'Everybody In, Nobody Out': What We Know So Far About the Medicare for All Act of 2019

As the 2019 legislative session in Congress kicks off, the Democratic majority in the House will, in very short order, have to address a national surge of support for Medicare for All (otherwise known as single-payer healthcare). At the close of the last Congress, almost two-thirds of Democratic Representatives had signed onto HR 676, the Expanded & Improved Medicare for All Act. They will be joined by the long list of freshman Democrats who ran and won on this issue.

"Understandably, the transition to a new lead sponsor and an extensive rewrite process has created some nervousness and confusion in sections of the single-payer advocacy community."

Leading the charge in the House will be Rep. Pramila Jayapal (D-Wash.), who is assuming lead sponsorship of the Medicare for All bill after Keith Ellison stepped down to run for Attorney General of Minnesota. Jayapal got her start in the immigrant rights and civil rights movements, and has extensive ties to the social justice and labor movements in Washington State.

Her willingness to take the lead on the Medicare for All Act will come as no surprise: last year she helped to launch the first Medicare for All Caucus in the history of Congress, and, as Co-Chair of the Congressional Progressive Caucus, is helping to prioritize the CPC's work on single-payer healthcare. She brings an organizing approach and a deep understanding of the power that political momentum brings. She has won commitments from committee chairs to hold actual hearings on the bill and convinced speaker Pelosi to waive the "PayGo" rules as the bill is being marked up.

Rep. Jayapal's office is also in the midst of significantly rewriting the legislation, a move that has become necessary as the social movement for Medicare for All has grown, and the details of how it can be accomplished come under growing scrutiny. Bernie Sanders learned this the hard way when, during the 2016 Presidential primaries, he floated the outline of a plan for single-payer healthcare that received intense criticism from his opponents - most of it dishonest and misleading, but made easier by the lack of some details in the original proposal. The new bill not only will be much more detailed, it will also add additional benefits and correct some major shortcomings in both HR 676 and the Senate Bill (S 1804).

"The new bill not only will be much more detailed, it will also add additional benefits and correct some major shortcomings in both HR 676 and the Senate Bill (S 1804)."

Jayapal's organizing approach impelled her to engage in extensive deliberations with single-payer advocates and to bring to the table voices that are often marginalized in the healthcare policy world, including advocates from the racial justice and disability rights communities. All of this takes time and the process has also been delayed by the government shutdown, leadership transition and the ongoing disruptions of an out of control Trump Administration. This means that the opportunity has passed to submit the new bill under the old HR 676 number beloved by single-payer diehards. The new bill will have a higher number. But it will be a serious piece of legislation ready to undergo the scrutiny of congressional committees and the Congressional Budget Office. More importantly, we believe the new bill will reflect the values of the healthcare justice movement.

Understandably, the transition to a new lead sponsor and an extensive rewrite process has created some nervousness and confusion in sections of the single-payer advocacy community. This has allowed a range of rumors and misrepresentations to run rampant among activist groups, including some rumors that have started spilling into published articles.

The two of us lead Healthcare-NOW and the Labor Campaign for Single Payer Healthcare, the national organizations representing community members and organized workers fighting to win healthcare as a right. Neither one of us has seen the final bill nor are we authorized to speak on behalf of Congresswoman Jayapal. However, we have been involved in extensive briefings and consultations with Jayapal's staff and we want to explain what is happening with the bill, and express our confidence that it is shaping up to be a much stronger and more detailed piece of single-payer healthcare legislation than the bills submitted in the last Congress.

Messaging vs. Comprehensive Legislation

HR 676, the Medicare for All bill filed in the House of Representatives for the past fifteen years, was a "messaging" bill. It was intended to outline the key features of what a Medicare for All system would look like and to serve as a rallying point for the growing single payer movement. Many of its laudable features were little more than bullet points describing the essential components of such a system.

"The new bill--which will be filed as the Medicare for All Act of 2019--is more than 120 pages long and tries to flesh out the elements of a Medicare for All system in a comprehensive fashion."

The new bill--which will be filed as the Medicare for All Act of 2019--is more than 120 pages long (HR 676, by contrast, ran 30 pages from start to finish) and tries to flesh out the elements of a Medicare for All system in a comprehensive fashion. This is in expectation that the bill will receive serious consideration and review by the appropriate Congressional committees. It incorporates many new provisions and elaborates on the bullet points in HR 676.

Below are what we believe to be the essential features of a real Medicare for All program, and how we understand the new bill will address them:

Everybody In. Nobody Out.

