meaning a doctor in California or New York will have to see many, many more patients to make a living compared to a doctor in Minnesota or Texas.
- Unless the Regional or State Directors can get an exemption, but since the Secretary has to follow the uniformity guidelines, that seems to be an uphill battle. While uniform treatment and medication reimbursement makes sense, there needs to be an allowance of adjustment for geographic location simply for cost of living--which isn’t included in the evaluation for salaries or fees.
- Non-Profit Salaries. A little known fact, non-profits have no salary caps and give out bonuses. The IRS only calls for “fair” compensation for every position, and it can be audited at any time. However, given the current non-profit situation (i.e., SuperPACs) and the IRS’ lack of action via deregulation, this is an area ripe for abuse in the Act that isn’t address. For-profit entities will not want to give up high salaries at the highest levels. A CEO may have to give up a million dollar salary, but it’s not hard to imagine that same CEO justifying a $500k salary--it is a 50% pay-cut, after all. Non-profits seem like an easier way to spot abuse in the system, but without some sort of salary minimum/maximum laws and an IRS willing to go after suspicious incomes, CEOs and high-ranking employees will still be a part of that income inequality that this Act is supposed to help negate.
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Regarding Administration
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Lack of ID Integration. This plan requires a healthcare card to receive services, however this ID would be unrelated to your Social Security Number (SSN). There’s positive and negatives to this, however every other Federal program uses the SSN to associate a person with a program. While these could be tied together, it seems like an excessive administrative cost that’s not needed.
- There is also, of course, that subset of people in America who are already reluctant to have even SSN cards, much less any other form of ID.
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National Electronic Database. For those of you not in the know, healthcare facilities hate updating and changing their systems. For instance, Texas mandated an update to electronic files (for better record keeping). Not only did every healthcare collective object and try to stop it, the largest facility in the state dragged their feet in the hopes that they wouldn’t have to (in the end, the state made them, 5 years after the fact). Getting every healthcare facility in the nation onto a single system will be a nightmare.
- That’s not even addressing the privacy concerns and panic that would stem from the patients themselves, and the fact that not even the VA and Military’s Insurance (Tricare) computers are able to communicate with each other after years and millions of dollars trying.
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Political Appointees. Not only is the Secretary an appointee of the President (and so would be the Regional Directors by proxy), but the board of appointees to advise the Secretary is also by political appointment. This Act requires certain criteria (x amount of doctors, x amount of knowledgeable civilians, x amount of non-profit leaders), but all are to be selected by the President with the advice from the Senate. In a liberal majority, this is a rational panel of people who use science and facts. In a conservative majority it has been proven time and again that science and facts (i.e., vaccines work, contraception works, etc) aren’t part of their worldview. Meaning any political shift in the government could lead to coverage criteria changing as little as from every 6 months to as much as every 4 years.
- While the FDA is our current guideline for Medicare coverage, there is no stipulation in this Act that the FDA--which can also be influenced by political majorities--be the definitive guideline by which Medicare for All follows. In fact, the Secretary and board of advisors make up the final list for drugs and procedures.
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Regarding Transitioning
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Time Table. This Act allows for only one (1) year after it has passed to get everything in place and prepare for the dramatic change to the nation. To give us some perspective, the Affordable Care Act provided four (4) years to wind up and transition everyone to the new system--and we all recall how that first month went. The time this Act apportions for all the changes it envisions is impossible without a sudden character change from each and every individual in this nation. Four years might be closer to what’s needed, but for change like this, it might even take up to ten.
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Non-Profit Conversion. Those public companies that convert to non-profits continue to be privately owned. That’s not all bad, however, “owners of such for-profit providers shall be compensated for reasonable financial losses incurred as a result of the conversion from for-profit to non-profit status.” So a CEO making millions will continue to get that compensation from the government (over a 15 year period) while still making a salary for his company.
- There is a stipulation that this compensation cannot include ‘loss of business profits’ and needs to be paid for by sale of 15-year government bonds, however given the bond market, unless there’s a sudden uptick of interest it’s doubtful the government can succeed on this using just bonds alone in this area (it would exceed our current government discretionary funding of $1 trillion easily).
