Progressive Democrats have rallied around “Medicarefor All,” a single-payer health plan popularized bySen. Bernie Sanders (I-Vt.). Now, some ofWashington's official bean counters are trying to add a newframework around what it might look like. The picture they offerhighlights just how complicated that shift might be.
|Areport released Wednesday by the nonpartisan CongressionalBudget Office outlined a veritable laundry list of options andtechnicalities lawmakers would need to consider if they are seriousabout such a proposal.
|“The conversation about single-payer is getting more in theweeds, more detailed, which is a good thing because it's such acomplicated issue,” said Jodi Liu, an associate policy researcherat the Rand Corp. who studies single-payer proposals.
|Related: CBO: Medicare for All a 'majorundertaking'
|The takeaway: There's a lot left to be answered about theconcepts of Medicare for All specifically and the more broadcategory of single-payer before policymakers and voters can comeclose to understanding what it would mean in practice. The term“single-payer” generally refers to a system in which health care ispaid for by a single public authority.
|“Even single-payer systems around the globe vary from each otherin many, many ways,” said John McDonough, a Harvard health policyprofessor who helped draft the Affordable Care Act. “There's justso many aspects of it that differ from a Canada to a Sweden to aTaiwan — and those are all intensely consequential.”
|The report comes as this once-lefty pipe dream becomesofficially mainstream.
|Medicare for All has been name-checked by Democrats running for president. On Tuesday,Democrats and Republicans alike put the proposal under themicroscope at a House Rules Committee hearing. And that won't be the last timethat happens. House Ways and Means Committee Chairman Richard Neal(D-Mass.) said he, too, intends to hold a hearing on the issue thissession. Meanwhile, Sanders' latest Medicare for All bill,reintroduced in the Senate in April, and a similar House bill, have 14 and 108 co-sponsors,respectively.
|Let's break down the most crucial issues raised by the CBOreport — what single-payer might cover, why “what it would cost”isn't easy to determine and what it could mean for how Americansget their health care.
|Medicare for All backers say the program wouldcover all medically necessary services. But what does that trulymean?
|What may seem obvious — the notion of medical necessity — isn'tso easy to distill into policy rules. And different single-payersystems around the world handle the benefits question differently,the CBO noted.
|For instance, Canada doesn't cover prescription drugs, but theUnited Kingdom and Sweden do. Of those three, only Sweden fullycovers long-term support services, according to the report.
|There are two questions at the heart of it, said RobertBerenson, a health policy analyst at the Urban Institute, aleft-leaning think tank.
|What benefits would be covered? Would it include dental care orprescription drugs or vision, as Sanders' bill would? And, how doesone determine the discrete services included within those benefitscategories?
|Single-payer architects could look at existing standards, suchas the so-called essential health benefits that govern Obamacarehealth plans, to determine what's covered. They could be moregenerous by including long-term care, which isn't currently coveredby Medicare or most private insurance plans.
|Even the two “Medicare for All” bills in Congress have slightlydifferent takes. Though both provide for long-term support andservices, they diverge on how to pay for it. Sanders' bill covers only at-home long-term care and keepsMedicaid intact for services provided in institutions. The House bill by Rep. Pramila Jayapal (D-Wash.) covers both.
|And there are questions about new medical treatments, and how todetermine whether they provide added value. The CBO reportsuggested some kind of “cost-effectiveness criterion” coulddetermine what the government is willing to cover. In practice,though, that standard could be difficult to develop and fall victimto political lobbying or trigger contentious debate.
|Separately from the CBO report, McDonough noted, controversialmedical services could bring up different kinds of politicalbaggage — whether this plan would cover abortion, for instance,likely would change the single-payer debate.
|Next: Single-payer health care would probably requirenew taxes. Just what level of taxes, though, and whom they'd hithardest remain open questions.
|Notably, the single-payer report avoids a question that criticsfrequently surface: How much would this cost? How would you pay forit?
|That's because there's no uniform cost estimate for single-payerand no easy formula to apply.
|For one thing, the price tag depends on what services arecovered — something like long-term care would make the idea muchmore expensive.
|There's also the question of cost sharing. In some single-payersystems, people must pay a copay, meet a deductible or pay apremium as part of the health plan. That would alleviate some needfor new taxes.
|“I don't think you can put numbers on it until someone defines abenefit package and defines cost sharing,” Berenson said.
|The current Medicare for All bills eschew cost sharing.Other health reform proposals would keep premiums intact to helpfoot some of the bill.
|The CBO report suggests that new taxes would likely play a rolein financing a new single-payer plan. But what kind of taxes — apayroll tax, an income tax or a sales tax, for instance — has notyet been stipulated. And each would have differentconsequences.
|The single-payer approach could bring down healthexpenses, or at least increase value. But how effectively it woulddo so — and its larger economic impact — would depend on otherdesign choices.
|Single-payer backers dismiss the “pay-for” questions because,the reasoning goes, this approach would save lots of money in otherways, ultimately making it a good deal.
|Yet again, though, the CBO said, whether that actually happensdepends on the system's design.
|By eliminating most private insurers, a single-payer systemwould likely slash hospitals' administrative overhead. Thegovernment could then pay a rate that better reflects reducedhospital costs, according to the CBO report.
|But, ultimately, the single-payer bottom line depends on whatthe system pays hospitals, doctors and drug companies for differentservices and products. That answer also would inform other economicassessments — ascertaining, for instance, how single-payer affectsa small town where the hospital is the main employer.
|Even without clear answers, outlining those questions moves theball, Liu said.
|“This area is moving really fast,” she said. “To me, it seemslike this is the beginning of a longer conversation.”
|Kaiser Health News isa nonprofit news service covering health issues. It is aneditorially independent program of the Kaiser Family Foundation,which is not affiliated with Kaiser Permanente.
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