On Wednesday, Rep. Pramila Jayapal (D-WA) will introduce the Medicare for All Act of 2019, and already more than 100 House Democrats have said they support the bill.
ThinkProgress reviewed a section-by-section summary of the bill and participated in two press calls with the congresswoman and her staff. Jayapal’s plan is likely the most ambitious yet among the crowded list of Democratic universal-coverage proposals.
The plan would fundamentally reshape the health care system by moving millions of Americans who get insurance through employers into a single-payer plan within two years. The bill builds upon the original single-payer plans in the House, sponsored by former Rep. John Conyers (D-MI), and Senate, sponsored by Sen. Bernie Sanders (I-VT).
“It is time to put health over profit and we have a plan — we have a real plan and that plan is the Medicare for All Act of 2019,” Jayapal said at a press conference on Tuesday. “This Medicare for All bill really makes it clear what we mean when we say ‘Medicare for All.’ … We believe that the market is broken and that is the core idea here we are trying to fix.”
Jayapal staff called the bill the “gold standard Medicare for All proposal,” describing it as a single-payer plan that covers everyone and offers comprehensive benefits, including long-term care services, which have been left out of past proposals.
There would be no premiums, deductibles, co-pays, or other out-of-pocket costs — a provision that goes further than Sanders’ plan, which allows the government to charge for some prescription drugs but caps it at $200 per year.
Like Conyers’ bill, Jayapal’s would eliminate virtually all private insurance, solely permitting coverage that complements, but does not duplicate benefits offered in the Medicare for All program. The Veterans Affairs’ health system and the Indian Health Services (IHS) also remain untouched.
But the Jayapal bill goes further, for example, by covering abortion services and by repealing the Hyde Amendment, which bans any federal insurance program from covering abortion.
Medicare for All is the rallying cry for progressives, and has even garnered mainstream support, including from 2020 Democratic presidential candidates. This means the Jayapal proposal could easily be the health policy Democrats consider when they take back the White House.
This isn’t to say the bill is ready for legislative prime time. It hasn’t been analyzed by the Congressional Budget Office, nor is staff expecting this to happen any time soon. Furthermore, staff members haven’t decided how the bill would actually pass — whether through reconciliation or through a 60-vote majority in the Senate. The bill also doesn’t include how the plan is going to be financed. Staff did emphasize that it’s impossible to imagine a system more expensive than the current one, but added that they are contemplating progressive tax proposals, like increasing marginal tax rates. This is why Jayapal called for House hearings, and even secured hearings in the Rules and Budget committees in March, for further input.
What sets Jayapal’s Medicare for All bill apart?
The Jayapal bill implements a national health insurance program over a two-year period; alternatively, the Conyers and Sanders bills provide one and four years, respectively. Administrative changes are primarily done within the first year, and by the end of the second year and into the third, all U.S. residents — a criteria set by the Department of Health and Human Services (HHS) secretary — will be covered by the Medicare for All program.
The bill also creates a Medicare Transition buy-in plan during the two-year period, which will be offered on the Affordable Care Act (ACA) marketplaces. The plan’s benefits will be the same benefits available under the Medicare for All program.
Staff said there’s growing evidence to suggest a faster transition period is necessary, specifically citing a recent study from the Political Economy Research Institute (PERI) at the University of Massachusetts-Amherst. The thinking is that as the federal government radically reforms the system, insurance companies may exit existing marketplaces, leaving patients without plans or increasing premiums. This means a Medicare for All program would need to be implemented as quickly as possible. Advocates with the Center for Popular Democracy told ThinkProgress in January they were pushing for a faster transition period because they wanted the president who signs the Medicare for All bill into law to be the one who oversees implementation.
Additionally, the bill uses existing policy ideas to tackle prescription drug costs and health care spending. Specifically, the proposal adapts ideas from a bill introduced by Rep. Lloyd Doggett (D-TX) that allows Medicare to directly negotiate drug prices but sidesteps pharmaceutical companies by issuing competitive licenses when they refuse to offer a reasonable price.
The bill also creates a global budget program to pay “institutional providers” and contain costs. This means providers like hospitals, community health centers, and nursing homes will be paid a lump sum global operating budget on a quarterly basis to provide covered benefits. Jayapal’s staff cited Maryland as an example of how this could work; early results from a federal analysis of Maryland’s global budget program for hospitals show it reduced total expenditures and total hospital expenditures “without shifting costs to other parts of the health care system outside of global budgets.” Providers who work in non-institutional settings — which staff suspects to be “a narrow group of people” — will be paid on a fee-for-service basis. The HHS secretary will set a national fee schedule within a year of enactment.
Staff also emphasized that the bill strives to do better on long-term care, as many disability advocates were critical of past Medicare for All proposals. The bill covers long-term care without cost-sharing and diverges from Medicaid by prioritizing home and community based services over institutional care.
Jayapal is really excited about the long-term care provisions, as her staff worked closely with disability rights organizations and individual advocates.
“Long term care in this country is a deeply forgotten, left behind issue and it has such urgency,” she said. “The people who have disabilities, need care, seniors, and when you think about the workforce that is essentially paying the cost of this right now — the unpaid workforce is largely female of caregivers and often a lot of people of color.”
The bill also addresses the increasing costs of prescription drugs, requiring the HHS secretary to establish a prescription drug formulary that promotes the use of generic medications and “to promulgate rules on using off-formulary medications and [allow] clinicians and patients to petition to add or remove medications from the formulary,” according the bill summary. Staff said the bill will require a public consultation process with representatives, including people with disabilities, when the secretary promulgates rules to ensure medications for specific populations are covered.
The HHS secretary has some discretion, per the summary, but staff emphasized that the bill’s intent is clear. An administration with a different ideology couldn’t take away benefits, but states could add benefits or cover U.S. residents not already covered in the Medicare for All program.