To hear Bernie and Elizabeth talk, you’d think the only way to universal healthcare coverage in the US was through Medicare for All. Not so. Universal healthcare systems in other developed countries offer plenty of alternatives to Medicare for All. For instance, in most of these healthcare systems, private insurance supplements public coverage by covering co-payments and deductibles or specific services not available through the public system. In some cases (e.g., Switzerland, Germany, the Netherlands, Australia, Ireland) private insurers cover primary care for all or part of their populations. In contrast, Medicare for All has no private insurance option.
As if the example of other countries’ healthcare systems weren’t enough for ideas on how to fix the US system, the Urban Institute recently released a report comparing six multi-payer health reforms with two single-payer reform options, including Medicare for All. Care of the Commonwealth Fund, here is a nice summary of the eight possible reforms:
Reforms that build on the Affordable Care Act (ACA):
1. ACA Enhanced I: Improves the ACA’s current premium and cost-sharing subsidies and adds a reinsurance program for the individual market to protect insurers against very high claims.
2. ACA Enhanced II: In addition to the above reforms, this package includes restoration of the ACA’s individual mandate penalty and reversal of the Trump administration’s expansion of short-term, limited-duration plans.
3. ACA Enhanced III: This package builds on Reform 2 by closing the Medicaid eligibility gap for adults with very low incomes in states that have not expanded their Medicaid program. It also introduces a limited autoenrollment mechanism for most people receiving benefits from the Temporary Assistance for Needy Families (TANF) or Supplemental Nutrition Assistance Program (SNAP) programs.
4. ACA Enhanced IV: Adds to the reforms in #3 a public plan option and/or a capping of the provider payment rates in private nongroup insurance plans.
5. Universal Coverage I: The first reform plan to achieve universal coverage, this builds on #4 by enabling workers to opt for subsidized nongroup coverage instead of their employer’s insurance plan and introducing a mechanism through which all legal U.S. residents are deemed insured. This reform features a public option in the nongroup market.
6. Universal Coverage II: Adds to #5 by boosting premium and cost-sharing subsidies further.
Single-payer plans:
7. Single Payer “Lite”: A single-payer plan that covers all people legally residing in the U.S. and includes all the ACA’s “essential health benefits.” There is cost-sharing for individuals pegged to income (consistent with those in reforms 1–5) but no premiums. There is no private insurance option.
8. Single Payer Enhanced [aka “Medicare for All]: This plan covers all U.S. residents, including undocumented immigrants, and features a broader set of benefits than Single Payer “Lite,” including adult dental, vision, and hearing care as a well as a home- and community-based long-term services and supports benefit. In addition, there are no cost-sharing requirements. There is no private insurance option.
The “essential health benefits” referred to in these reforms include:
Ambulatory patient services (outpatient services)
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services, including behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services (those that help patients acquire, maintain, or improve skills necessary for daily functioning) and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care
Care of me and based on the Urban Institute’s report, here is the nice summary of the coverage and net revenues needed for a 2020 implementation of each reform option:
Wow! Medicare for All (Reform 8) costs a whole lot more than the other reforms. Why? For starters, Medicare for All would cover those not legally present: some 11 million or so individuals. Then there’s all that additional coverage (dental, vision, etc.). And, finally, no cost-sharing!. All the other reform options include some sort of cost-sharing pegged to income, such as premiums, co-pays and deductibles. As do all the other developed countries with universal health care systems. Check it out:
Draw your own conclusions.
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References
“Comparing Health Insurance Reform Options: From “Building on the ACA” to Single Payer” Linda J. Blumberg, John Holahan, Matthew Buettgens, Anuj Gangopadhyaya, Bowen Garrett, Adele Shartzer, Michael Simpson, Robin Wang, Melissa M. Favreault, and Diane Arnos/Commonwealth Fund October 16, 2019
“From Incremental to Comprehensive Health Reform: How Various Reform Options Compare on Coverage and Costs” Linda J. Blumberg et al/The Urban Institute October 16, 2019