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What You Need to Know About “Medicare and Medicaid-for-all” to Survive the Current Election Cycle

By Jennifer S. Bard

Just as medical students find themselves being asked at parties to look at rashes, this year health law students (and professors) are being asked about the proposals to fix our broken health care system being offered by the many candidates vying for the Democratic Party’s nomination for president. Talk about these issues are certain to continue through the primaries as 81% of Democrats agree that “the federal government has a responsibility to make sure all Americans have health coverage.” While Republicans are less sure about who should pay, health care remains a top issue for 69% of the electorate.

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Monthly Round-Up of What to Read on Pharma Law and Policy

By Ameet Sarpatwari, Charlie Lee, Frazer Tessema, and Aaron S. Kesselheim

Each month, members of the Program On Regulation, Therapeutics, And Law (PORTAL) review the peer-reviewed medical literature to identify interesting empirical studies, policy analyses, and editorials on health law and policy issues relevant to current or potential future work in the Division.

Below are the abstracts/summaries for papers identified from the month of July. The selections feature topics ranging from the price increases of protected-class drugs in Medicare Part D, to the impact of price regulation on the availability of new drugs in Germany, to the association between FDA advisory committee recommendations and agency actions. A full posting of abstracts/summaries of these articles may be found on our website.

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Photograph of a Medicare for All rally

Medicare-for-All Wouldn’t be Medicare if it Eliminated Private Insurance

By Robert Field

Should Medicare-for-All replace private insurance? That question, although central to many current health reform debates, presents a fundamental contradiction. If Medicare-for-All were to eliminate private coverage, it wouldn’t be Medicare, which has made room for private insurers from the start.

Medicare could have been designed as a pure single payer with comprehensive coverage for all health care needs. However, that approach would have risked alienating several important constituencies, including the insurance industry, and provoking their opposition. Before the program was enacted, private Insurers enjoyed a sizeable market through which they sold coverage of some sort to about half the nation’s elderly. Medicare eliminated that market but created an attractive new one to replace it. It did this by enabling insurers to sell Medigap policies that filled some of the program’s most significant coverage gaps, such as coverage for vision and dental care, and that reduced or eliminated its sizeable copayments and deductibles. When the program launched, more than 80 percent of beneficiaries who had previously maintained private coverage purchased these new supplemental policies. Medicare also gave some insurers the chance to earn additional revenue by administering claims as carriers and intermediaries.

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Medically Tailored Meals and the Reverberating Impact of Public Demonstration Projects

Recent headlines highlighted a $40 million investment by a range of Blue Cross Blue Shield companies in Solera Health, a start-up focused on improving chronic disease management. Solera Health will use the investment to scale up its wellness programs, which seek to improve social determinants of health for patients.

One of Solera’s initiatives focuses on providing medically tailored meals to beneficiaries. The concept behind medically tailored meals is simple. Patients with diabetes, congestive heart failure, and other chronic illnesses can be treated only to a limited extent in doctor’s offices. By extending services like meal provision to beneficiaries—thus improving their long-term health—insurers can potentially avoid paying for more costly interventions down the line. Read More

Defining and Establishing Goals for Medicare for All

It is increasingly difficult to find a Democratic presidential hopeful who has not paid at least some lip service to “Medicare for all.” Indeed, ignoring this popular rhetoric would likely be political suicide for Democratic candidates.

In one poll, 73 percent of registered Democrats said they were more likely to vote for a presidential candidate who supported a Medicare for all health care policy. In response to the popularity of Medicare for all, House Democrats launched an official Medicare for All Caucus, with about 70 members.

Medicare for all, however, means many things to many people. As the fight to become the Democratic presidential candidate unfolds in 2019, it will be important to see how this term gets defined.

Many take Medicare for all to be policy shorthand for health or health care being a human right, entitling individuals to certain services and obligating the government to support access to health care.

For example, the Center for American Progress toted its proposal, Medicare Extra for All, by arguing that health care constitutes a right, as opposed to a privilege. Presidential hopeful U.S. Senator Elizabeth Warren (D-Mass.) similarly released a statement justifying her support of a Medicare for all bill by stating that “health care is a basic human right.”

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Medicaid Buy-In and Section 1332 State Innovation Waivers

As a new Medicare-for-all bill was introduced in the House recently, a number of state-level legislative projects are generating parallel excitement about Medicaid buy-in plans.

