UPDATE: In which Kamala Harris splits the difference between #Med4America & #Med4All

(IMPORTANT: As my friend Shawn Pierce keeps pointing out, the phrase "Medicare for All" has two very different meanings...one is the brand "Medicare for All", which simply refers to any healthcare plan which ensures 100% universal, comprehensive healthcare coverage for everyone; the other is the specific bills introduced by Sen. Bernie Sanders and/or Rep. Pramila Jayapal, which would indeed completely eliminate private major medical insurance for 100% of the population as well as completely eliminating all out-of-pocket costs in favor of 100% federal public funding).

For months now, California Senator and Presidential candidate Kamala Harris has repeatedly struggled with how to address her support of Bernie Sanders' 100% mandatory, $0 out-of-pocket-cost, 100% comprehensive "pure" single payer "Medicare for All" healthcare bill.

At various times and in various venues, she's stated that she full supports "getting rid of" private health insurance altogether, but also allowing room for private supplemental insurance...even as she underscored that there'd be very little left for the supplemental market under Bernie's plan anyway, since the whole point is to make Medicare so comprehensive that it'd cover nearly everything under the sun.

The main issue which seems to have tripped Harris up in the past when it comes to employer-based private insurance coverage has been how to deal with unions. Some unions have negotiated hard to get gold- or platinum-plated private insurance deals with corporations, oftentimes giving up other benefits for those plans.

To them, not only would seeing their hard-fought private insurance plans be dissolved mean they effectively gave up those other benefits for nothing, it could actually be a net negative in some cases, since their taxes to pay for the new "Medicare for All" program could end up (depending on their income) increasing by more than the amount they'd be saving relative to their existing plans.

Harris has, at times, made it sound like she's actually open to something more along the lines of "Medicare for America", which would (after a transitional period) eventually end up with the following breakout:

  • ~50% of the population would be enrolled in either (greatly enhanced) Medicare or (greatly enhanced) Medicare Advantage
  • ~50% of the population would be enrolled in either (greatly enhanced) employer-based private coverage, (greatly enhanced) Medicare or (greatly enhanced) Medicare Advantage.

The private individual market as it exists today would indeed be gradually phased out. The private group/employer market would still be allowed to exist...but every plan would have to be at least gold-level or higher, and would have to be expanded to include dental, vision and so forth.

Since the "gold-plated" union plans which Harris is rightly concerned about tend to comply with these criteria already, Medicare for America seems to check off that item on her "must have" list. However, she's still stated that she's in favor of (mandatorily) replacing private major medical coverage, which sets up a bit of a contradiction on this point.

In response to these issues, this morning, just ahead of the 2nd round of Democratic Presidential debates, Harris has unveiled her own official universal healthcare coverage plan, which she once again calls...Medicare for All. Remember, every reference to "Medicare for All" below refers to HARRIS' version, NOT Bernie's.

WHO WILL BE COVERED UNDER MEDICARE FOR ALL AND WHAT BENEFITS WILL BE OFFERED?

Medicare for All will provide every individual in America with access to comprehensive health care. It will cover all medically necessary services, including emergency room visits, doctor visits, hearing aids, vision, dental, mental health and substance use disorder treatment, and comprehensive reproductive health care services. These benefits will be covered — no deductibles, and no copays for high-quality care. The plan will also have strong caps on out-of-pocket costs. It will also empower the Secretary of Health to negotiate for lower prescription drug prices. My plan will give more Americans more options to gain access to the health care they need.

In terms of comprehensiveness, it sounds pretty much the same as both Bernie's M4All and Med4America: Just about everything. There's a reference to long-term services & supports as well, which is the other major box checked off by both of the other bills. On this front, all three variants sound pretty much the same.

In terms of out of pocket costs, it sounds very similar to Med4America: No deductibles, extremely reasonable premiums/co-pays. I presume the premiums would be based on a sliding scale the way Med4America would be as well (there's a reference later on to "financial assistance for those who qualify based on income" later on, although that's referring to the transitional period).

IMPORTANT UPDATE: OK, I might have been reading the "out of pocket costs" part wrong. I assumed it meant no premiums/co-pays for low-income folks but low or moderate premiums/co-pays for middle/upper income enrollees, like in Medicare for America. However, according to this CNN article on it:

A campaign aide says Harris' health care proposal would expand Medicare's coverage to dental, vision and long-term care. Out of pocket costs would be capped at $200, similar to the Sanders plan, so Harris' plan virtually eliminates cost sharing and ensures no deductibles or copays.

