2020 OPEN ENROLLMENT ENDS (most states)

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An Inconvenient Truth: Eight months later, Elizabeth Warren FINALLY admits it'll take at least TWO bills to achieve M4All

 

For several years now, I've been pleading with the powers that be in Congress to pass two major healthcare reform bills:

  • FIRST, a robust ACA 2.0 upgrade bill which would:
    • REPAIR the law from the Trump/GOP sabotage inflicted on it to date (weakening of 1332 guiderails, cut-off of CSR funding, slashing of the marketing/navigator budget, zeroing out of the mandate penalty; reinstatement of restrictions on short-term plans/etc.);
    • PROTECT it from any further damage (the Trump Administration's attempt to make the subsidy formula stingier; their attempts to require separate invoices for abortion; etc.);
    • FIX THE GLITCHES which were inherent in the bill as passed into law in 2010 (such as the Family Glitch, the Skinny Plan glitch, etc.); and
    • STRENGTHEN the law by expanding it (including removing the 400% FPL subsidy cliff; beefing up the subsidy formula; requiring wider network minimums; etc.)

This first bill would also hopefully include some sort of Public Option as well, although even without one the above improvements would still be a quantum leap ahead of the current istuation.

After these improvements were baked in, there'd then be followed by a SECOND BILL A FEW YEARS LATER, which would be the next Big Thing. This, of course, is where the Democratic healthcare debate has gotten very ugly over the past year or so: Should we go with mandatory, "pure" Medicare for All or would a robust Public Option be the stopping point...with the assumption being that if the PO was good enough, everyone would eventually choose it over a private policy anyway, thus making it a moot point?

I feel so strongly about this "two stage rocket booster" approach that I even included it in my "Where the Democratic Candidates Stand" summary table from a few months back. As you can see at the bottom, while the candidates keep pushing for one particular bill/plan or another, I've been urging them to pass ACA 2.0 first and then worry about the next phase later on, whether it's "pure" M4All or my preferred long-term plan, Medicare for America (which amounts to "Medicare for All with a PRIVATE Option").

Back in May, I noted that that Massachusetts Senator Elizabeth Warren, who was my unofficial top pick for the primary until last month, not only introduced an excellent ACA 2.0 bill last year (which was even co-sponsored by most of her fellow Senators running for President alongside her including Bernie Sanders), but even re-introduced the same bill with a formal press release and everything this year. The bill, S.1213, is officially titled the "Consumer Health Insurance Protection Act", or CHIPA, but I just call it ACA 2.0, since that's what it amounts to.

To the best of my knowledge, the only change to the bill is who's cosponsoring it...last year it included Bernie, Kamala Harris, Kirsten Gillibrand, Tammy Baldwin and Maggie Hassan. This year, Bernie and Hassan have dropped their support...but both Cory Booker and Amy Klobuchar have signed onto it, as has Richard Blumenthal of Connecticut.

Here's a cheat-sheet comparison of the House and Senate ACA 2.0 bills:

I was thrilled to hear this...especially when a similar ACA 2.0 bill (with an even worse official title), H.R. 1884, was not only introduced by House Democrats the same week but portions of which have actually already passed the House (they broke H.R.1884 into about a dozen smaller bills and pushed through 5 of them back in May, although the more dramatic portions are still pending).

Since then, however, I've grown increasingly disheartened as the Democratic Presidential field seems to have become bogged down into two main camps: Bernie Sanders & Elizabeth Warren insisting that full-blown, "pure" single payer is the next step, while Joe Biden, Pete Buttigieg, Amy Klobuchar and several others have insisted that a Public Option is the logical choice.

There's also a third camp sandwiched in between the two consisting of Kamala Harris, Beto O'Rourke and Julian Castro, who are pushing for either Medicare for America or something similar, which would guarantee universal coverage but also keep a role for major private medical insurance.

While the plans put forth by candidates in the Public Option camp do include a lot of ACA 2.0 elements, in terms of rhetoric, Biden & Buttigieg seem to still be focusing on the Public Option part...and (again, at least rhetorically) they seem to be suggesting that ACA 2.0 + PO would be the end of the line. Some might disagree with my interpretation of their stances, but that's the story I'm getting from them.

In other words, the overwhelming message from nearly the entire Democratic field for the past six months has been *either* a Public Option *or* M4All...while the ACA itself is under threat of complete destruction via a Republican-brought lawsuit even as I type this. Even those talking about "building on Obamacare" like Joe Biden seem to have kind of lost the forest for the trees here.

As for Warren, meanwhile, I've become more and more distraught to see her seeming to dive deeper and deeper into the "pure" M4All pool. She went from giving a fantastic 5-minute response to the question of how to achieve M4All back in March to a simple "I'm With Bernie on healthcare" in the first debate at the end of June, and seems to have dug herself in even deeper ever since.

Two weeks ago, Sen. Warren, under tremendous pressure from all sides to explain how she planned on funding her vision of "pure" Medicare for All" without raising taxes on the middle class, rolled out an impressively-detailed (if still extremely unlikely) plan to do just that. It includes some extremely questionable assumptions about how much healthcare providers would be willing to reduce their reimbursement rates, about whether a major immigration policy reform bill would be passed and so forth, but the numbers themselves did add up if all of those assumptions were to come true.

She also, at the time, promised that she'd be coming out with a different transition plan from Bernie's. This, to me, was actually the more interesting question. Bernie's plan does include a 4-year transition period plan, but it's a fairly simplistic one--essentially, a big age-based slice of the entire population would be transferred over each year, culminating in nearly 100% of the U.S. population being moved by year four. Done and done.

I've been very curious to see how Warren's vision would differ from Bernie's. I even made the following predictions:

As I said I’m actually more interested in her impending transition plan proposal. I’m willing to bet it includes expanding the transition period to 6-8 years (a la Harris/Beto) and adding her own ACA 2.0 bill during that period.

