GRAHAM-CASSIDY REPEAL BILL DEADLINE:

Time: D H M S

UPDATE: Bernie's *new* plan is here. Let's take a first look.

OK, here it is. I've linked to a PDF with the full legislative text at the bottom of this blog entry; here's the summary version, with some notes:

TITLE I—ESTABLISHMENT OF THE UNIVERSAL MEDICARE PROGRAM

Establishes a Universal Medicare Program for every resident of the United States, including the District of Columbia and the territories. Guarantees patients the freedom to choose their health care provider. Provides for the issuance of Universal Medicare cards that all residents may use to get the health care they need upon enrollment. Prohibits discrimination against anyone seeking benefits under this act.

OK, so it apparently would cover undocumented immigrants, and every doctor/hospital/clinic/etc. would be required to participate, with anyone in the country being covered by any healthcare provider nationally.

Effective date of benefits: For children ages 0 to 18, benefits shall first be available on January 1 of the first calendar year that begins after enactment; for all others, benefits shall be made available on January 1 of the fourth calendar year that begins after enactment.

Assuming this bill hypothetically was passed and signed into law in 2021, childrens coverage would kick into effect on January 1, 2022, and everyone else would start on January 1, 2025.

TITLE II—COMPREHENSIVE BENEFITS

Requires coverage of the following benefits: hospital services, including emergency services and inpatient drugs; ambulatory patient services; primary and preventive services, including disease management; prescription drugs, medical devices, and biological products; mental health and substance abuse treatment services, including inpatient care; laboratory and diagnostic services; comprehensive reproductive, maternity, and newborn care; pediatrics; oral health, vision, and audiology; rehabilitative and habilitative services and devices; other items as deemed necessary.

Basically, everything, including dental and vision coverage, which I agree have always seemed like an odd thing to separate out to me under most current insurance policies.

States may provide additional benefits at their expense.

This section eliminates out-of-pocket spending for medical benefits, which includes deductibles, coinsurance, and copayments. The Secretary may impose limited copayments for prescription drugs in order to encourage the use of lower-cost generic drugs.

No co-pays, deductibles or premiums of any sort for anyone, except for a few prescription drugs? I believe this goes beyond even other "pure" Single Payer nations such as Canada and Taiwan. The risk here is people popping into the doctor's office for every papercut and sore throat, jacking up costs. Granted, no one likes wasting half their day driving to the doctor's office and sitting in a waiting room for an hour before being seen, so I suppose that would be enough disincentive to cut down on most of this problem, but it's still a big red flag.

Long-term care coverage for seniors and people with disabilities will continue as it is currently covered under Medicaid, complete with a maintenance of effort provision; no one receiving benefits through Medicaid or any other federal or state health program will lose support.

OK, that's good.

TITLE III—PROVIDER PARTICIPATION

Requires all providers to sign a participation agreement. Participation agreements may be terminated by the agency for cause, or by the provider for any reason.

Providers shall be considered qualified if they are properly licensed and certified under State and federal law to provide such services. Applies Medicare’s current provider standards.

Allows providers to opt out of the system on an annual basis.

Every doctor, hospital and clinic in the U.S. would be legally required to participate.

TITLE IV—ADMINISTRATION

Establishes this program under the Department of Health and Human Services, run by the Secretary. Provides for general duties of the Secretary related to the administration, including developing policies, procedures, guidelines, and requirements related to eligibility, enrollment, benefits, provider participation, payment methods, and data collection.

Provides for a Beneficiary Ombudsman to assist individuals enrolled in the Act. Applies all current Medicaid fraud provisions to this Act.

One criticism of the ACA all along has been that too much authority is left in the hands of the HHS Secretary. This was seen as a positive under Sylvia Burwell in the Obama Administration...but is shaping up to be a disaster under Tom Price in the Trump Administration.

TITLE V—QUALITY ASSESSMENT

Requires CMS’ Center for Clinical Standards and Quality, in coordination with the Agency for Healthcare Research and Quality to review and evaluate all practice guidelines, profile practices and patterns of health care, conduct quality reviews, and report to the agency on outcomes research.

Requires the Center to evaluate and address health care disparities, and issue a report to Congress and the Secretary on such disparities.

TITLE VI—BUDGET AND PROVIDER PAYMENT

Applies Medicare’s current payment structures to Universal Medicare, including payment reform activities established by the ACA and MACRA.

Requires the agency to create an annual budget, which shall include the cost of covered health services; quality assessment activities; health professional education expenditures; administrative costs; innovation; operating and other expenditures; capital expenditures; and public health activities. For the first five years following the date of enactment, the budget may also provide transition assistance to health insurance administration workers who may be displaced because of the implementation of this Act. Provides for a reserve fund to anticipate natural disasters or other such public health emergencies.

Um...OK, so some unspecified amount of money would be allocated towards retraining the 2-3 million people who work either directly for the insurance industry or in directly related services for five years.

Creates an Office of Primary Health to promote access to primary health care.

Requires the Secretary to negotiate the price of prescription drugs. Requires the Secretary to establish a prescription drug formulary for the Universal Medicare Program that is evidence-based and will encourage the use of generic drugs.

TITLE VII—UNIVERSAL HEALTH INSURANCE TRUST FUND

Creates a trust fund for this Act. Includes all current federal health insurance program receipts, as well as all extra dollars attributed to changes in the Internal Revenue Code. Prohibits Hyde restrictions from following current appropriated funds into the Trust Fund.