- Doctor Participation. This Act states any doctor licensed by their state can agree to enter this plan as long as they are part of a public or non-profit. In other words, doctors don’t HAVE to provide coverage for patients and accept federal reimbursement rates, the Act just encourages them to do so. Unless reimbursement rates are higher than they currently are, many will try to keep a for-profit model going as long as they can--and they may succeed. In the Bay Area alone, there are plenty who would be willing to bypass waiting times and long schedules for a private instantly available doctor for a couple extra dollars.
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Free Market Politics. I admit I’m not a big fan of the free market, but by outlawing insurance companies this Act immediately invalidates itself. You can bet the insurance companies will go to the courts to fight this, and unfortunately precedent is in their favor. If the government offers it, the private sector is allowed to offer an alternative.
- This is even before you get into making corporate entities into non-profits. Since insurance companies will be made illegal, many will have to make that move. Forcing a company to accept government guidelines is old-hat, but forcing an entire industry to convert or conform will also be fought in court. In fact, this would probably be the provision that gets the law restricted if not struck down.
Boiling it all down, this is not a Medicare for All act, this is a proposal to eliminate an entire industry and make it government run without any consideration of the infrastructure already in place. There is some precedent, such as Disability and Social Security, but even those don’t rely 100% on the government, and in fact look to the private sector to make up some of the deficiencies of the system. In essence this is a “pie in the sky” dream that won’t happen in our lifetime, probably not for at least 100 years. At least half this nation--aka the Red States--don’t believe healthcare is a right, and this bill will only make them dig in harder to resist any sort of further change.
If we can’t even get Medicaid Expansion across all 50 states, this is dead before it’s even in committee.
Now, could some of this be adapted and made to work on the state level? Possibly, but probably not with the focus on elimination of insurance companies. But while some of this is impossible ideals, there are points here and there that are actually feasible. We should be encouraging our Senators and Representatives to introduce these aspects right now that, while Republicans wouldn’t like, might actually resonate with the conservative (small c) base that, with the right hype, could actually pass successfully.
Feasible Healthcare Legislative Proposals
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Expanded Medicare Coverage. Medicare currently only covers one (1) vision evaluation a year, and doesn’t cover lenses, glasses, or any of the costs unless corrective surgery or medication is needed. There is no dental coverage at all. This Act’s provision of expanding coverage to include Vision and Dental could be worked into the Medicare coverage guidelines--and should be!
- Not part of the Act, but other “low hanging fruit” Medicare improvements include closing the prescription drug “donut hole” that costs retirees at least $2000 each year for medications and allowing 55 year olds to “buy-in” to Medicare coverage early especially given the rate of baby boomer layoffs.
- Equal Mental Healthcare Reimbursement. Private insurance companies and Medicare alike reimburse mental health visits at a lower rate than medical visits. This Act would rectify it--and it’s a detail that could be pulled out and made its own proposal easily! Equalize the reimbursement rate, remove the limitation of visits per year, and diminish the prescription paperwork requirements for Medicare beneficiaries so more prescribers are willing to aid that population.
- Healthcare Infrastructure. Part of the budget calls for renovations and building new facilities. This was part of Clinton’s healthcare plan and it’s something a lot of the conservative (small c) base wants--easier access to healthcare. Working with the opposing party is not easy, but an amendment to the federal infrastructure budget for this specific aspect of the Act would be hard to ignore, especially given national attitudes from all sides in regards to healthcare access and desire for modern facilities.
There are other things that, taken separately, are fantastic and need to be addressed eventually. But the odds of getting, say, more funding for Territories or reasonable tax reform to pay for healthcare or building a national electronic patient database is implausible with today’s government (ironically, that last one is being pursued commercially).
This Act is great political theater and destined for failure, no matter who’s in charge or how much hype it gains given the details that are included. However, like the three suggestions above, there are parts of it that could be addressed now, fought for now, actually
solved now that are being ignored for the slogan
#MedicareforAll. Dramatic change is great to cheer for, but incremental is how a nation runs.