— Charles #GetCovered-ba (@charles_gaba) November 1, 2019

Ten bucks says she incorporates her excellent #ACA2.0 bill (#CHIPA, #S1213) into her plan for a few years before the existing 4-year transition included in Bernie’s bill begins. https://t.co/OZ9JgwBora

— Charles #GetCovered-ba (@charles_gaba) November 1, 2019

Well, today she did indeed roll out her own Transition Plan. Let's take a look!

The Affordable Care Act made massive strides in expanding access to health insurance coverage, and we must defend Medicaid and the Affordable Care Act against Republican attempts to rip health coverage away from people. But it’s time for the next step.

OK, good...she starts off giving praise to the ACA and acknowledging that it's still in imminent danger.

Every serious proposal for Medicare for All contemplates a significant transition period. Today, I’m announcing my plan to expand public health care coverage, reduce costs, and improve the quality of care for every family in America. My plan will be completed in my first term. It includes dramatic actions to lower drug prices, a Medicare for All option available to everyone that is more generous than any plan proposed by any other presidential candidate, critical health system reforms to save money and save lives, and a full transition to Medicare for All.

These references to "completed" and "full transition" in her first term (four years) is important, as I'll explain later on.

The First 100 Days of a Warren Administration

Donald Trump has spent nearly every day of his administration trying to rip health coverage away from tens of millions of Americans – first by legislation, then by regulation, and now by lawsuit. When I take office, I will immediately work to reverse the damage he has done.

Good. Again, she's acknowledging the insane TexasFoldEm lawsuit which threatens to strike down the entire ACA en masse. Sadly, there's not much she (or anyone else) can do about that at the federal level until at least 2021 anyway; it's in the hands of the 5th Circuit Court of Appeals and then the Supreme Court, which likely won't hear it until next spring and won't rule on it until next fall...if not until after the election itself...

But I’ll do much more than that.

In my first 100 days, I will pick up every tool Donald Trump has used to undermine Americans’ health care and do the opposite. While Republicans tried to use fast-track budget reconciliation legislation to rip away health insurance from millions of people with just 50 votes in the Senate, I’ll use that tool in reverse – to improve our existing public insurance programs, including by giving everyone 50 and older the option to join the current Medicare program, and to create a true Medicare for All option that’s free for millions and available to everyone.

Take another look at my table above, and you'll see the first references to two other existing bills:

Anti-Corruption Reforms to Rein in Health Industry Influence...

  • Close the revolving door. My plan will close the revolving door between health care lobbyists and government, and end the practice of large pharmaceutical companies like Novartis, United Health, Roche, Pfizer, and Merck vacuuming up senior government officials to try and monopolize government expertise, relationships, and influence during a fight for health care reform.

  • Tax excessive lobbying. My plan will also implement an excessive lobbying tax on companies that spend more than $500,000 per year peddling influence – like Pfizer, Amgen, Eli Lilly, Novartis, and Johnson & Johnson. Money from the tax would be used to strengthen congressional support agencies, establish an office to help the public participate in the rule-making process, and give our government additional resources to fight back against an avalanche of corporate lobbying spending.

  • End lobbyist bribery. My campaign finance plan will ban all lobbyists – including health insurance and pharma lobbyists – from trying to buy off politicians by donating or fundraising for their campaigns. This will shut down the flow of millions of dollars in contributions.

  • Limit corporate spending to influence elections. My plan bans all election-related spending from big corporations with a significant portion of ownership from foreign entities. That would block major industry players like UnitedHealth, Anthem, Humana, CVS Health, Pfizer, Amgen, AbbVie, Eli Lilly, Gilead, and Novartis – along with any trade associations that receive money from them – from spending to influence elections.

  • Crowd out corporate contributions with small dollar donations. I support a constitutional amendment to get big money out of politics. But until we enact it, my plan would institute a public financing program that matches every dollar from small donations with six more dollars so that congressional candidates are answering to the people who need health care and affordable prescription drugs, rather than health insurance and pharmaceutical companies.

Passing these reforms will not be easy. But we should enact as much of this agenda as possible, as quickly as possible. I will also use my executive authority to begin implementing them wherever possible – including through prioritizing DOJ and FEC enforcement against the corrupt influence-peddling game. And I will voluntarily hold my administration to the standards that I set in my anti-corruption plan so that all our federal agencies, including those involved in health care, serve only the interests of the people.

Warren rightly notes that most of this would require separate legislation to pass the House and Senate.

Immediate Executive Actions to Reduce Costs and Expand Public Health Coverage.

There are a number of immediate steps a president can take entirely by herself to lower drug prices, reduce costs, and improve Medicare, Medicaid, and ACA access and affordability. I intend to take these steps within my first 100 days.

It's good that she's making a clear distinction between what she'd be able to do on her own vs. what would require actual legislation.

Dramatically Lower Key Drug Prices

As drug companies benefit from taxpayer-funded R&D and rake in billions of dollars in profits, Americans are stuck footing the bill. The average American spends roughly $1,220 per year on pharmaceuticals – more than any comparable country. As president, I will act immediately to lower the cost of prescription drugs, using every available tool to bring pressure on the big drug companies. I’ll start by taking immediate advantage of existing legal authorities to lower the cost of several specific drugs that tens of millions of Americans rely on.

...The government has two existing tools to combat price-gouging by brand-name drug companies, in addition to tough antitrust enforcement against companies that abuse our patent system and use every trick in the book to avoid competition. First, the government can bypass patents (while providing “reasonable and entire compensation” to patent holders) using “compulsory licensing authority.” The Defense Department has used this authority as recently as 2014. Second, under the march-in provisions of the Bayh-Dole Act, the government can require re-licensing of certain patents developed with government involvement when the contractor was not alleviating health or safety needs. Just in this decade, federal research investments have contributed to the development of hundreds of drugs – all of which could be subject to this authority.

This seems to be very much in Elizabeth Warren's wheelhouse...remember, she was the creator of the Consumer Financial Protection Bureau, after all.

...On the first day of my presidency, I will use these tools to drastically lower drug costs for essential medications – drugs with high costs or limited supply that address critical public health needs. And during my administration, we will use these tools to make other drugs affordable as well.

