The Medicare for All Bill, proposed by Senator Bernie Sanders (I-VT) in September of 2017, has made the rounds in the past year with both critics and supporters. In order to fully understand M4A and the effects it would place on U.S. medicare and insurance industry, I will be analyzing and breaking down each section.
Medicare for All was proposed in the midst of Republican failure to overhaul the Affordable Care Act, with the idea of implementing a single payer system. Bernie Sanders, the proponent of the bill, has been a strong supporter of single payer healthcare for many years, and believes that it is a moral issue. In an opinion piece with the New York Times, Sanders cites that “We remain the only major country on earth that allows chief executives and stockholders in the healthcare industry to get incredibly rich, while tens of millions of people suffer because they can't get the health care they need” (Sanders 2). The proposition, while unlikely to make it through congress at the moment, brings the idea of single payer healthcare to the forefront of healthcare reform. With the 2020 election on the horizon, many democrats will begin to take sides on single payer healthcare, as we can see already happening in 2018 with Andrew Gillum being a proponent.
Title 1
The first primary section of the M4A bill is Title 1, regarding Universal Medicare, Entitlement and Enrollment. In Title 1, Sanders proposes that every resident of the United States is entitled to the benefits for Health Care Services under the act. It is important to note that he states Resident, not citizen. Resident implies that if someone is residing in the country, including refugees, green card holders, and potentially illegal immigrants. The morality of this is commonly critiqued by the republican party, questioning whether those residing in the US however not paying all the same taxes as full citizens should be entitled to programs at an equal rate. However, Sanders includes that the Secretary must regulate eligibility in order to inhibit people from travelling to the United States for the purpose of Health Care alone. In addition, Sanders includes that residents have the freedom to obtain services from outside sources beyond government coverage. The section additionally covers non-discrimination, protecting individuals from having healthcare withheld from them due to a number of identities, from a provider and includes the damages that a provider would face for violation of the non-discrimination subsection.
In Section 105 of Title 1, the process and restrictions of enrollment are broken down. The thorough coverage of enrollment establishes automatic enrollment upon birth, immigration or establishment of residency in the United States. Additionally, the issuance of Universal Medicare Cards is broken down in this section. The process would be that each individual is issued a card that acts as identification and used in processing claims. Section 106 lays out the dates in which the bill goes into place, regarding qualification. The bill would begin coverage starting January 1st of four years following its passage. Lastly, in Section 107, the legalities of private insurers competing with the M4A coverage as described. As stated in the bill, no private insurance or employer providing benefit may offer coverage that duplicates the benefits in the Act. In addition, it states that nothing should be construed as prohibiting the sale of health insurance for additional benefits.
Title II
In Title II, the comprehensive benefits are described, with what may be covered by the plan. As described, individuals are entitled to payment for the following; Hospital services, ambulatory services, primary and preventive service, prescription drugs, medical devices and biological products, mental health and substance abuse treatment, laboratory services, reproductive, maternity and newborn care, pediatric, oral, audio services, and short term rehabilitative and habilitative services. In order to cover updates to the bill, this section states that the Secretary should evaluate the effectiveness of the coverage regularly and make recommendations to Congress for improvements. The bill also discusses how complementary and integrative medicine should be added to the benefits package, with consultation of research findings, in addition to identifying barriers to effective interaction of new practices and developing systems to overcome the barriers. Complementary and integrative medicine is the use of coordinated approaches of holistic health. The people with whom should be consulted with regarding the addition of complementary and integrative medicine are as follows; the director of the national center for complementary and integrative health, the commissioner of Food and Drugs, institutions of higher education and research, nationally recognized providers and other officials with expertise on medicine as determined by the Secretary. The bill also allows states to add additional coverage at the expense of the state. The next section of Title II covers cost-sharing, stating that no cost-sharing of deductible, coinsurance, copayments or similar be imposed on individuals for the benefits provided, with the exception of setting a cost-sharing schedule for prescriptions with a strong evidence base, and it doesn’t exceed $200 annually per individual. It practically eliminates all spending out-of-pocket from individuals with the secretary given the power to impose copays for drugs in order to encourage the purchase of generic drugs. In Section 203, exclusions of benefits are outlined. The first clause is that the Secretary makes national determinations regarding experimental services, that are consistent with the Social Security Act. Additionally, the secretary creates an appeals process for individuals that follows the same process as Medicare and the Social Security Act. Section 204 establishes an amendment to the Social Security Act that clarifies how long-term services will be used in conjunction with Medicare for All.
Title III
In the first section of Title III, a participation agreement is established in order to ensure that providers participate legally. The agreement states that they must act in accordance with the non discrimination clause, with no charge to the individuals, However, the agreement can be terminated by the Secretary or Provider with proper notice. Additionally it states that providers are qualified for participation as long as they are properly licensed under federal and state laws. In Section 303, the bill givers individual protections against unlawful contracts and beneficiary protections.