In his recent Bill of Health post, Rahul Nayak explained how Medicaid Buy-In would allow states to introduce a public option to their insurance marketplaces. Rahul points to some major questions about how buy-in plans might be implemented. Some of these questions relate to how these plans will operate within the federal statutory system that governs health care marketplaces and Medicaid. In a December Ohio State Law Journal article, for example, Professor Lindsay Wiley explored how Medicaid buy-in plans could be enacted within the waiver systems that shape state implementation of marketplaces and the availability of premium tax credits. Most recently, Emma Sandoe, in an interview for this blog, discussed the ways states are innovating in this space.

Specifically, states seeking to implement buy-in plans will navigate questions about how to leverage the Section 1332 waiver provision of the ACA. Section 1332 of the ACA allows states to apply for waivers of certain marketplace requirements. Through these waivers, states are empowered to provide insurance options that don’t meet all QHP standards and may receive premium tax credits to directly fund insurance products. How states choose to approach this waiver system will dictate what type of funds are available to subsidize coverage, the design of buy-in offerings, and the level of coverage buy-in plans will offer.

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The Future of Health Care? How States are Trailblazing Medicaid Buy-In Programs

States can be laboratories of health reform.

Massachusetts and Oregon expanded insurance coverage during previous periods of federal inaction, and with solutions unlikely to come from a politically divided Washington D.C., how will states tackle the problem of health insurance becoming increasingly unaffordable and unattainable for many families?

Is there a role for the government to play a greater role in making health insurance affordable and accessible? As public support for action on health care grows, what options are available to states now?

I spoke to former Petrie-Flom Student Fellow and Medicaid policy scholar Emma Sandoe about states that have begun to explore Medicaid Buy-In policies, which allow people to purchase government backed health insurance or Medicaid-like plans. Read More

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Administration’s Guidance on State Innovation Waivers under the ACA Violates the Act’s Statutory Guardrails

By Joel McElvain

This post was originally published on Take Care. 

The Affordable Care Act reformed the individual health insurance market to protect persons with pre-existing conditions. Insurers who participate in this market must sell plans with a standard set of comprehensive benefits, and may not deny coverage to, or impose higher premiums on, persons with pre-existing conditions.

Through legislative, regulatory, and litigation efforts, the Trump Administration has sought to depart from the ACA’s regime to allow the sale of plans that are medically-underwritten, offer more limited health benefits, or both.

The Administration’s latest such effort comes in the form of guidance by the Departments of Treasury and Health and Human Services that adopts a broader reading of the Act’s provision for state innovation waivers. Read More

Public Charge and the Expressive Effects of Immigration Law

In early October, the Department of Homeland Security published a proposed redefinition of the Immigrant and Nationality Act’s “public charge” provision, stirring serious concern among health-care and immigrant advocacy groups.

The “public charge” provision of the INA currently allows immigration officers to deny green cards to legal immigrants who are likely to become “primarily dependent on the government for subsistence.”

DHS’s proposed rule would widen the scope of “public charge” to include any legal immigrant who uses cash or non-cash government benefits. In expanding the scope of the public charge inadmissibility determinations, DHS would empower immigration officers to consider immigrants’ current or prior use of programs like Medicaid and SNAP in evaluating applications. Read More

Some takeaways from Montana’s Medicaid expansion ballot initiative

As Nicholas Terry wrote in his recent blog post, the 2018 midterm elections produced some big wins for Medicaid. Voters in Idaho, Nebraska and Utah decided to expand Medicaid coverage under the ACA. These states followed the lead of Maine, where Medicaid was expanded by ballot initiative in November of 2017.

One exception to this trend is Montana. On November 6, Montanans rejected I-185, a ballot initiative proposing to fund the state’s Medicaid expansion through a tobacco tax. The ballot initiative would have removed a sunset provision that automatically terminates funding for the expansion in 2019. The outcome of the initiative has not necessarily killed Montana’s expanded program. The Republican legislature may still act to appropriate funding for the program, and—given that the expansion was originally passed with bipartisan support in the state legislature—this route to securing financing is not foreclosed. In August, the oversight committee in charge of the expansion bill recommended that the state fund the program regardless of the outcome of the ballot initiative.

However, even if the future of the Montana expansion remains unclear, there are still some important immediate takeaways from the result of I-185. Read More