She notes that Insulin, EpiPens, Naloxone etc., which are widely needed and absurdly overpriced, could be reduced dramatically via her executive authority. I have no idea whether this is correct or not, but I'll assume it is for the moment.

Make Mental Health and Substance Use Treatment A Reality

The law currently requires health insurers to provide mental health and substance use disorder benefits in parity with physical health benefits. But in 2018, less than half of people with mental illness received treatment and less than a fifth of people who needed substance use treatment actually received it. As president, I will launch a full-scale effort to enforce these requirements – with coordinated actions by the IRS, Centers for Medicare and Medicaid Services, and Department of Labor to make sure health plans actually provide mental health treatment in the same way they provide other treatment.

This is an important reminder that a lot of change can indeed be made simply by fully enforcing existing laws and regulations.

OK, now we get into the actual "ACA 2.0" stuff:

Reverse Trump’s Sabotage

I will reverse the Trump administration’s actions that have undermined health care in America. Key steps include:

  • Protecting coverage for people with pre-existing conditions. The Trump administration has abandoned its duty to defend current laws in court, cheering on efforts to destroy protections for pre-existing conditions, insurance coverage for dependents until they’re 26, and the other critical Affordable Care Act benefits. In a Warren administration, the Department of Justice will defend this law. And we will close the loopholes created by the Trump administration, using 1332 waivers, that could allow states to steer healthy people toward parallel, unregulated markets for junk health plans. This will shut down a stealth attack on people with pre-existing conditions who would see their premiums substantially increase as healthier people leave the marketplace.

This refers to last year's "Section 1332 Guidance" from Trump CMS Administrator Seema Verma, which basically would allow individual states to turn what's supposed to be a tool to come up with innovative ways to improve ACA coverage into a tool to strip away protections for those with pre-existing conditions. The part of the House ACA 2.0 bill which tackled this, H.R. 986, was actually passed back in May, and it's part of Warren's own CHIPA bill, but of course it's gone nowhere in the Senate and would be vetoed by Trump even if it did pass.

Since Verma's 1332 mutation is being done via executive order by Trump, it can be easily reversed via executive order by Warren (or any Democratic President).

  • Banning junk health plans. The Trump administration has expanded the use of junk health insurance plans as an alternative to comprehensive health plans that meet the standards of the ACA. These plans cover few benefits, discriminate against people with pre-existing conditions, and increase costs for everyone else. And in some cases they direct as much as 50 percent of patient premiums to administrative expenses or profit. I will ban junk plans.

Again, this part of the House ACA 2.0 bill (H.R.1010) was passed by the House in May, and is included in Warren's CHIPA bill, but is going nowhere in the Senate...and again, #ShortAssPlans (officially "short-term, limited duration" plans) were originally heavily restricted by President Obama via executive order...and then had the floodgates opened on them by Donald Trump. Again, this can be reversed via a Warren XO. She's actually proposing to go further than Obama, who merely restricted them to 90 day periods, by banning them outright as some states like California and New Jersey have done.

Short-term plans actually can serve some useful purpose for some people today...but they'd be unnecessary if ACA 2.0 passed anyway, as you'll see below.

  • Expanding ACA enrollment. I’ll re-fund the Affordable Care Act programs that help people enroll in ACA coverage, programs that have been gutted by the Trump administration.

Once again: Donald Trump slashed HealthCare.Gov's marketing, outreach and navigator budgets by around 90% over the past few years, hurting enrollment and causing a lot of confusion. This was done via regulatory power. H.R.'s 987 and 1386 (which would codify proper funding levels for both as well as requiring that the money be used for its intended purpose) both passed the House earlier this year, and again, are included in the Senate ACA 2.0 bills (one of them is part of a separate bill instead for some reason, S.1905).

And once again: What is slashed by the executive order pen can be restored by the executive order pen.

  • Expanding premium tax credits. I will reverse the Trump administration rule that artificially reduced premium tax credits for many people, making coverage less affordable – and instead will expand these credits.

In the final Notice for Benefit & Payment Parameters rule from CMS, they proposed tweaking the ACA's subsidy formula to make it slightly less generous to those who qualify for financial assistance, as well as bumping up the maximum out of pocket limit as well. It wouldn't have a huge impact...a couple hundred bucks at most for most people...but that can make a big difference for low-income folks.

It's fairly new so it didn't make it into either the House or Senate ACA 2.0 bills, but again, it's something which could be reversed via executive order/HHS regulation.

  • Rolling back Trump’s sabotage of Medicaid. I’ll reverse the Trump administration’s harmful Medicaid policies that take coverage away from low-income individuals and families. I’ll prohibit restrictive and ineffective policies like work requirements – which have already booted 18,000 people in Arkansas out of the program – as well as enrollment caps, premiums, drug testing, and limits on retroactive eligibility that can prevent bankruptcy.

Again, this is mostly just reversing Trump Administration executive orders and/or HHS/CMS regulation back to the Obama Administration policies. Of course, work requirements specifically seem to be nearly at death's door anyway after being repeatedly shot down by federal judges, but it'd be nice not to have to worry about them at all.

  • Restoring non-discrimination protections in health care. I will immediately reverse the Trump administration’s terrible proposed rule permitting health plans and health providers to discriminate against women, LGBTQ+ people, individuals with limited English proficiency, and others.

  • Ending the Trump administration’s assault on reproductive care. I’ll roll back the Trump administration’s domestic and global gag rules, which deny Title X and USAID funding to health care providers who provide abortion care or even explain where and how patients can access safe, legal abortions. And I will overturn the Trump administration’s embattled proposed rule to roll back mandatory contraceptive coverage.

I don't think either of these are specifically addressed by either the House or Senate ACA 2.0 bills, but they might be. Again, live by the XO, die by the next XO.

OK, that's the low-hanging fruit. Next?