If that's the case, Harris' plan is actually much closer to Sanders' plan after all...the chief distinctions would be that it would be phased in more gradually, would start the tax hikes higher up the income chain, and would allow for high-end Medicare Advantage plans...except that they'd be entirely paid for by the federal government instead of by the enrollees.

I'm hoping to get some clarity on the premium/co-pay question soon. I'm honestly stunned that Harris failed to clarify this--it's not a minor, obscure detail; whether or not there are premiums/OOP expenses and for whom is a critically important part of any healthcare coverage plan.

Under my Medicare for All plan, we will also expand the program to include other benefits Americans desperately need that will save money in the long run–for instance, an expanded mental health program including telehealth and easier access to early diagnosis and treatment, and innovative patient navigator programs to help people identify the right doctor and understand how to navigate the health system. It will provide a serious auditing of prescription drug costs to ensure Americans aren’t paying more for their prescription drugs than other comparable countries; a comprehensive maternal & child health program to dramatically reduce deaths, particularly among women and infants of color; and meaningful rural health care reforms, such as increasing residency slots for rural areas with workforce shortages and expanding loan forgiveness for rural health care professionals, to promote high-quality access to people regardless of their zip code.

This part sounds very simliar to Med4America's robust student loan forgiveness program:

Given the intended expansion of healthcare coverage to tens of millions more people, Medicare for America also accounts for the need to ensure there are enough healthcare providers by creating a new student loan forgiveness program for healthcare workers like direct care workers, mental health counselors, licensed marriage and family therapists, physician assistants, pharmacists, dentists, dental hygienists, doctors, and nurses. The program will forgive 10 percent of student loan debt for each year the provider or institution the provider works for accepts the Medicare for America plan.

WILL I BE ABLE TO KEEP MY DOCTOR UNDER MEDICARE FOR ALL?

Yes. 91% of eligible doctors participate in the Medicare program today. Envision a program where you can walk into a doctor’s office knowing that they are in-network and you can walk out without worrying about your out-of-pocket costs or a surprise medical bill. My plan recognizes that doctors, nurses, and your entire health care team who provide high-quality care will have a voice in their workplace and be paid at appropriate rates under my plan.

Again, pretty much the same as both Med4All and Med4America, which utilize the existing Medicare provider network...which amounts to the vast majority of doctors/hospitals/clinics etc. in the U.S.

HOW DOES THIS PLAN WORK AND HOW WILL WE TRANSITION TO MEDICARE FOR ALL?

Under my Medicare for All plan, we will immediately allow people to buy into a Medicare Transition Plan through an extended 10-year phase-in period.

Here's the first major difference between Harris' plan and both Med4All and Med4America.

Jayapal's House Med4All bill purports a 2-year transition period. Bernie's Senate Med4All bill would be phased in over 4 years. Med4America would have roughly a 6-year transition period: The first 2 years would amount to "ACA 2.0", followed by 4 years of different groups being transferred over to the Med4America program (existing Medicare enrollees, the ACA individual market, the uninsured, Medicaid & CHIP...as well as (optionally) small group employees/employers). After that, large employers (or their employees) would also have the option of making the move if they wished.

Harris' proposed 10-year phase-in is either more or less realistic than either of these, depending on your point of view, both pragmatically and politically.

We will automatically enroll newborns (with an opt-out provision for families with employer-sponsored insurance) and the uninsured into a Medicare Transition Plan, and provide a commonsense path for employers, employees, the underinsured, children, and others on federally-designated programs, such as Medicaid or the Affordable Care Act exchanges, to transition into the Medicare Transition Plan. The Medicare Transition Plan will provide enhanced benefits with limited cost-sharing requirements and financial assistance for those who qualify based on income. During the transition, seniors will be able to keep their Medicare with immediate coverage of additional benefits such as dental, vision, and hearing aids.

This part, again, sounds very similar to Med4America: The auto-enrollment of newborns, the restricted cost-sharing and sliding scale financial assistance, and seniors having dental/vision added to their existing Medicare coverage.

A couple of bits are different from Med4America, however: The newborn opt-out for employer coverage is a nod to the union plan issue, and the bit about seniors gaining enhanced benefits doesn't say whether or not seniors would have their current payment levels grandfathered in or not, as Med4America does.