Title IV
Title IV discusses the role of the Secretary and other administrative processes within the act. It is stated that the Secretary should develop policies and procedures to carry out the act relating to eligibility, enrollment, benefits, provider participation, funding, etc. Also in this section is reporting requirements to a national database with information about the health practicioners, approved providers and costs. The section requires an annual report form the Secretary with the status of implementations, enrollment, benefits, expenditures, cost-containment measures, quality assurance, health care utilization, changes in per-capita costs, and more. Additionally there shall be an audit of the effectiveness of the act every fifth fiscal year. Another requirement of the Secretary is consultation with Federal agencies, Native American tribes and urban Native American health organizations, along with private entities for input on the administration of the act. Regionally, there will be offices for access to the facilities and the Secretary should incorporate the Medicare and Medicaid office for it. Additionally there will be regional and state directors appointed, along with deputy directors for each State and one to represent Native tribes in the region. In Subtitle B, the Medicaid fraud provisions that are currently in place are applied to the M4A bill.
Title V
Title V establishes quality assessment standards. The measures are to be performed by the Center for Clinical Standards and Quality of the Centers for Medicare and Medicaid Services. The center is required to review all guidelines in the Public Health Service Act, and determine whether or not they should be a national guideline. Additionally, they must evaluate the standards for quality performance and determine if they are appropriate for reviewing services. Additionally, the center is to develop a minimum for competencies that entities must qualify in order to ensure coordination in standards. Lastly, the findings should be reported to the Secretary annually about the outcomes of research and development. Next, in Section 502, the requirement of addressing healthcare disparities by the Center is laid out. The Center has to report on the evaluation within 18 months after the date benefits become available. The report should look at the disparities of identities and include recommendations regarding effective ways to minimize those disparities. Those recommendations should be implemented within 2 years after the date of which the benefits become available.
Title VI
Title VI breaks down the budget and payment for the Act. Section 601 discusses the National Health Budget, and establishes that by Sept. 1st each year the Secretary establishes a health budget for the following year. The budget is divided between subsections of Quality assessment, health professional education, administrative costs, innovation, operating costs, capital expenditures and prevention/public health activities. Additionally, it also has the budget include transition assistance for displaced workers from the Act. Additionally it requires a fund in case of natural disaster of public health emergency. Lastly in section 614, it requires the Secretary to negotiate the price of drugs, supplies and equipment each year.
Title VII
Title VII creates a trust fund for the act. The fund includes all the extra funding from the IRC. The Fund is known as the Universal Medicare Trust Fund. The appropriations into the Trust Fund are from Taxes, Program Reciepts, Transfer of Funds, and the same Provisions of section 1817 in the Social Security Act.
Title VIII
Title VIII establishes how the amendments to the Employee Retirement Income Security Act of 1974 will be conformed to the bill. With the bill, employee benefits being duplicated under universal medicare would be prohibited. Additionally, this title establishes coordination with employers if an individual requires workers compensation. These amendments would be added at the same time as the Act being effective in Section 106.
Title IX
Title IX establishes amendments to other Federal Programs that would assist in transition into M4A. The transitions provided are for Medicare, Medicaid and State Children’s Health Insurance Plan. These services would be abolished after the implementation date and would be transitioned into the new system. With those three, it covers what to do if those under care face hospitalization during the transition, and any other holes that would happen in the transition. Additionally it clarifies that nothing in this act will affect Veterans benefits nor the Indian Health Service without consultation from tribal leaders and stakeholders.
Title X
In Title X, the specifics of transition into Universal Medicare are established. Some of the changes that would be made are the expansion of Medicare for seniors and individuals with disabilities by including coverage for audio, oral, and visual care. Within the first year all deductibles for Medicare Part A, B and D would be abolished. The first year would have a plan that provides affordable coverage and makes sure no one loses coverage. The second year would change the age for eligibility from 45 years old to 35 years old by the start of the third year. In the 4th, and final year of transition every resident of the United States will be entitled to benefits. By the end of the fourth year all individuals get Medicare cards to use and receive their benefits.
Synthesis
While I read this bill there a few things that I question. Throughout the bill there seems to be avoidance of answering hard questions, such as wear is the funding coming from, and specifics regarding care. First off, no where in the bill does it state where exactly the funding for the “Trust Fund” would come from specifically. The bill states that extra funds would go into the “trust fund”, but where are those extra funds coming from. Additionally, there is a section titled “Taxes” but it does not establish a specific tax increase to fund the act. Regarding the specific coverage, in Title II it lists the types of coverage provided, such as Mental Health, Ambulatory, etc, however the list does not elaborate on what is considered under each category. For example, for Mental Health and Substance abuse treatment, does it consider therapy or group therapy sessions, or only the prescription and physical health maintenance. However, other parts of the bill are overwritten. While legislation is supposed to be up for interpretation, many of this bill is either left up for too much interpretation and other parts are over legislated.