The new Medicare for All Act will contain the same inclusive language as both HR 676 and Senator Sanders's Medicare for All bill: every resident of the United States would be eligible for coverage under the new health plan. The Secretary of Health and Human Services would define, through regulations, who exactly qualifies as a resident. Because they are younger and healthier than the general population, immigrants have low healthcare costs and pay far more into the system than they use, making full inclusion both the morally and economically right thing to do. The lack of a "citizenship" test is intentional and important, but both of our organizations (Healthcare-NOW and the Labor Campaign) would like to see more explicit language that doesn't provide wiggle-room to the Secretary of HHS.

Full and Comprehensive Medical Coverage

"We are assured that the new bill will follow Senator Sanders' Medicare for All Act and shelter the new national health plan from the Hyde Amendment, ensuring women's access to the full range of reproductive health services."

We expect that the final bill will include the full range of health services covered by the previous House bill (HR 676), as well as additional services that reflect new advances in medical treatment and the needs of the disability community and other vulnerable care recipients. Services covered include primary care, emergency care, mental health coverage, addiction treatment services, prescription drug coverage, medical devices, dental, and vision among others. Freedom to choose providers will be protected.

Long-Term Care

Long-term care (LTC) describes the range of services and supports that help people carry out tasks of everyday living (such as bathing, dressing, eating, taking medications, etc.) for those who need them. HR 676 committed to covering those services but it devoted only one sentence to how this large and life-saving sector would be funded and what benefits would be covered.

"The new House bill's LTC plan is being written after extensive consultation with disability advocacy and senior citizen communities, and incorporates their insights in developing comprehensive coverage that fosters independence and community-based care."

The Senate Medicare for All bill as it was written last session would not expand LTC coverage, and preserves the current system whereby people have to make themselves poor (if they are not poor already) to qualify for LTC under Medicaid. Medicaid LTC coverage varies tremendously from state-to-state, and institutional care (such as at nursing homes) is easier to qualify for than home-based care, even though it is more expensive and typically less beneficial for the recipient.

The new House bill's LTC plan is being written after extensive consultation with disability advocacy and senior citizen communities, and incorporates their insights in developing comprehensive coverage that fosters independence and community-based care.

Reproductive Healthcare

One major shortcoming of the previous House bill was that it remained silent on access to reproductive healthcare and abortion services. This meant that the move to a national healthcare plan coupled with the Hyde Amendment--which prohibits the use of federal funds for abortion and related services--would have denied all women access to insurance coverage for abortion services, even if they currently receive such coverage through their private insurance. We are assured that the new bill will follow Senator Sanders' Medicare for All Act and shelter the new national health plan from the Hyde Amendment, ensuring women's access to the full range of reproductive health services.

No Financial Barriers to Care

"There will be no co-payments, deductibles or other charges at the point of service for any category of care... The bill embraces the principle of a single standard of care for all Americans."

Like HR 676, there will be no co-payments, deductibles or other charges at the point of service for any category of care. And it will not include the Senate Bill's imposition of small drug co-payments to encourage the use of generic pharmaceuticals.

A Single Standard of Care for All

The bill embraces the principle of a single standard of care for all Americans. It will not allow participating institutions and providers to offer private care for covered services to the rich. Allowing the wealthy to "buy out" of the system has led to the erosion of care for everyone else in countries, such as Australia, who have experimented with it. The new House bill will also include substantial new language to begin to remedy healthcare disparities and expand service to underserved communities.

National and Regional Budgeting

Like the previous House bill's authors, Rep. Jayapal supports global budgeting for hospitals and other institutions, and fee-for-service for physicians. Furthermore we expect the bill will prohibit the use of funds for incentives that discourage utilization, increase profits or net revenues for providers, or rely on so-called "value-based payment" models. These are the best policies for minimizing administrative costs and avoiding payment methods that give providers an incentive to undertreat their patients or avoid the sick in favor of the healthy.

Protect Workers and Healthcare Professionals

"We expect the bill to include robust 'just transition' benefits for any healthcare and insurance industry workers displaced by the transition to Medicare for All."

We expect the bill to include robust "just transition" benefits for any healthcare and insurance industry workers displaced by the transition to Medicare for All, as well as prohibitions on using any funds intended for medical care towards union busting. There is also a commitment to ensure safe staffing levels, and to allow healthcare professionals to use their judgment to protect the best interests of their patients.

Transition Period

HR 676 had a transition period of between 1 and 2 years (if the bill was passed on January 2, it wouldn't be implemented for 2 full years), with no benefits until full implementation at the end of that period. The new House bill being drafted by Jayapal will likely have a transition period of two years, with significant benefits kicking in at the end of year one to improve Medicare and to extend a single-payer plan to about half the population. This is shorter than the four-year transition plan built into the Senate Medicare for All bill last session. Both the Sanders and the Jayapal bills are also using their transition periods to try to catch people who may lose their insurance if private insurance plans go under or refuse to write coverage after passage of the single-payer bill, which is likely.

