This is how Bernie Sanders wants to implement single-payer health care

Here's what you need to know about Sanders' Medicare for All plan.

Credit: Diana Ofosu/ ThinkProgress
Credit: Diana Ofosu/ ThinkProgress

Sen. Bernie Sanders’ (I-VT) Medicare for All bill would eliminate out-of-pocket costs and deductibles for any resident of the United States, as well as build on the health care services covered by the Affordable Care Act, according to an executive summary and outline of the bill provided to ThinkProgress.

Sanders, a longtime single-payer advocate, will hold a press conference on Wednesday afternoon to detail his policy ideas for transforming the current health care landscape.

Entitled the Medicare for All Act of 2017, Sanders’ legislation has already racked up several prominent co-sponsors — including Sens. Elizabeth Warren (D-MA) , Brian Schatz (D-HI), Kirsten Gillibrand (D-NY), Cory Booker (D-NJ), Mazie Hirono (D-HI), Kamala Harris (D-CA), Edward Markey (D-MI), Jeff Merkley (D-OR), Tammy Baldwin (D-WI), Sheldon Whitehouse (D-RI), Richard Blumenthal (D-CT).

The Democratic Party has broadly embraced the principle of universal health care. “Democrats believe that health care is a right for all,” Senate Minority Leader Chuck Schumer (D-NY) said Tuesday.

The question, however, is how exactly to get there. So far, there are a number of different bills on the table. Sens. Brian Schatz (D-HI) and Debbie Stabenow (D-MI), for example, are advocating to expand public programs like Medicaid and Medicare. But it’s Sanders’ plan that has garnered the most attention.

Sanders’ bill could serve as a next step for Democrats who hope to build off the success of the Affordable Care Act (ACA). The number of people without health insurance fell to 8.8 percent in 2016, according to Census data released Tuesday. Still, 27 million people are without health insurance.

“Our job will not be completed until we build upon the success of the ACA through the establishment of a Medicare for All, single-payer health care system,” write the bill’s drafters.

The objective is clear, but what about the wonky details?

Sanders’ bill aims to create a universal Medicare program for every resident in the United States, in which each resident would use a universal Medicare card they receive upon enrollment to obtain health services.

The executive summary and section layout of the bill provided to ThinkProgress by Sanders’ team were not comprehensive and prompted as-of-yet unanswered questions about how the legislation plans to handle enrollment and coverage.

Additionally, Sanders’ team has yet to release a funding plan. Instead, they say they will release the funding in a separate “white paper.”

What the summary and layout does include is a four-year transition period that would gradually move people from employer-based insurance and onto the government-run Medicare program. By the end of implementation, Medicare would be unrecognizable to its current beneficiaries. 

How would the U.S. move from mostly private to public insurance?

Within the first year, the bill would expand traditional services covered under the government-run Medicare program to include prescription drugs, dental, vision, and hearing aids. Residents older than 55 and younger than 18 will become eligible for Medicare within the first year of implementation.

In the second year, eligibility for Medicare would be extended to people older than 45; in the third year, the eligibility threshold would move down to 35. By year four, anyone who is a resident of the United States would be entitled to enroll in Medicare — though it’s unclear how the drafters intend to define “resident.”

What would coverage look like?

Deductibles and out-of-pocket costs, like co-insurance and co-payments, would be eliminated. The Department of Health and Human Services, however, may impose limited co-payments for prescription drugs to encourage the use of lower-cost generic drugs.

The plan would also provide comprehensive coverage. Like the ACA, Medicare for All covers hospital and emergency services, primary and preventative care, prescription drugs, mental health and substance abuse treatment services, laboratory and diagnostic services, and pediatrics services. It diverges from current health law by guaranteeing dental, vision, and audiology coverage.

It also expands reproductive services, like maternity and newborn care, to include abortion. Notably, however, the bill does not call for a repeal of the Hyde Amendment, which currently makes it illegal for any federal funds to pay for abortions, except in rare circumstances.

Other federal health programs like the Veterans Affairs Health Benefits, Indian Health Service, and Medicaid — which offer care to veterans, Native American tribes, and Alaska Native people, seniors, and people with disabilities — will continue.

How would doctors be affected?

Doctors would be paid the same as they are under the current Medicare payment structure. Under the Obama administration, Medicare was transitioning from payment based on a fee-for-service to payment based on performance metrics, patient experience, and patient outcomes.

Additionally, the plan eliminates the idea of in- and out-network care providers. 

“Patients will have the freedom to choose their doctors, hospitals and other health care providers without worrying about whether that provider is ‘in-network,’” the executive summary says. “They will also be able to get the care they need without having to read any of the fine print or trying to figure out the out-of-pocket costs.”

During its first five years, the bill may create a fund to provide financial assistance to health insurance administration workers who are displaced.

How would the plan address health care costs?

The main objective of the bill is to streamline how U.S. residents obtain health care, which drafters say would ultimately save money.

“Instead of wasting hundreds of billions of dollars trying to administer an enormously complicated system of hundreds of separate insurance plans, there would be one insurance plan for the American people with one single payer,” write the drafters.

The bill would also allow the government to negotiate directly with drug companies — something the Affordable Care Act did not do, much to the ire of many single-payer advocates — which would hopefully lower the cost of these drugs.

“Administrative costs and profits under a single payer plan would almost certainty be lower,” tweeted Kaiser Family Foundations’s Larry Levitt. But, Levitt added, there will be trade-offs. Health policy experts typically caution that single-payer plans result in higher taxes and reduced choice between different health plans.

How would this plan be funded?

The outline does not say how the government would pay for the program — a major question for single-payer plans, which create several new funding streams in order to expand coverage to additional people. The bill does not address how it will fund what is likely going to be an older, sicker marketplace during the first four years, and it does not include incentives for young people to enroll.

Sanders says he will release more details about his funding plan later on Wednesday.

***
The executive summary provided by Sanders’ office praises the ACA, but calls it “only the beginning.” It’s also only the beginning for this bill. Health experts, both those who advocate for single-payer and those who call for more incremental change, will likely identify a host of follow-up questions and concerns.

But this bill does force a conversation about achieving universal coverage in an ambitious way. Republicans in Congress failed to produce their own health care vision when various iterations of ACA repeal and replace bills died under a Republican-controlled Congress and White House this past summer.

Concurrently, Democrats are still looking shore up the 2018 ACA individual marketplace, which is riddled with its own problems, making the bill’s timing is especially challenging.

Even so, Sanders says he is trying to address the calls from his supporters, who’ve been adamant about single-payer, and cries from consumers across the country who are unsatisfied with the current system.

And, as the executive summary of the bill, notes, citing a poll from The Economist and YouGov, there is widespread support for the policy: 60 percent of Americans — including 75 percent of Democrats, 58 percent of Independents, and 46 percent of Republicans — support expanding Medicare coverage to all Americans.

Correction: An earlier version of this story misidentified Sen. Elizabeth Warren’s state.