Strengthen the Affordable Care Act

As president I will use administrative tools to strengthen the ACA to reduce costs for families and expand eligibility. Key steps include:

  • Stop families from being kicked out of affordable coverage. Because of something called the “family glitch,” an entire family can lose access to tax credits that would help them buy health coverage if one parent is offered individual coverage with a premium less than 9.86% of their family income. I’ll work to make sure that a family’s access to tax credits is based on the affordability of coverage for the whole family – not just one individual – so families who don’t actually have access to affordable alternatives don’t lose their ACA tax credits.

Unlike a lot of other problems with the ACA, the Family Glitch was not caused by sabotage to the ACA by the GOP and/or Donald Trump; it's due to a drafting error in the original ACA itself. Basically, ACA subsidies aren't supposed to go to people who have affordable, qualifying coverage via their employer...but the wording of the ACA also means that their family also doesn't qualify either, even if the employer coverage isn't available to them.

In a way the GOP is "responsible" for this since then-Senator Al Franken offered a bill to fix the problem way back in 2014 which Mitch McConnell has refused to pick up, of course. It's currently in the form of S.1935 with Sen. Sherrod Brown as the lead sponsor.

Anyway, I'm not sure whether "work to make sure" means she'll try to get the bill passed through Congress or that she thinks she can unilaterally do it herself?

  • Expand eligibility to all legally present individuals. I’ll also work to extend eligibility for ACA tax credits to all people who are legally present, including those eligible for the Deferred Action for Childhood Arrivals program.

I believe this refers to the horrific "public charge" policy which was recently blocked by federal judges anyway, which would make it extremely difficult for legally-present immigrants to access public services.

  • Put money back in workers’ pockets. The Affordable Care Act requires insurance companies to spend at least 80 percent of total premium contributions on health care claims (and, in many cases, at least 85 percent), leaving the rest to be spent on plan administration, marketing, and profit. Insurers who waste money must issue rebates – but too often, these are returned to employers who don’t pass on the savings to their employees. Insurance companies are expected to pay out $1.3 billion in rebates in 2019, with employers in the small-group market receiving an average rebate of $1,190 and employers in the large-group market receiving an average rebate of $10,660. My plan will require employers to pass along the full value of the rebate directly to employees.

This refers to the ACA's Medical Loss Ratio rule, but I admit I'm a bit confused by what she's talking about here re. employers not passing along the rebate...it's my understanding that employers already have to provide the employees with their share of the MLR rebates. If an employee policy costs, say, $1,000/month, with the employer covering $700 and the employee paying $300 of that, and the MLR rebate is $100 total, then it makes sense that $70 would go to the employer and $30 to the employee.

Warren makes it sound like all $100 would go to the employee, which makes zero sense to me.

In fact, as I've written about before, the only serious flaw in the MLR program right now is the exact opposite...individual market enrollees are receiving 100% of the MLR rebates even though many of them are heavily subsidized, which means some of them are actually profiting from the MLR provision! Recouping the government's portion of those rebates could free up several hundred million dollars per year to be utilized for increased subsidies or whatever.

UPDATE: Hmmm...Loren Adler points out that the employer's portion of the premiums is technically "forgone wages" for the employee, so the employee is entitled to 100% of the rebate after all. I'll have to think about this one, to be honest...I've been self-employed for over 20 years so it's been a very long time since I've had employer coverage at all...

I could be misunderstanding her meaning on this one, however.

Strengthen Medicare

As president I will use administrative tools to strengthen Medicare:

  • Expand Dental Benefits. The Medicare statute prohibits coverage of dental care that is unrelated to other medical care, unless it is medically necessary. This has been interpreted to largely exclude any oral health care. As a result, almost two-thirds of Medicare beneficiaries, or nearly 37 million people, lack access to dental benefits. I will use my administrative authority to clearly expand the medically necessary dental services Medicare can provide, improving the health of millions of Medicare beneficiaries.

  • Stop private Medicare Advantage plans from bilking taxpayers. Roughly one-third of Medicare beneficiaries get coverage through a private Medicare Advantage plan. Medicare payments to these plans for each enrollee are supposed to reflect the cost of covering that person through traditional Medicare, but overwhelming evidence shows that these private plans make their enrollees appear sicker on paper than they actually are to earn inflated payments at the expense of taxpayers. Some suggest that this adds $100 billion or more to Medicare spending over ten years. My administration will put an end to this fraud.

Again, this gets into an area of executive authority which I don't know enough about to comment on. If she has that power, awesome. If not...well, she'll try, I guess.

Strengthen Medicaid

As president I will use administrative tools to strengthen Medicaid and potentially allow millions more to access the program.

  • Use waiver authority to increase Medicaid eligibility. With the approval of the federal government, states can use Section 1115 demonstration waivers to expand coverage to people who aren’t otherwise eligible for Medicaid. Currently, however, states can only obtain these waivers if projected federal spending under the new program will not be higher than without the waiver. While I pursue legislative reforms to expand coverage, I’ll also change this administrative restriction to allow these demonstrations to fulfill their promise of providing affordable health coverage, including working with states that want to expand Medicaid to uninsured individuals and families above the statutory upper limit of Medicaid (138% of the poverty level). Any state that chooses to expand in this way will not be penalized for doing so when full Medicare for All comes online.

This is essentially the exact opposite of what Trump is doing with his administative power, of course...instead of interpreting the rules to make Medicaid more restrictive, she'd do so in a way to make it more expansive. Again, I've no idea how far she can push this without legal challenges.

  • Streamlining eligibility and enrollment. Far too many people miss out on Medicaid coverage because of red tape. Some states take coverage away if someone misses just one piece of mail or forgets to notify the state within 10 days of a change in income. These kinds of harsh policies help explain why more than a million children “disappeared” from the Medicaid and CHIP programs in the past year. I will eliminate these kinds of unfair practices, and instead work with states to make it easier for everyone – families, children, and people with disabilities – to maintain this essential coverage.

This is absolutely within the purview of the executive branch, although I always thought these sorts of red tape hoops were handled (and thus have to be fixed) at the state level,not federal. I could be wrong, however.

  • Ensuring access to care for beneficiaries in managed care plans. I’ll roll back the Trump administration’s proposed changes to rules regulating Medicaid managed care plans, which would dilute important standards, such as requiring health plans to maintain adequate provider networks guaranteeing access to care for Medicaid enrollees.