Second, after the 10-year transition period, we will have a new Medicare framework where most Americans will be in an expanded and improved public Medicare plan. In my Medicare for All system, similar to Medicare Advantage today, private insurance plans can contract through Medicare and compete with the public Medicare plan. However, these private Medicare plans will be subject to stricter consumer protection requirements than under current law, such as getting reimbursed by Medicare for less than the cost of the public Medicare plan to ensure taxpayers aren’t subsidizing insurance company profits. Americans can then choose whether to stay in the public Medicare plan or opt-into a private Medicare plan.

BOOM. This is the main thing which inspired my "split the difference" headline. Using my bullets above, under Harris' plan:

  • ~50% of the population would be enrolled in either (greatly enhanced) Medicare or (greatly enhanced) Medicare Advantage
  • ~50% of the population would be enrolled in either (greatly enhanced) employer-based private coverage, (greatly enhanced) Medicare or (greatly enhanced) Medicare Advantage.

The crossed-out part is the main difference...instead of three different types of coverage options (Medicare, Medicare Advantage or private employer coverage) there'd be two (Medicare or Medicare Advantage...which is publicly funded but privately managed, which is how Harris can reasonably state that she'd be "getting rid of all that" and "keeping a role for private coverage" at the same time:

WHAT ABOUT EMPLOYER-BASED PLANS?

During the transition period, employers can continue to provide private health coverage to employees. However, employers will also have the opportunity to provide health care for their employees through the Medicare Transition Plan, with a shared responsibility payment. Employees will also have the option on their own to buy into the Medicare Transition Plan during the transition period.

Again, this is very much like Med4America...the main difference is that under Med4America, this option would run from Year 3 on, while under Harris' plan it sounds like it would be an option from Year 1 - Year 10 only, I think.

Following the transition period, under my Medicare for All system, employers will have the option to provide a private Medicare plan for their employees that will be certified by the Medicare program, similar to how employers can offer Medicare Advantage plans today. Employees could choose to be in that employer Medicare plan, a different private Medicare plan, or the public Medicare plan.

This is what I'm talking about above. Under Med4America, they'd have three options (Medicare, Medicare Advantage or a fully private plan; under Harris' plan, they'd have the first two options).

WHAT ABOUT ORGANIZED LABOR AND UNION WORKERS?

Under my Medicare for All plan, union workers will have the option to join Medicare and stop sacrificing wages for better health care. Unions could also continue working with employers to offer a private Medicare plan option or supplemental benefits in addition to the Medicare plan.

Workers should and will be guaranteed the opportunity to join together in a union or other worker organization and have a collective voice in discussions concerning the health care issues that affect them. They can and should be allowed to pay dues and be active in organizations without retaliation.

And here's her response to the Union issue: They could still negotiate private coverage, it'd just have to be under the umbrella of the enhanced Medicare Advantage. Whether this "counts" as "private coverage" or not depends on your POV, of course.

DOES YOUR PLAN AFFECT THE VA HEALTH SYSTEM OR THE INDIAN HEALTH SERVICE?

No. Those programs will remain untouched, but my Administration will stay vigilant to ensure that Veterans and Native Americans receive high-quality health care.

I find it very intersting that none of the universal coverage plans being proposed, including Med4America or either the House or Senate Med4All bills, touch the VA or IHS. There may be legal/logistical reasons for that, of course; messing with the IHS would probably involve screwing around with soverignity issues, for instance. Both are funded via federal public money already anyway, though, so I suppose this doesn't violate any philosophical issues for M4All supporters.

HOW DOES YOUR PLAN AFFECT SENIORS?

Seniors will be able to keep their Medicare with immediate coverage of additional benefits such as dental, vision, and hearing aids, and the Secretary will have the authority to use market leverage to secure the best prices for these products and services. Medicare Advantage plans would continue uninterrupted during the transition. And employer-sponsored health insurance would continue to be an option until we meet these shared principles as all Americans gain access to better coverage over the next decade. My Medicare for All plan would also phase-in coverage of comprehensive long-term services and supports, with a focus on consumer-directed home and community-based services.

Most of this is a rehash of the earlier points, but the mention of LTSS (long-term services & supports) is important, as I noted earlier. Again, the immediate addition of dental/vision/hearing doesn't state whether current Medicare enrollees would have to pay more for those added services or not...and the fact that they'd be "immediately" added raises the question of what happens to existing MediGap plans (i.e., the supplemental plans which currently cover those services). Would they become superfluous right away? If Medicare premiums increased to cover them, would MediGap enrollees be double-paying?

HOW DOES YOUR PLAN AFFECT CHILDREN?

