NOTE: I added this to my diary yesterday in an update, but the diary was already pretty long and the 500+ comments are bogging down the browser load time, so I’m posting it as a standalone diary by request today.
OK, Bernie has officially rolled out his revised version of the MFA bill. I don’t know what all of the changes include, but the biggest one is that, as I stated above, it now includes the same Long-Term Services & Support that were already included in the Medicare for America bill and the House MFA bill.
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 14. One of those doesn't count since Al Franken resigned, but Jeanne Shaheen (NH) has bailed. Martin Heinrich isn’t listed in the text itself but I’ve confirmed that he’s still a cosponsor; not sure how that happened:
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
Here’s what still isn’t included in the bill: Any funding mechanism beyond existing federal healthcare spending on Medicare, Medicaid, FEHB, TRICARE and so on, which look like they add up to roughly $1.4 trillion in 2018. There’s been no official CBO score about how much MFA is projected to cost, of course, but several 3rd-party projections suggest that total federal spending would be similar to total healthcare spending (federal, state and private) is today (around $3.8 trillion this year). Current law projections are for total spending to increase to nearly 6.0 trillion in 2027.
In other words, the bill itself does technically include roughly 37% of the funding, since that’s what the federal government is already spending.
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.
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…
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.
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 would 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's already a thing...and would still be a thing. Presumably the removal of the profit motive would improve those decisions.
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….just by a government council instead of a private insurance council.
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 dealing with the 500,000 — 2.7 million people who work for insurance companies today (500K work directly for health insurance carriers; 2.7 million covers the entire insurance industry, as well as related industries. The larger number includes other types of insurance (auto, life, homeowners, etc), but there’s a lot of overlap since many insurers sell multiple types of policies, so the health insurance-specific number is somewhere between 500K — 2.7M.
Note that not all of them would end up losing their jobs...but most of them would at least be understandably concerned about losing their jobs, or having to relocate, etc.
Note: In my diary yesterday I put my range of health insurance employees (direct/indirect) at 2.5 — 3.0 million. After subir protested and made his case, I’ve reconsidered and reduced my estimated range.
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 earlier in this diary"
"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.
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.
In other words, MFA would technically only cover around 97% of the population. The other 3% would be enrolled in...two other federally-funded healthcare programs. 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.
I’ll have to dig into the full legislative text to find other changes from the old Senate version, but it looks like the LTSS addition is by far the biggest one.
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