Again, all good stuff.

Antitrust Enforcement for Hospitals and Health Systems

For years, both horizontal mergers (where hospitals purchase other hospitals) and vertical mergers (where hospitals acquire physician practices) have produced greater hospital and health system consolidation, contributing to the skyrocketing costs of health care. Today, “not a single highly competitive hospital market remains in any region of the United States.” Study after study shows that mergers mean higher prices, lower quality, and increased inequality due to the growing wage gap between hospital CEOs and everyone else. Bringing down the cost of health care means enforcing competition in these markets.

As president, I will appoint aggressive antitrust enforcers who recognize the problems with hospital and health system consolidation to the Department of Justice and Federal Trade Commission. My administration will also conduct retrospective reviews of significant new mergers, and break up mergers that should never have taken place.

This, again, seems to be well within Warren's comfort zone.

Bringing Health Records into the 21st Century

Congress spent $36 billion to get every doctor in America using electronic health records, but we still do not have adequate digital information flow in health care – in part because two big companies make up about 85% of the market for medical records at big hospitals. As they attempt to capture more of the market, these companies are making it harder for systems to communicate with each other. My administration will ramp up the enforcement against information blocking by big hospital systems and health IT companies, and I will appoint leaders to the FTC and DOJ who will conduct a rigorous antitrust investigation of the health records market, especially in the hospital space.

The ACA was supposed to result in doctors & hospitals updating to electronic medical records, but it's my understanding that it hasn't gone very well. Sounds like she'd focus on cracking down on this.

Elevating the Voices of Workers in the Transition to Medicare for All

...In my first weeks in office, I will issue an Executive Order creating a commission of workers (including health care workers), union representatives, and union benefit managers that I will consult at every stage of the transition process. The commission will be responsible for providing advice on each element of the transition to Medicare for All, including, at a minimum:

  • Ensuring workforce readiness and adequate access to care across all provider types.

  • Determining national standards of coverage and benefits, including long-term care.

  • Learning from successful existing non-profit health care administrators and integrating them into the new Medicare for All system.

  • Ensuring a living wage for all health care workers and that savings generated within the new system by hospitals and other health care employers are shared fairly with all of the workers in the health care system.

  • Ensuring that workers are able to use the collective bargaining process during the transition period and under the new Medicare for All system to ensure both effective health outcomes and to ensure that savings generated by the new system are fairly shared with workers.

This goes into the whole "unions having to give up hard-fought gold-plated healthcare plans" issue, among others. I don't know much about that area, so I'm gonna take a pass on this one, but at least she's thought it through, anyway.

So far, she's basically covered about half of the ACA 2.0 provisions (the "lower hanging fruit), plus some other stuff which isn't included in those bills...and some of these are indeed pretty important.

NEXT comes the big stuff:

Legislation to Expand Medicare and Create a True Medicare for All Option

In 2017, Senate Republicans came within one vote of shredding the Affordable Care Act and taking health care coverage away from more than 20 million people. How did they get so close? By using a fast-track legislative process called budget reconciliation, which only requires 50 votes in the Senate to pass laws with major budgetary impacts. President Obama also used this process to secure final passage of the Affordable Care Act.

I am a strong supporter of eliminating the filibuster, which I believe is essential to preventing right-wing Senators who function as wholly owned subsidiaries of major American industries from blocking real legislative change in America. Any candidate for president who does not support this change should acknowledge the extreme difficulty of enacting their preferred legislative agenda. But I’m not going to wait for this to happen to start improving health care – and I'm not going to give Mitch McConnell or the Republicans a veto over my entire health care agenda.

That’s why, within my first 100 days, I will pass my own fast-track budget reconciliation legislation to enact a substantial portion of my Medicare for All agenda – including establishing a true Medicare for All option that’s free for millions and affordable for everyone.

Careful there, Senator Warren...even with a simple majority in the Senate, you can't assume 51 Democrats will be on board with your "fast-track" legislation...might want to run it by Joe Manchin and Kyrsten Sinema first.

Having said that, her "True Medicare for All Option" sounds an awful lot like the proposal in "Medicare for America"...my preferred long-term bill:

  • Benefits. Unlike public option plans, the benefits of the true Medicare for All option will match those in the Medicare for All Act. This includes truly comprehensive coverage for primary and preventive services, pediatric care, emergency services and transportation, vision, dental, audio, long-term care, mental health and substance use, and physical therapy.

Fully comprehensive. This is pretty much in line with the Med4America proposal (it was the first bill to include Long-Term Services & Supports (LTSS), as well as the House & Senate M4All bills. Fair enough.

  • Immediate Free Coverage for Millions. This plan will immediately offer coverage at no cost to every kid under the age of 18 and anybody making at or below 200% of the federal poverty level (about $51,000 for a family of four) – including individuals who would currently be on Medicaid, but live in states that refused to expand their programs.

That "100% free for everyone under 200% FPL" is identical to the Medicare for America bill, although under Med4America they wouldn't be auto-enrolled until Year 3. Making it $0 cost for kids under 18 (regardless of family income) is also a new addition in Warren's plan.

  • Free, Identical Coverage for Medicaid Beneficiaries. States will be encouraged to begin paying a maintenance-of-effort to the Medicare for All option in exchange for moving their Medicaid populations into this plan and getting out of the business of administering health insurance. For states that elect to maintain their Medicaid programs, Medicaid premiums and cost sharing will be eliminated, and we will provide wraparound benefits for any Medicare for All option benefits not covered by a state’s program to ensure that these individuals have the same free coverage as Medicaid-eligible people in the Medicare for All option.

Interesting...the states wouldn't be forced to move their Medicaid enrollees over, but they'd be strongly encouraged to do so, and if they did, they'd have to keep paying their existing levels of funding into the federal system. I honestly can't remember whether that's the same as Med4America or not.