OK, here's the first mention of how it'd be paid for: Everything in the federal budget which currently goes towards Medicare, Medicaid, CHIP, the Veterans Administration, TriCare, FEHB, the Indian Health Service, the ACA exchange tax credits (APTC & CSR) and Medicaid expansion would be used to pay for it. That amounts to around $1 trillion/year all told, from what I can tell. Assuming no cost savings (i.e., if the total system cost as much as we spend on healthcare nationally today), that would leave something like $2.2 trillion per year to be covered somehow.

Right now, employer-based healthcare coverage premiums for around ~155 million Americans is not subject to a payroll tax. Move all those people off of ESI and that would theoretically mean around $280 billion per year (call it $300B a few years from now) in additional federal tax revenue...assuming that every employer increased every employee's salary/wages by the exact same amount, dollar for dollar, that they were previously paying for their healthcare policies. Somehow I find that a stretch...if you earn $40,000 & your employer is currently paying $5,000 towards your ESI policy, they might bump your salary up to $45,000...or they might just pocket the difference. Most likely it'd be somewhere in between.

Still, if you assume that full $300B would be added to the kitty, that leaves perhaps $1.9 trillion per year in new taxes/revenue which would have to be drummed up...again, assuming no cost savings whatsoever, which I'm assuming is coming up...

I see the Hyde Amendment mentioned...does this mean it's repealed, or what?

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UPDATE: OK, I've started reading through the actual legislative text and think I've cleared up the confusion regarding the Hyde Amendment. On Page 9, under the Essential Health Benefits, it lists:

7) Comprehensive reproductive, maternity, and newborn care.

Then, on Page 56, under the details of the Medicare Trust Fund (that is, the money that would for the entire program), it says:

(3) RESTRICTIONS SHALL NOT APPLY.—Any other provision of law in effect on the date of enactment of this Act restricting the use of Federal funds for any reproductive health service shall not apply to monies in the Trust Fund.

In other words, it doesn't actually repeal the Hyde Amendment, it just states that the Hyde Amendment "shall not apply" to the M4A funds. And since M4A would at that point have completely replaced all other healthcare coverage funding for everyone, it would effectively neuter Hyde entirely (in theory).

Why the bill doesn't simply repeal the Hyde Amendment outright, I have no idea. Perhaps it has to do with how Hyde was passed or some other legislative rule (maybe you can only repeal Hyde as direct amendment to whatever bill it was an Amendment to or something?), or perhaps they somehow thought wording it this way would let them quietly slip it by the GOP if it were to actually be voted on (which is unlikely, to put it mildly).

In one way, this isn't that different from either of the GOP's repeal bills (AHCA/BCRAP), which didn't technically repeal the ACA's individual mandate...they simply changed the amount of the mandate to $0.00 or 0.00%. There was a specific reason for that, however: It was the only way to do it using the reconciliation process. Not sure what the deal is here.

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TITLE VIII—ERISA CONFORMING AMENDMENTS

Conforming amendments to the Employee Retirement Income Security Act of 1974. Prohibits employee bene ts duplicative of the benefits under the Universal Medicare Program. Provides for coordination with employers in cases of workers’ compensation.

TITLE IX—RELATIONSHIP TO EXISTING FEDERAL HEALTH PROGRAMS

Provides for a transition from Medicare, Medicaid, FEHB, SCHIP, and any other federal health insurance program into the Universal Medicare Program.

Nothing in this legislation will impact the eligibility of veterans for the medical benefits and services provided under the VA, or of Native Americans for the medical benefits and services provided by or through the Indian Health Service. Those benefits will be kept intact. Requires HHS to consult with tribal leaders and stakeholders before making any determination with respect to the Indian Health Service.

Hmmm...OK, perhaps the Indian Health Service, VA and TriCare wouldn't be touched after all?

TITLE X—TRANSITION

This section sets up a just transition to Universal Medicare. It will immediately improve and expand Medicare for seniors and people with disabilities by covering dental, vision and hearing aids which are not covered under current law. Medicare Part A, Part B, and Part D deductibles would also be eliminated in the first year.

A Medicare Transition plan would be established during the first year to provide affordable coverage for all Americans and to make sure that no one loses coverage.

During the second year of implementation, the Medicare eligibility age would be reduced to 45 and to 35 by the third year.

By the fourth year, every individual who is a resident of the United States will be entitled to benefits for comprehensive health care services and will get a Universal Medicare card that they can use to receive the health care they need.

I'll have to read the full legislative text (it's 96 pages total, which is more like 60 pages given the wide margins and double-spacing) to answer a lot of other details and clarify some of the above, but my initial thoughts are pretty much the same as what I said last night:

Between his open acknowledgement that it has "no chance of passage" under a GOP-controlled Congress and the lack of any details on the funding levels or tax formula, this strikes me as a completely symbolic bill, meant purely as a showpiece/rallying cry for the Democratic Party about the direction that they should be pushing (hard) regarding healthcare going forward. The general message here is, "The ACA got us started down the field, now it's time to focus on running the ball all the way into the end zone".

I'm completely OK with that myself, believe it or not. If that's what it takes to rally the troops, raise moral, get everyone on board for a unified Democratic Party, move the Overton Window and so on, I'm fine with that.

...For all of his "outsider" rhetoric, Bernie Sanders has been a U.S. Senator or U.S. Congressman for 27 years. He understands how these political games are played. He understands that you "can't start negotiations on the 50-yard line" and that you have to ask for more than you're willing to settle for in order to get as much of what you want as possible, etc etc. In a situation like that, sure, you try to get co-sponsors, etc...but for the love of God, don't make not signing on into an ultimatum. There are plenty of great sitting Democratic members of the House, Senate, state legislatures and so on who support universal coverage of some sort but don't necessarily think that this particular plan is the best way to go about getting there.

The problem with this strategy, in other words, is that it only works if your supporters understand what you're doing and are on board with it.

I'll leave it at that for the moment.