Medicare for All is back in Congress for a second committee hearing just two weeks after lawmakers on the House Rules Committee broke new ground with theirs.
But on Wednesday, the House Budget Committee will take its own approach to the issue that has gained huge momentum in the last few months, focusing on recent Congressional Budget Office analysis for how a single payer design could look in the U.S.
Unlike the first hearing this Congress, the Budget Committee has only summoned CBO analysts.
Here are five things to listen for as Republicans look for points for 2020 campaign messaging and Democrats try to keep the focus on how to close the coverage gap that persists despite the Affordable Care Act.
- Cost. The CBO notably didn't include a cost estimate because the analysis wasn't focused on particular legislation. This was at the behest of the Budget Committee Chair John Yarmuth (D-Ky.) who asked the agency for the report. But cost and financing are two of the major questions, as experts predict the federal government would assume almost all the expenses — which are currently split almost 50-50 with the private sector. Healthcare spending was $3.5 trillion in 2017 and in the CBO's own words this would mean a major recalibration.
- Hospital ownership. The CBO report asked whether the government would have to take over the nation's hospitals, 70% of which are privately owned. With possibilities ranging from replicating the Veterans Affairs health system to getting more involved in converting for-profit hospitals into not-for-profits or quasi-public hospital, the question could hit home.
- Private insurance. Sen. Kamala Harris (D-Calif.) made waves when she suggested eliminating private insurance shortly after she announced her presidential campaign. Now the House lawmakers will grapple with the industry's future, supplemental insurance suggestions and what it could mean for access to care.
- Rates. The reimbursement question has dominated in the debate over various Democratic proposals to offer a public option through Medicaid and Medicare. The healthcare industry has been forceful in opposing accepting government-set rates for patients who might otherwise bring in commercial rates. The CBO found that three major insurers' hospital inpatient payments were 89% higher than Medicare's in 2013. Medicaid rates, while technically much lower than Medicare, can overall come in about the same for the hospitals that get a good portion of the various Medicaid supplemental payments. But the CBO and other analysts say that all the healthcare savings of a single-payer system would have to come from provider cuts — a massive battle in an environment where Congress isn't completely on board with the Trump administration's limited site-neutral payment policy.
- Limiting utilization. The CBO noted that unlike commercial insurers that zealously limit costs with prior authorizations and co-pays, public programs haven't put many management tools in place. A single payer system could co-opt some of the insurance companies' methods, the CBO said, but this would be a big change for people who are used to fee-for-service Medicare or Medicaid. The same conversation is already happening in the CMS, as the agency's Innovation Center plans to roll out a managed primary care model and direct contracting for health systems and MA within fee-for-service Medicare.