  • Eventual Free Coverage for Everyone. This plan will begin as high-quality public insurance that covers 90% of costs and allows people to utilize improved ACA subsidies to purchase coverage and reduce cost sharing. There will be no premiums for kids under 18 and people at or below 200% of the federal poverty level. For individuals above 200% FPL, premiums will gradually scale as a percentage of income and are capped at 5.0% of their income. Starting in year one, the plan will not have a deductible -- meaning everyone gets first dollar coverage, and cost sharing will be zero for people at or below 200% FPL. Cost sharing will scale modestly for individuals at or above that level, with caps on out-of-pocket costs. In subsequent years, premiums and cost sharing for all participants in this plan will gradually decrease to zero.

The "gradually decrease to zero" part aside, everything else in this bullet is directly taken from Medicare for America: Zero cost under 200% FPL, zero deductibles for anyone regardless of income, sliding scale premiums over that, and sliding scale maximum out of pocket cost sharing with a cap, although it sounds like it'd be even more generous than Med4America.

Here's the formula for Med4America, for what it's worth:

Warren doesn't specify at what income threshold the 5% maximum premiums would hit or how much the cost sharing cap would be at the upper end, but I assume it would be a more generous version of the above table.

  • Reducing Drug Prices. The Medicare for All option will have the ability to negotiate for prescription drugs using the mechanisms I’ve previously outlined, helping to drive down costs for patients.

  • Automatic Enrollment. Anyone who is uninsured or eligible for free insurance on day one, excluding individuals who are over 50 and eligible for expanded coverage under existing Medicare, will be automatically enrolled in the Medicare for All option. Individuals who prefer other coverage can decline enrollment.

  • Employee Choice. Workers with employer coverage can opt into the Medicare for All option, at which point their employer will pay an appropriate fee to the government to maintain their responsibility for providing employee coverage. In addition, unions can negotiate to include a move to the Medicare for All option via collective bargaining during the transition period, with unionized employers paying a discounted contribution to the extent that they pass the savings on to workers in the form of increased wages, pensions, or other collectively-bargained benefits. This will support unions and ensure that the savings from Medicare for All are passed on to workers in full, not pocketed by the employer.

THIS, again, is very similar to how Medicare for America would work (with some tweaks): A temporary public option with very reasonable premiums/cost sharing, with employers being given the option of choosing between employer coverage or the public enhanced Medicare plan, and employers having to pay in one way or the other (either the way they do now or the equivalent amount to the government).

  • Provider Reimbursement and Cost Control. I have identified cost reforms that would save our health system trillions of dollars when implemented in a full Medicare for All system. The more limited leverage of a Medicare for All option plan will accordingly limit its ability to achieve these savings – but as more individuals join, this leverage will increase and costs will go down. Provider reimbursement for this plan will start above current Medicare rates for all providers, and be reduced every year as providers’ administrative and delivery costs decrease until they begin to approach the targets in my Medicare for All plan. The size of these adjustments will be governed by overall plan size and the progress of provider adjustment to new, lower rates.

This is very interesting. Other plans I've read about (including both Medicare for All and Medicare for America) may wrestle with how much higher than Medicare rates to set the reimbursements at, but they all seem to think it should be locked in at that rate for the long term. This is the first time I've read a plan which admits up front that the rates will adjust as time goes on. I presume the idea is that it would be something like 150% of Medicare the first year, 140% the third year and so on as economies of scale/increased efficiency ramps up.

Expand and Improve Existing Medicare for Everyone Over 50. In addition to the Medicare for All option, any person over the age of 50 will be eligible for expanded coverage under the existing Medicare program, whose infrastructure will allow it to absorb new beneficiaries more quickly. The expanded Medicare program will be improved in the following ways:

  • Benefits. To the greatest extent possible, critical benefits like audio, vision, full dental coverage, and long-term care benefits will be added to Medicare, and we will legislate full parity for mental health and substance use services.

  • Eventual Free Coverage for Everyone. Identical to the Medicare program, enrollees will pay premiums in Part B and D, with a $300 cap on drug costs in Part D. Plugging a huge hole in the current Medicare program, out-of-pocket costs will be capped at $1,500 per year across Parts A, B, and D, eliminating deductibles and reducing cost sharing. In subsequent years, premiums and cost sharing will gradually decrease to zero.

  • Employee Choice. Identical to the Medicare for All option, workers 50-64 can opt into expanded Medicare, at which point their employer will pay an appropriate fee to the government to maintain their responsibility for providing employee coverage.

  • Reducing Drug Prices. The expanded Medicare program will receive the ability to negotiate for prescription drugs using the mechanisms I’ve previously outlined, helping to drive down costs for patients. And we will create a publicly run prescription drug plan that is benchmarked off the best current Part D plan.

  • Automatic Enrollment. Every person without health insurance over the age of 50 will be automatically enrolled in the expanded existing Medicare program.

  • Provider Reimbursement and Cost Control. Provider reimbursement for new beneficiaries will start above current Medicare rates for all providers, and be reduced every year as providers’ administrative and delivery costs decrease until they begin to approach the targets in my Medicare for All plan. It will be a new condition of participation that providers who take Medicare or other federally subsidized insurance also take the Medicare for All option. We will also adopt common sense reforms to bring down bloated reimbursement rates, including reforms around post-acute care, bundled payments, and site neutral payments.

Hmmmmmm...this is also interesting. She's basically proposing moving those 50+ into an enhanced version of the current Medicare architecture (Part A, B & D) while giving everyone under 50 the option of enrolling in a second enhanced Medicare program. I'm honestly not sure what the rationale is for this...perhaps to ease transition concerns among those within a few years of turning 65? Perhaps for risk pool reasons? Huh.

In any event, this basically amounts to an enhanced version of Senator Stabenow's "Medicare at 50" bill in practice.

NOW we get to the MEAT of CHIPA/ACA 2.0:

Improving the Affordable Care Act. My reforms will also strengthen Affordable Care Act plans – including the new Medicare for All option – by making the following changes:

  • Expand Tax Credit Eligibility. We will lift the upper limit on eligibility for Premium Tax Credits, allowing people over 400% of the federal poverty level to purchase subsidized coverage and greatly increasing the number of people who receive subsidies.

