• The Medicare for All Act is more than just universal coverage

    Senator Sanders has released the text of his Medicare for All Act. This bill won’t be enacted in this Congress, so the point of introducing it now is to stimulate discussion, above all about the principles that should guide the design of the American health care system. Most of the discussion so far has focused on universal coverage, and the bill delivers that:

    Every individual who is a resident of the United States is entitled to benefits for health care services under this Act.

    But there’s a lot more than just universal coverage in Senator Sanders’ bill and I want to quickly highlight some of those features.

    Comprehensive benefits. The Act requires the provision of hospital, ambulatory care, preventive care, and prescription drugs. It also covers several important domains of health care that have not been adequately supported: oral health (that is, dentistry), mental health, substance abuse, and

    comprehensive reproductive, maternity, and newborn care.

    In any reasonable construal of comprehensive reproductive care, this would require providers to supply contraceptive care. This will be controversial, to say the least. Because it includes mental health, substance abuse care, and dentistry, this list is notably better than covered services required by the Canada Health Act.

    Non-discrimination. By design, the Act eliminates discrimination on the basis of pre-existing conditions. But it also bans discrimination

    on the basis of race, color, national origin, age, disability, or sex, including sex stereotyping, gender identity, sexual orientation, and pregnancy and related medical conditions (including termination of pregnancy) [emphasis added]

    Working out what the italicized words require will be, let’s say, interesting.

    Health disparities. The Act identifies health disparities associated with

    race, ethnicity, gender, geography, or socioeconomic status

    as a quality of care problem. The mention of geography is particularly interesting, in that accessibility problems associated with living in rural or remote areas are an underappreciated dimension of health disparities.

    Evidence-based policymaking. The Act requires HHS to

    develop methodological standards for evidence-based policymaking.

    This brief phrase tells us nothing about the scope of such standards, what criteria would be used to develop them, or how evidence should constrain policy-making. Nevertheless, if we could do this right…!

    National reporting. Currently, Medicare is too much about just cutting checks and policing fraud. Medicare for All would have a mandate to improve system performance on

    outcomes, costs, quality, and equity.

    The inclusion of equity in this list is important and — please correct me — a first. At the same time, the Act would require providers to supply data while balancing this with a goal to minimize

    the administrative burdens of data collection and reporting on providers.

    These goals are in tension, but that doesn’t mean that the Act is incoherent. They are in tension because that is how the world is. The legislation also includes whistleblower protections for providers who report problems in billing and quality.

    Negotiation of prices. The government would be able to negotiate prices on prescription drugs, medical devices, and equipment (and, please God, let this allow the government to negotiate prices for information technology).

    Destruction of Employer-Sponsored Insurance. As Aaron has described,

    The single largest tax expenditure in the United States is for employer-based health insurance.

    The expenditure is wasteful and highly regressive. The Act bans employer-sponsored benefits that duplicate the comprehensive benefits offered by Medicare for All.

    Automatic enrollment. The plan to automatically enroll people into Medicare for All might seem like a detail. However, many Americans cannot exercise rights or access entitlements because they have difficulty completing burdensome enrollment procedures.

    No-balance billing. The Medicare for All Act bans co-pays. This will generate much discussion. But note that the Act also states that

    no provider may impose a charge to an enrolled individual for covered services for which benefits are provided under this Act.

    This would, among other benefits, eliminate surprise billing.

    Increased coverage of long-term care. I study kids and long-term care is beyond my remit. But I read this act as seeking to increase Medicare’s coverage of long-term care.

    When I wrote about the Canada Health Act, I noted that we have many significant gaps between the principles in the Act and its implementation. In that light, there are many points in the Medicare for All Act which require further clarification. There is also a list of points that worry me.

    Nevertheless, if the Medicare for All were passed and successfully implemented, it would have far reaching effects on US health care beyond universal coverage.


    DISCLOSURE: I provided Senator Sanders’ staff with comments and suggested language in the drafting of the bill.

    @Bill_Gardner

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