First in a series.

Like it or not, the 2020 presidential election campaign is well underway. With it comes the latest in public policy ideas, including more attempts to overhaul health care in the U.S.

The phrase “Medicare for All” has captured the minds, if not the hearts, of several candidates and an impressive portion of the voting public. It has shifted the conversation about health care in politics, at least temporarily, away from both “repeal and replace” and “protect the Affordable Care Act.”

But what is Medicare for All, really? The words garner loads of media mentions (and more than 4 million results in a Google search). The use of the label, however, may have outpaced public understanding of what it means, as public opinion polling reveals widely different results depending on the definition.

In this and future posts, we examine the concept, not using the rhetoric around the use of the phrase but rather by examining the proposals to which it refers.

Senator Bernie Sanders (an Independent from Vermont, and self-described democratic socialist) was arguably the first to offer a specific Medicare for All bill in the post-2016 election cycle. During the 2016 presidential campaign, Sen. Sanders advocated for a government-run health care system as he captured 22 states and nearly upset the Democratic frontrunner in the race for the presidential nomination.

In September 2017, Sen. Sanders introduced the Medicare for All Act of 2017 (S. 1804), which would expand Medicare gradually over four years to make the federal government the single payer of health care expenses for all U.S. residents. Services through the Veterans Administration and the Indian Health Service would remain, but all private health insurance would be limited to services not covered under the Act. Long-term care services would be available through Medicaid, which would continue under the bill.

Sen. Sanders’ 2017 Act includes coverage of inpatient and outpatient care, mental health and substance abuse treatment, preventive services and prescription drugs, as well as dental, vision and hearing aids benefits. Insurance premiums and out-of-pocket expenses would be eliminated, except that the bill would allow for limited copays on certain prescription drugs.

Most recently, on February 27, 2019, Rep. Pramila Jayapal (D – WA) introduced the Medicare for All Act of 2019 (H.R. 1384). As in Sen. Sanders’ bill, the 2019 Act retains services through the Veterans Administration and the Indian Health Service. Otherwise, everything else as we know it would pretty much be replaced, including Medicaid. The phase-in would occur over two years. And, like Sen. Sanders’ legislation, the 2019 Act would reduce commercial health coverage to services not provided under the 2019 Act, whose coverage would be comprehensive. The 2019 Act would also include the Essential Health Benefits and long-term care, all without cost-sharing.

Another single-payer plan, the Medicare for America Act of 2018 (H.R. 7339), offered by Rep. Rosa DeLauro (D – CT), differs from the previously described Medicare proposals by requiring consumers to pay limited, subsidized premiums. Consumers would also incur limited out-of-pocket costs that vary by income. Coverage would transition over two years, and the Act would retain Medicare Advantage, the Federal Employee Health Benefits Program and the TRICARE program for the military services in addition to the VA and Indian Health Service.

An earlier bill, the Expanded and Improved Medicare for All Act (H.R. 676), introduced in 2017 by Rep. Keith Ellison (D – MN), resembles Sen. Sanders’ legislation with a few exceptions. The Ellison bill would eliminate all cost sharing, including even limited copays on certain prescription drugs. Further, services through the VA and the Indian Health Service would be phased out.

By contrast, there are also “Medicare for Some” or “Medicare Buy-in” proposals. Generally, these proposals continue the premium and cost-sharing obligations of current commercial coverage, though there may be limits.

One such proposal was introduced as Medicare at 55 Act in 2017 (S. 1742). The proposal would allow individuals aged 55 to 64 (pre-Medicare age) to buy into Medicare as an alternative to commercial insurance. Buyers would receive the same benefits as those provided to Medicare members in Parts A, B and D. A similar proposal would let individuals buy in to Medicare starting at age 50 (Medicare Buy-In and Health Care Stabilization Act of 2019—H.R. 1346; Medicare at 50 Act—S. 470).

The Choose Medicare Act (S. 2708, H.R. 6117) would create Medicare Part E to coexist with commercial coverage as a public option available to individuals and employers. All without access to Medicare or Medicaid would be eligible. A more limited proposal, but similar in concept, is the Medicare-X Choice Act of 2017 (S. 1970, H.R. 4094), available to individuals and small employers in a phased launch.

Still another proposal concentrates on the states, creating a Medicaid buy-in program to enable government health care expansion on a state-by-state basis (State Public Option Act (S. 489, H.R. 1277). States could choose to participate, and they could receive federal matching funds if they did.

While the more comprehensive proposals have attracted the most attention, the viability of the Medicare for All proposals is uncertain. Democrat leaders have shown that their party stops short of wholehearted support for any of the various proposals. That’s not surprising, given the disruption that would occur in eliminating the source of commercial coverage for more than 150 million people and displacing millions of health insurance industry employees. That’s on top of a price commitment in excess of $30 trillion over ten years to fund the broader Medicare for All proposals.

On the other side of the political aisle, no Republicans have signed on to Medicare for All legislation—and none is expected to. And the President? His new $4.75 trillion budget proposal would reduce Medicare spending by $818 billion over 10 years.

Despite the unlikely prospects for passage of an Act today, the words “Medicare for All” are likely to remain at the forefront of political and policy discussion. And in less than two years, the 2020 election campaign will have run its course. The outcome will factor heavily into future consideration of Medicare for All and related proposals.

Next: More on Medicare for All: Cost, financing and impact on provider payment.

For more information on Medicare for All and other proposals potentially affecting health care in the United States, contact a member of the Husch Blackwell Healthcare Law team.

As usual, Katie Kieth provides a comprehensive description of the Medicare for All Act of 2019 in the Health Affairs Blog. The Commonwealth Fund has developed a simple tool for comparing “The Many Varieties of Universal Coverage.” Both were among the resources used in compiling information for this post.