BOOM. That's H.R.1868, which I've been pushing hard for months now. It's also part of Warren's existing CHIPA bill. It's also part of Joe Biden's plan. It's also part of Pete Buttigieg's plan. It's also part of Amy Knobuchar's plan.

  • Employee Choice. We will allow any person or family to receive ACA tax credits and opt into ACA coverage, regardless of whether they have an offer of employer coverage. If an individual currently enrolled in qualifying employer coverage moves into an ACA plan, their employer will pay an appropriate fee to the government to maintain their responsibility for providing employee coverage.

This, again, is basically from Medicare for America, although to be honest it's also a little bit like the Trump administration's newly-announced HRA rule...except that Trump is pushing for those subsidies to be used for junk plans as well as ACA-compliant plans, which is kind of a turd in the punch bowl.

  • Lower Costs. Right now, people may pay up to 9.86% of their income before they get subsidies. Under my plan, this cap would be lowered – and to make sure those tax credits cover more, we will benchmark them to more generous “gold” plans in the Marketplace. And we will increase eligibility for cost sharing reductions, ensuring that more individuals can get into an affordable exchange plan immediately.

BOOM. The first part of this is also from H.R.1868 (and is also from Biden, Buttigieg & Klobuchar's plans). The second part (upgrading to Gold) is also from Warren's own CHIPA plan, as well as Biden, Buttigieg & Klobuchar's.

  • Eliminate the Penalty for Getting a Raise. Right now, if someone’s income goes up, they can be forced to repay thousands of dollars in back premiums. We will change this and base tax credits on the previous year’s income. And if someone’s income goes down, they will get the higher subsidy for that year.

Hmmmm...that's a new one. Could cause some tax headaches, I'd imagine, but perhaps not.

  • State Single-Payer Innovation Waivers. To help states try out different payer arrangements and pilot programs, we will allow states to receive passthrough funding to expand or improve coverage via the ACA’s Section 1332 waivers. Combined with Medicaid waivers, these changes will allow interested states to start experimenting immediately with consolidating public payers and move towards a single-payer system.

A standalone bill to allow just this was just introduced by Rep. Ro Khanna the other day, actually. I thought this was already allowed under existing 1332 waivers, but apparently this would smooth away a lot of the red tape.

Additional Financing. My plan to pay for Medicare for All identifies $20.5 trillion in new revenue, including an Employer Medicare Contribution, which will cover the long-term, steady-state cost of a fully functioning Medicare for All system. The cost of this intermediate proposal will be lower. Any revenue needed to meet the requirements of fast-track budget reconciliation will be enacted as part of this legislation from the financing options that I have already proposed.

On the one hand, a lot of her $20.5 trillion in revenue is unlikely to ever come to pass.

On the other hand, simply restoring existing levels of CSR funding would free up a good $20 billion/year to be used for enhanced/expanded ACA subsidies anyway (thanks to the magic of CBO 10-year scoring methodology), so I'm not too concerned about this particular bullet.

She throws in a whole mess of other stuff which I'm getting too tired to delve into, so I'll just list them as is:

Additional Health System Reforms to Save Money and Lives

After pursuing administrative changes, expanding existing Medicare, and creating a true Medicare for All option, every person in the United States will be able to choose free or low-cost public insurance. Tens of millions will likely do so. But we can’t stop there. We must pursue additional reforms to our health system to save money and save lives. Some of my priorities include:

Investing in Medical Miracles. Many medical breakthroughs stem from federal investments in science – but in 2018, 43,763 out of 54,834 research project grant applications to the National Institutes of Health (NIH) were rejected. We will boost medical research by investing an additional $100 billion in guaranteed, mandatory spending in the NIH over ten years, split between basic science and the creation of a new National Institute for Drug Development that will help take the basic research from the other parts of NIH and turn it into real drugs that patients can use. We will prioritize treatments that are uninteresting to big pharmaceutical companies but could save millions of American dollars and lives. Any drugs that come out of this research and to American consumers can be sold abroad, with the proceeds reinvested to fund future breakthrough drug development. And by enacting my Affordable Drug Manufacturing Act, the government can manufacture generic drugs that are not available due to cost or shortage.

Ending the Opioid Epidemic. The opioid epidemic is a public health emergency. In 2017, life expectancy in the United States dropped for the third year in a row, driven in large part by deaths from drug overdoses. We will enact my legislation, the CARE Act, to invest $100 billion in federal funding over the next ten years in states and communities to fight this crisis – providing resources directly to first responders, public health departments, and communities on the front lines of this crisis. 

Improved Administration. To cut down on time wasted on paperwork, we will create single standardized forms for things like prior authorizations and appeals processes to be used by all insurers (private and public), and we will establish uniform medical billing for insurers and doctors.

All-Payer Claims Database. Right now, there are so many middlemen in health care that no one knows for certain how much we pay for different services across the whole system. A centralized repository of de-identified claims data will help the government, researchers, and the market better understand exactly what we pay for health care and what kind of quality it gets us. Demystifying what we pay for what we get will be a critical part of ensuring fair reimbursement under Medicare for All.

Antitrust Enforcement. In addition to administrative actions to rein in anti-competitive hospital and electronic medical record practices, we’ll also ban non-compete and no-poach agreements and class action waivers across the board, while making it easier for private parties to sue to prevent anti-competitive actions. I’ll work with states to repeal Certificate of Public Advantage, or COPA, statutes that shield health care organizations from federal antitrust review and can lead to the creation of large monopolies with little to no oversight. And I’ll also push to ensure our antitrust laws apply to all health care mergers.

Ending Surprise Billing. Imagine being a woman who schedules her baby’s delivery with her obstetrician at an in-network hospital, but it turns out that the anesthesiologist administering the epidural isn’t in-network. Even though she had no choice – and probably had no idea that doctor was out-of-network – under the current system she gets hit with a huge bill. We will end the practice of surprise billing by requiring that services from out-of-network doctors within in-network hospitals, in addition to ambulances or out-of-network hospitals during emergency care, be treated as in-network and paid either prevailing in-network rates or 125% of the Medicare reimbursement rate, whichever is lower.