What About Investor-Owned Facilities?

The new bill will likely not include one provision previously featured in HR 676 that banned investor-owned providers from participating in the new national health plan (this includes hospitals, nursing homes, dialysis clinics, dental and eye-care providers, etc). This provision would have required tax-payers to reimburse the shareholders of these providers for their lost stock value, and to ostensibly convert the facilities to nonprofit status. Instead, the new bill will seek to minimize profit taking through a series of budgetary and regulatory provisions.

Supporters of the "buy out" model maintain that it will cost $150 billion or so (approx. 5% of the entire federal budget) to reimburse the entire industry, and remind us that studies consistently show that for-profit providers produce abysmal outcomes. But there is considerable disagreement in our movement about whether buying out the for-profits is the best way to deal with the distortions of profit taking. Given the federal courts' propensity to privilege private property over public goods, it is all but certain that this buyout provision would spark a protracted legal battle. It is also difficult to guarantee under this provision that new non-profit providers would be created to replace every single for-profit company that closes its doors, since there is no way to compel a new non-profit to form. And the nonprofit section of the industry itself has gone through extensive consolidation and often embraces a business model that is virtually indistinguishable from that of investor-owned facilities. While we can honestly disagree about the best ways to begin to squeeze profit taking out of our bloated healthcare industry, we believe it is disingenuous for any sincere advocate of Medicare for All to maintain that any bill that fails to require the buyout of investor-owned facilities is fatally flawed and not worthy of support.

Negotiating Lower Prescription Drug Costs

Moreover, Jayapal intends to rein in the 500-pound gorilla in the profiteer room: Big Pharma. While HR 676 empowered the new national health plan to negotiate with drug manufacturers, it contained no backup plan if Pharma refuses to negotiate and holds the country hostage. Rep. Jayapal, taking a page from a bill introduced by Rep. Lloyd Doggett (D-Texas) last year, is in favor of putting real teeth behind that negotiating authority by empowering the federal government to strip drug makers of their patent rights--making them compete with generic producers--if they fail to negotiate reasonable prices in good faith.

Maintaining Our Commitment to Native American and Veterans' Healthcare

Another provision of the previous House bill has been cause for concern: HR 676 was written to phase out the Indian Health Services (IHS) after five years, and to begin a discussion of phasing out the Veterans Administration (VA) after ten years. The thinking was that these populations would be fully covered under the new national health plan, and would have their choice of providers - whether at IHS facilities, VA hospitals, or elsewhere. The language was not written in consultation with the potentially impacted communities, though, and these two healthcare systems are vital for fulfilling our country's historic debt to these two communities. Converting IHS and VA facilities into general providers for anyone in the population could significantly diminish their ability to offer targeted, effective service for Native Americans and veterans. The new Medicare for All Act will keep the IHS and VA systems fully funded and intact, even while their target populations will gain access to broader range of providers and services.

Collaborative Drafting Process

In part because of rumors circulating about the bill and the extended drafting period, there has also been a call for Rep. Jayapal to immediately release the full text of the bill draft to advocates, and to conduct an open revision process. We are not aware of any major piece of legislation--including previous iterations of the bill--that has been drafted in public. There are obvious reasons not to do so: the bill has to undergo legal review before committing to any provisions; you may want to give potential cosponsors the chance to weigh in before they read about it in the press; and you may not want to give your opponents and industry lobbyists the chance to dig in before the full bill is even released.

"We are entering into the fight of our lives... We will need all hands on deck to fight this two-front war."

In truth, Rep. Jayapal has included a number of major single-payer advocacy organizations in the redrafting process and, after reaching a rough draft phase, brought in an even larger range of national grassroots organizations and trade unions. While it is certainly frustrating that it has taken longer than expected to prepare the final draft of a bill that we are all eagerly awaiting, we have to say that Jayapal's office has been extraordinarily open to sharing their views and taking advice from the healthcare justice community.

We are entering into the fight of our lives. Support for Medicare for All has never been stronger and Congress, for the first time in modern history, has been compelled to hold hearings on what an effective Medicare for All bill should look like. As our momentum grows, we will be facing the concentrated power of the Medical Industrial Complex whose tentacles reach into almost one fifth of the U.S. economy. In addition, we will be confronted with a Democratic establishment intent on diluting and undermining our vision in ways that will be very confusing to the American people and will peel off substantial institutional support from labor and other social movement organizations. We will need all hands on deck to fight this two-front war.

As we move from an aspirational phase into dealing with the nuts and bolts of implementing a concrete piece of legislation, the greater the potential will be for tensions within our movement to grow and to be used strategically against us. We are looking forward to the next phase of scaling up our organizing, as well as paying particular attention to building unity within the movement as we do so.

Onwards to Medicare for All!