Newborns will be automatically enrolled into the Medicare Transition Plan with an opt-out provision for parents who have employer-sponsored coverage. Children currently covered by the state Children’s Health Insurance Program (CHIP) and Medicaid will have a pathway to transition onto the Medicare Transition Plan and ultimately into my Medicare for All system. Comprehensive services including prevention, wellness, and services to assist children with developmental delays will be included. All currently available Medicaid supplemental benefits to children, such as EPSDT, will be provided under my Medicare for All plan.

There's not specific timeline for any of this to be phased in beyond "10 years", which is an important omission. Does it mean Medicaid/CHIP enrollees would be phased in by age group, like under M4All? Does it mean they'd be transitioned all at once, but not until the 5th year, like under Med4America? That's left open.

HOW DOES YOUR PLAN AFFECT PEOPLE WITH DISABILITIES?

People with disabilities will also transition to the Medicare system and have access to comprehensive long-term services and supports, as well as necessary equipment and assistance devices. Under my Medicare for All plan, long-term services and supports will be consumer-directed and provided in home- and community-based settings, unless the individual chooses otherwise.

This is a really big deal to the disability community. Like, hugely important. It's why Med4America made sure to include LTSS and home/community settings as a major part of the bill last year, and why Bernie added it to the 2019 version of his M4All bill.

HOW DOES YOUR PLAN AFFECT AMERICANS LIVING IN RURAL AREAS?

By expanding high-quality health care coverage to the uninsured and underinsured, my plan will substantially increase patient access at rural hospitals and clinics. Rural Americans will have better access to care through telehealth services. We will work to redesign and prioritize delivery system reforms for rural areas to promote innovative solutions to deal with critical workforce shortages and a lack of reliable access to trauma, obstetrics, and other hospital services.

HOW DOES YOUR PLAN AFFECT MEDICAID?

Medicaid will transition to the Medicare for All system, which will ensure that all current Medicaid benefits for low-income individuals will be covered. States will be required to make maintenance of effort payments to the Medicare program equal to the amounts they currently spend on Medicaid and CHIP, which will grow with inflation.

This is identical to Med4America and Bernie's Med4All bill. It basically means the states don't get off the hook for chipping in to help cover the new program costs.

DOES YOUR PLAN ELIMINATE ALL PRIVATE INSURANCE?

No. Under my Medicare for All system, the power of big insurance companies will be greatly diminished. After the transition period, private insurance will only exist in two ways:

1) At the end of the day, Americans want to be able to choose their doctor and the care they receive, not the insurance company that provides it. Under my plan, private insurers can compete with the new public Medicare plan, as long as the plans they offer adhere to strict requirements like those laid out below. This would function similarly to how Medicare Advantage operates within the Medicare system today. Today, 35% of seniors are enrolled in private Medicare plans that get paid directly by Medicare and, in fact, 25% of current private Medicare insurance plans are already at or below 95% of Medicare costs.

In my Medicare for All system, Medicare will continue to set the rules of the road for these plans, including price and quality, and private insurance companies will play by those rules, not the other way around. But unlike under the current program, these private Medicare plans will be held to stricter consumer protection standards than they are today, such as getting reimbursed less than what the public Medicare plan will cost to operate, to ensure that they are delivering meaningful value and unable to profit off of gaming consumers or the government.

This appears to be lifted directly from Med4America, which would reimburse Medicare Advantage carriers 95% of what they'd get under "public" Medicare.

Unlike Med4America, however, fully private major medical plans would not be allowed anymore, even for those with employer coverage, which is much closer to the Med4All ideal. Of course, that would only happen after 10 years, so it's a matter of perspective.

2) People will be able to purchase supplemental insurance covering services not included under Medicare for All, such as medical insurance for traveling abroad and cosmetic surgery. Employers will still be able to offer their employees retiree supplemental coverage through a private insurance plan.

This is the same as both Med4America and Med4All.

HOW WILL WE PAY FOR MEDICARE FOR ALL?

Right now, the US spends $3.5 trillion a year on health care. If we do nothing over the next decade, that number will skyrocket to an estimated $6 trillion a year.

That’s why over 200 economists around the country have said we will dramatically save money over the long run if we expand the Medicare program to include everyone and limit profits for drug companies and insurance companies. We will also save money by accelerating delivery system reforms and value-based care that rewards meaningful outcomes instead of promoting performing unnecessary tests and procedures.

Senator Sanders, for example, has put forward a number of ways to help pay for his Medicare for All plan, including an income based premium paid by employers, higher taxes on the top 1%, taxing capital gains at the same rate as ordinary income, among others.