Again: Elimination of surprise billing is one of the core features of several other plans, including Warren's own S.1213 ACA 2.0 bill.

Preventing Provider Shortages. With more people seeking the care they need, it will be essential to increase the number of providers. I will make these critical investments in our clinicians, including by dramatically scaling up apprenticeship programs to build a health care workforce rooted in the community. I will lift the cap on residency placements, allowing 15,000 new clinicians to enter the workforce. I will expand the National Health Service Corps and Indian Health Service loan repayment program to allow more health professionals – including physicians, physician assistants, registered nurses, nurse practitioners, and other licensed practitioners – to practice in underserved communities. I will also provide grants to states that expand scope-of-practice to allow more non-physicians to practice primary care. And I will push to close the mental health provider gap in schools.

OK, so now we've reached THE END OF THE FIRST BILL (it's actually a combination of several bills, along with a whole bunch of executive orders/etc), to achieve a mish-mash of:

  • ACA 2.0
  • Medicare 50+ Public Option
  • Medicare 49- Public Option
  • Medicare for America

...and that's where we get to THE SECOND BILL:

Completing the Transition to Medicare For All

By pursuing these changes, we will provide every person in America with the option of choosing public coverage that matches the full benefits of Medicare for All. Given the quality of the public alternatives, millions are likely to move out of private insurance as quickly as possible.

No later than my third year in office, at which point the number of individuals voluntarily remaining in private insurance would likely be quite low, I will fight to pass legislation to complete the transition to the Medicare for All system defined by the Medicare for All Act by the end of my first term in office.

Remember way up above when I made note of the "complete the transition" language? THIS is what I was referring to. She makes reference to "Senator Sanders' Medicare for All Act"...which includes a 4-year transition period. Under Warren's vision, if she's able to pull off everything listed above, the burden would have been reduced so much that by three years in, she thinks Bernie's bill could be completed within a single year...thus, four years from start to finish.

At least, I think that's the reasoning. The actual language is a bit fuzzy, and honestly, even if everything above went as planned, making the rest of the move still seems extremely...unlikely. But...that's what she seems to be proposing, anyway.

Moving to this system would mean integrating everyone into a unified system with zero premiums, copays, and deductibles. Senator Sanders’s Medicare for All Act allows for supplemental private insurance to cover services that are not duplicative of the coverage in Medicare for All; for unions that seek specialized wraparound coverage and individuals with specialized needs, a private market could still exist. In addition, we can allow private employer coverage that reflects the outcome of a collective bargaining agreement to be grandfathered into the new system to ensure that these workers receive the full benefit of their bargain before moving to the new system. But the point of Medicare for All is to cut out the middleman.

Every successful effort to move the United States to create and expand new social programs – like Social Security and Medicare and Medicaid – has required multiple steps. In fact, every credible Medicare for All proposal has a significant, multi-step transition built in. That’s why it’s important to have both short-term goals and long-term goals to guide the process and to deliver concrete improvements to people’s lives at every stage.

But seriously, the critical point is that SHE'S FINALLY ADMITTING THAT MOVING TO MEDICARE FOR ALL WILL REQUIRE AT LEAST TWO SEPARATE PIECES OF LEGISLATION, SPACED SEVERAL YEARS APART.

I wish she had just admitted this in the first place instead of pretending that it could all be done in a single shot for the past six months or so...but she is, so that's something.

I pray that Bernie Sanders supporters and other “pure” M4All supporters would accept this as well.

Now, I’ll be frank: I still think she’s trying to bite off more than the country can chew in a single Presidential term. Personally, I think it's gonna take at least three separate bills spaced a few years apart:

  • ACA 2.0 w/PO
  • Med4America (or similar)
  • Medicare for All

...or possibly even four:

  • ACA 2.0
  • ACA 2.0 w/PO
  • Med4America (or similar)
  • Medicare for All

...but even acknowledging two separate bills is still a huge move forward in my book.

I'm including the rest of her explainer here because, at this point, why the hell not?

I believe the next president must do everything she can within one presidential term to complete the transition to Medicare for All. My plan will reduce the financial and political power of the insurance companies – as well as their ability to frighten the American people – by implementing reforms immediately and demonstrating at each phase that true Medicare for All coverage is better than their private options. I believe this approach gives us our best chance to succeed.

Why do we need to transition to Medicare for All if a robust Medicare for All option is available to everyone? The answer is simple and blunt: cost and outcomes. Today, up to 30% of current health spending is driven by the costs of filling out different insurance forms and following different claims processes and fighting with insurance companies over what is and is not covered. I have demonstrated how a full Medicare for All system can use its leverage to wring trillions of dollars in waste out of our system while delivering smarter care – and I’ve made clear exactly how I would do it. The experience of other countries shows that this system is the cheapest and most efficient way to deliver high-quality health care. As long as duplicative private coverage exists, we will limit our ability to make health care delivery more effective and affordable – and the ability of private middlemen to abuse patients will remain.

Medicare for All will deliver an $11 trillion boost to American families who will never pay another premium, co-pay, or deductible. That’s like giving the average working family in America a $12,000 raise. This final legislation will put a choice before Congress – maintain a two-tiered system where private insurers can continue to profit from being the middlemen between patients and doctors, getting rich by denying care – or give everybody Medicare for All to capture the full value of trillions of dollars in savings in health care spending. I believe that the American people will demand Congress make the right choice.

Medicare for All is the best way to guarantee health care to all Americans at the lowest cost. I have a plan to pay for it without raising taxes on middle class families, and the transition I’ve outlined here will get us there within my first term as president. Together, along with additional reforms like my plans to reduce black maternal mortality rates, ensure rural health care, protect reproductive rights, support the Indian Health Service, take care of our veterans, and secure LGBTQ+ equality, we will ensure that no family will ever go broke again from a medical diagnosis – and that every American gets the excellent health care they deserve.