The Journal of the Arkansas Medical Society Med Journal April 2020

Commentary by darrell r. over, md, ms c , faafp Medicare ... for All? M edicare For All” has become one of the most popular topics in American politics. Notably, when I have asked most of my resident physicians (who will be significantly impacted by its mandates), I have discovered a dearth of understanding of this topic. Given the potential ramifications of this program for changing the American health care landscape, I believe a re- view of its significant provisions is beneficial for all physicians. Medicare as we know it now was established in 1965, primarily as universal health care for people over 65 years age. In 1972, Medicare coverage was extended to persons with dis- abilities. Medicare For All is not Medicare as we currently understand the program. Currently, there are two competing models of the Medi- care For All program in the 116th Congress, House Resolution 1384 and Senate Bill 1129. Both HR 1384 and SB 1120 establish a national health insurance program that is administered by the Department of Health and Human Ser- vices (HHS). Both programs provide insurance for all U.S. residents; specify automatic enroll- ment of individuals upon birth or residency in the U.S.; and cover comprehensive health care including hospital services, prescription drugs, mental health and substance abuse treatment, dental and vision services, abortion, and home and community long-term care. Senate Bill 1129 specifies that state Medicaid programs must cover certain institutional long-term care services. Both bills prohibit cost-sharing (e.g., deductibles, coinsurance, and copayments and other charges for covered services) but SB 1129 allows co-payments for prescription drugs up to $200 annually for households with incomes >200% of the federal poverty limit. Both bills mandate that private health insurers and employers may only offer coverage that is supplemental to, and not duplicative of, benefits provided under the Medicare For All program. Under each bill, all health insurance exchanges and certain specified federal health programs terminate upon Medicare For All program im- plementation – the exception being coverage provided through the Department of Veterans Affairs or the Indian Health Service. HR 1384 220 • The Journal of the Arkansas Medical Society calls for transitioning to Medicare For All over a two-year period: individuals <18 years age or >55 years age or already enrolled in Medicare may enroll in the program starting one year after its enactment, and other individuals may also buy into the program at this time. Senate Bill 1129 calls for transitioning to Medicare For All over a four-year period: individuals <18 years age are eligible for benefits one year after enactment, while other individuals (depend- ing on age) may buy into a transitional plan or an expanded Medicare program during the transition period. Both HR 1384 and SB 1129 state that all licensed health care providers are eligible to participate, and both establish provisions for payments and costs. Each bill specifies that the HHS will negotiate prices for prescription drugs and establish a formulary. HR 1384 provides for individual health care provider reimbursement on a fee-for-service basis (value-based payment is prohibited) and implements a global operating budget for hos- pitals and other institutions. Senate Bill 1129 maintains the current Medicare methods for payment. Neither bill specifies the payment rates to health care providers or hospitals that will be applied. Neither bill includes financing mechanisms for implementation. In a 2017 New York Times article (updated online in 2019), writers Haeyoun Park and Margot Sanger-Katz summarized the various constituencies impacted by enactment of a Medicare For All insurance model: • 156 million people with employer insur- ance plans would have new taxes (but no premiums). • 73 million people with Medicaid would have increased choices, but possibly higher taxes. • 61 million people with current Medicare insurance would have more generous coverage. • 28 million un-insured people would have access to health care. • 21 million people who self-pay for health insurance would have new taxes but less out-of-pocket spending. • 9 million veterans will keep their Veteran Health Administration insurance intact. • 2 million Native Americans will keep their Indian Health Service insurance intact. • Doctors and hospitals would proba- bly face pay cuts (but no more unpaid claims). • Pharmaceutical companies would likely see smaller profits. • Private health insurance companies would, for the most part, be eliminated. Both versions of the Medicare for All plans summarized above have some real advantages over the status quo. However, as currently con- ceptualized, the challenges facing each version of the plan are immense and neither adequately addresses the economic and administrative re- alities that dominate U.S. health care. Writing in Health Affairs, Frakt and Oberlander quote an Urban Institute study that estimates that Medicare For All as currently proposed would increase federal spending by $34 trillion over the next 10 years. Even considering that a por- tion of this rise would be counterbalanced by lower private sector spending, net national an- nual health care spending would be increased 20% from about $3.5 trillion to $4.2 tril- lion. • For Further Reading: Frakt AB, Oberlander J. Challenges to Medi- care For All remain daunting. Health Aff 2020(Jan);39(1):142-145. • Johnson M. Kishore S, Barwick DM. Medi- care For All: an analysis of key policy is- sues. Health Aff 2020(Jan);39(1):133-141. • Pope C. Medicare For All? Lessons from abroad for comprehensive health care re- form. Manhattan Institute Report. Novem- ber 2019. https://www.manhattan-institute. org/using-lessons-from-international- health-care-medicare-for-all Accessed January 20, 2020. www.ArkMed.org

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