I think these are good options, especially making the top 1% and corporations pay their fair share through a more progressive income, payroll, and estate tax.

However, one of Senator Sanders’ options is to tax households making above $29,000 an additional 4% income-based premium. I believe this hits the middle class too hard. That’s why I propose that we exempt households making below $100,000, along with a higher income threshold for middle-class families living in high-cost areas.

This is the part which got Harris into some additional trouble/confusion a couple of weeks ago, when she vowed that her "Medicare for All" plan wouldn't involve any tax increases on the middle class. She threads this needle by defining "middle class" as "under $100K, or higher in high-cost areas"...and of course by allowing for some level of premiums/co-pays/cost sharing depending on your income, similar to Med4America.

UPDATE: From a few comments I've seen on Twitter, it sounds like some folks are under the impression that Harris is proposing that there'd be no premiums or co-pays for households under $100,000 either, but that's not what she said--she said there'd be no tax hike below $100K. I'm guessing premiums/cost sharing would be similar to Medicare for America, which sets them at $0 for anyone under 200% of the Federal Poverty Line (roughly $50,000 for a family of 4) and between 0 - 4% of income between 200 - 400% FPL ($50K - $100K for a family of 4).

To pay for this specific change, I would tax Wall Street stock trades at 0.2%, bond trades at 0.1%, and derivative transactions at 0.002%. Think of it like this: that’s a $2 fee on a $1,000 trade by investors and big banks. I would also end foreign tax shelters by taxing offshore corporate income at the same rate as domestic corporate income. Together, these proposals would raise well over $2 trillion over ten years, more than enough to make up the difference from raising the middle class income threshold.

In total, this plan will reduce our country’s health care costs and lower Americans’ out-of-pocket costs, all while extending health insurance coverage to every American.

And there you have it.

So, what do I think?

Well, there's some important gaps yet to be filled in (what's the actual phase-in period within those 10 years? what does the sliding scale for out of pocket costs look like? etc etc). This is a policy proposal, not actual legislative text, although it's a reasonably detailed one.

Overall, it looks like it's around 70% Medicare for America, 30% Medicare for All. There's a couple of areas where it's actually slightly more centrist than either (the longer phase-in period and the opt-out of newborn autoenrollment for those with employer coverage, for instance), but for the most part it fits in between the two "Med4" bills.

As I've noted before, my personal, ideal vision forward would be something like:

  • 1. Protect the ACA
  • 2. ACA 2.0 w/immediate effect for 1-2 years (Warren & Biden's plans, but only short term)
  • 3. Add robust public option for 1-2 years (Biden's plan, but only short term)
  • 4. Absorb existing public programs into a single federal public program over a few years (Med4All & Med4America)
  • 5. Allow private employer plans to exist but only if they're held to extremely high standards (Med4America), which would lead to...
  • 6a. ...either 100% public coverage (universal single payer with some cost sharing)... (Med4All, eventually, but w/cost sharing)
  • 6b....or a ~60/40 split between public coverage and high-quality private coverage. (Med4America)

Harris' plan is very much like Med4America up until step 5, at which point it sort of splits off into 5b and 6c...privately managed plans would be the only private major medical coverage still allowed.

I've noted several times before that regardless of their rhetoric on the campaign trail, regardless of what they say their preferred plan is, just about every one of the Presidential contenders would almost certainly SIGN other healthcare coverage expansion bills if that's what ends up being passed by a (presumably Democratically-controlled) House and Senate. If the Democrats don't hold onto the House and retake the Senate, most of this will be moot anyway, since Mitch McConnell won't allow any serious healthcare policy expansion bill to get through to the President's desk anyway.

Having said that, while some big questions remain for Harris' proposal, she's finally clarified what her vision is...and no, it's not BernieCare. Call it KamalaCare if you wish.

Three of the four major Democratic contenders have now laid out their long-term vision for national U.S. healthcare policy. The only one who is still up in the air at this point is, surprisingly, the same candidate who used to have what I felt was an ideal response to the question: Elizabeth Warren.

Warren has gone from a "multiple paths as long as we get there" response in March (which I was very happy with) to "I'm with Bernie on healthcare" (which I was not at all happy with)...while also seemingly abandoning her own excellent ACA 2.0 bill (which I love, and which I'm disappointed to see her cede to Joe Biden).

The ball's in your court now, Sen. Warren: Are you still all in on BernieCare?

Meanwhile, the stage has been set (literally) for Harris to face off against Biden this Wednesday.