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Expand ACA, Public Options, Buy-Ins, and Single-Payer: Options for What Comes Next on Health Care

Thanks to the new House majority, the threat of TrumpCare and repeal of the Affordable Care Act (ACA, also known as Obamacare) has largely passed. And while Trump can still sabotage—and is sabotaging—our health care system through the Executive Branch, legislative threats are behind us. But quality health care is still out of reach for too many Americans. So what comes next?

This document summarizes the different options Democrats have put forward to expand coverage.

The Options

Twenty million Americans gained coverage through the ACA, either through its expansion of Medicaid, through one of the marketplaces it established, or through other provisions like allowing young adults to stay on their parents’ insurance. But millions more remain uninsured, and coverage is too expensive for many who do have it. Reaching universal coverage and making it higher quality and more affordable continues to be the common goal of Democrats.

Proposals to get there have a few key differences. The options range from proposals that preserve much of the status quo system, minimizing disruption while trying to build on the successful aspects of the ACA; to proposals that give people the option of buying into an existing public health care plan while preserving private insurance for those who want to keep it; to proposals that eliminate private insurance and replace it with a true “single payer” system.

Stabilizing and Building on the ACA

House Democrats in the 115th Congress introduced legislation to stabilize and build on the ACA, helping more families get financial assistance to afford premiums, deductibles, and co-pays. Led by House Energy & Commerce Chairman Frank Pallone, they are expected to put forward similar legislation in the current Congress. This approach would incrementally increase the number of people with quality, affordable health care by making a few key changes to the Affordable Care Act:

  • It would eliminate the income cap on eligibility for tax credits to help afford monthly insurance premiums, making far more people eligible

  • It would expand eligibility for assistance with deductibles and co-pays

  • It would fix the “family glitch,” a key flaw of the ACA that limits the help certain people with unaffordable employer insurance can get to afford premiums

This approach would minimize disruption to our health care system, as it largely preserves the current framework but increases the financial assistance for many families to access it. It generally does not attempt to go beyond the ACA’s efforts to tackle the root causes of health care cost increases, or go beyond the ACA’s requirements to ensure a range of services are provided.

Public Options and Medicare/Medicaid Buy-In Proposals

Recognizing that many state marketplaces under the ACA don’t offer an adequate number of affordable options, several members of the House and Senate introduced legislation last Congress, and are expected to introduce again, proposals that would create a publicly-run insurance plan modeled after Medicare available through the marketplace. These plans:

  • Would generally use the same system of tax credits and cost-sharing subsidies to help make coverage more affordable

  • Would cover the same range of services as plans sold through the marketplace

  • Would increase competition in the marketplace, incentivizing private insurance companies to offer more affordable options with the same level of benefits or risk losing customers to the public option

Representatives Jan Schakowsky, Brian Higgins, and Cedric Richmond and Senators Whitehouse, Bennet, and Merkley all have bills that vary between them but generally function using this type of approach.

Other similar proposals would instead allow individuals who are not currently eligible for Medicare/Medicaid to choose to buy into those public programs. Senator Debbie Stabenow and Representative Brian Higgins have bills that make individuals aged 50 eligible for buying into Medicare, and both bills would cover the same range of benefits for those individuals as Medicare currently does.

All of these bills, except for the Stabenow bill, would allow Medicare to negotiate for lower prescription drug prices—an important policy change that would go a long way to control costs and help break the pharmaceutical industry’s power over consumers.

Senator Brian Schatz and Representative Ben Ray Lujan have a bill that would allow states to create a system for people to buy into Medicaid, offered through the marketplace. This proposal would use the same tax credit and cost-sharing subsidy system as the ACA, but, importantly, it would also cap premiums at 9.5% of family income for all families purchasing it. Under current law, help to afford monthly premiums isn't available for families earning more than 400% of the federal poverty level (FPL, about $100k for a family of four). The Schatz/Lujan bill would help all families, not just those under 400% FPL, afford their premiums.

To summarize, the approach of these proposals is to preserve existing facets of our current health care system—private insurers for individuals and employers, Medicare, Medicaid—but make people eligible for more affordable public options if they want them, without compromising the range of services they can get covered.

Single Payer

Finally, Representative Pramila Jayapal and Senator Bernie Sanders have bills that would move our health care system to a true “single payer” system. (Their bills are the only bills officially called “Medicare-for-All,” although because some of the buy-in and public option proposals either use Medicare or are modeled after it, they sometimes get referred to using the same moniker. A single payer system would look fairly different than Medicare does now.)

One reason health care costs are so high is because our health care system has so many “payers” (hundreds of primary and supplemental insurance companies, public programs like CHIP, Medicare, and Medicaid). These bills would eliminate all of those payers and instead provide care for everyone through a public system based loosely on Medicare. It also empowers that program to negotiate drug prices and uses competitive licensing to force drug manufacturers to either lower their prices or deal with competition from generic manufacturers.

These bills would guarantee everyone in America has access to primary care, hospital visits, prescriptions, dental and vision care, reproduction health services including abortion, maternity and newborn care, long-term services and supports, mental health and substance abuse treatment, diagnostic services, and more—with no premiums, deductibles, or co-pays. (You can read more about Rep. Jayapal’s bill here.)

What’s the Status of Each of These Proposals?

Most of these proposals were introduced as legislation in the 115th Congress and will likely be reintroduced soon. Rep. Jayapal introduced her Medicare For All Act, Sen. Stabenow introduced her Medicare at 50 bill, and Sen. Schatz introduced his Medicaid buy in bill all in February 2019.

It’s critical that Congress, particularly Democrats in control of the House, use this session of Congress to draft legislation, convene experts and hold hearings, and mark up bills in order to sort through policy debates. That way, should Democrats have unified control of government in 2021, they will have settled some of the big policy questions, built at least some consensus, and have legislation ready to quickly move through Congress in the next administration.

The 2020 presidential campaign will undoubtedly be another forum for debating these differing proposals. It’s worth noting that several of the announced 2020 candidates, generally, are cosponsors of more than one of these approaches:

Cosponsors of the Bernie Sanders Medicare For All bill:
Cory Booker
Kirsten Gillibrand
Kamala Harris
Elizabeth Warren

Cosponsors of the Debbie Stabenow Medicare at 50 bill:
Cory Booker
Sherrod Brown
Kirsten Gillibrand
Kamala Harris
Amy Klobuchar

Cosponsors of the Brian Schatz Medicaid Buy In bill:
Cory Booker
Sherrod Brown
Kirsten Gillibrand
Kamala Harris
Amy Klobuchar
Elizabeth Warren

Unsurprisingly, efforts to create public competition with private insurance companies, let alone overhaul the entire health care system, is already being met with fierce and coordinated opposition by the insurance and pharmaceutical industries. So far, they’re running the same plays out of their trusted playbook: scaring people into thinking the government (not their physicians) will make health care decisions for them, that disruption to our health care system will result in long lines and wait times, and that costs will go up.

The insurance and pharmaceutical industries are two of the most powerful lobbies in Washington. That’s why it’s critical that presidential candidates (and candidates for Congress too!) reject campaign contributions from corporate PACs representing these interests.

You can read more analysis about each of these proposals here and here.