The Guttmacher Institute is evaluating how sexual and reproductive health and rights fit into U.S. health care reform efforts. Previous analyses have described people’s wide array of sexual and reproductive health needs and laid out a set of principles for how to address them within the health care system. This analysis applies those principles to one specific health care reform proposal. Evaluations of additional proposals can be found here.

Proposal name and bill number: Medicare for America Act (H.R. 2452, 116th Congress)

Proposal sponsor/author: Rep. Rosa DeLauro (D-CT)

Proposal version date: 5/1/2019

Summary of Proposal

Creates a new national health insurance program that will be open to all U.S. residents, replacing many existing public and private plans (including Medicaid, Medicare and individual market coverage) but leaving employer-sponsored private coverage as an option. (Also creates a temporary public health insurance option during the transition period to Medicare for America, which is not analyzed here.)

Ensure Comprehensive Insurance Coverage for Everyone

Provide coverage to all without cost or paperwork barriers: Available to all U.S. residents, including those who are currently uninsured, eligible to purchase an individual or group plan, or enroll in Medicare, Medicaid or the Children’s Health Insurance Program. Maintains coverage options through employer-sponsored plans, privately run Medicare Advantage plans, active military and veterans’ plans, federal employee plans and the Indian Health Service. Caps premiums at 8% of household income, with exemptions for households below 200% of the federal poverty level (FPL) and subsides available for households between 200% and 600% FPL.  Appears to block undocumented immigrants and Deferred Action for Childhood Arrivals (DACA) recipients from coverage, but states have the option to self-fund coverage for those not included in the federal program.

Cover the complete scope of sexual and reproductive health services without barriers: Requires coverage for an extensive list of specific services, when medically necessary, including maternity and newborn care, reproductive health exams, family planning counseling and education, contraceptive drugs and devices, sterilization procedures, abortion, infertility treatment, services related to HIV and other STIs, gender-confirming procedures and breast pumps. Includes language intended to override restrictions on the use of federal funds for abortion coverage and care (like the Hyde Amendment). Requires cost-sharing, with exceptions for some services (including some preventive services, some drugs and pregnancy-related care) and some enrollees (including households below 200% FPL, anyone younger than 21 and anyone with a complex condition like HIV). Caps out-of-pocket costs and prohibits deductibles, lifetime and annual limits, prior authorization requirements and step therapy (requiring a patient to try a less expensive alternative before getting access to their preferred option).

Build and Maintain a Robust Provider Network

Ensure that patients may seek care from any qualified provider: Allows access to providers already in the Medicaid and Medicare networks, with the option for others to join. Includes explicit protections for providers, including those that offer reproductive health services (like Planned Parenthood), to ensure they may not be excluded for reasons other than their ability to provide care. Medicare Advantage plans would have their own provider networks that must meet network adequacy standards set by the U.S. Department of Health and Human Services (HHS).

Fully reimburse providers and invest in their education, facilities and technology: Requires HHS to reimburse providers at Medicare or Medicaid rates (whichever is higher) and increases reimbursement for primary care. Provides funding for medical education and training programs, and offers loan forgiveness to participating providers.

Keep pace with emerging services and methods, such as telehealth: Specifically covers telehealth services, when medically necessary.

Guarantee and Enforce Strong Patient Protections

Eliminate legal, cultural and safety-related barriers to care: Not addressed.

Respect patients’ privacy and autonomy and guard against coercion: Prohibits institutions and individual providers from denying covered services due to religious objections by explicitly overriding “any provision of law that allows for conscience protection” (provisions often referred to as “refusal of care” laws). Does not include any new provisions to promote patients’ right to provide informed consent to care; guarantee that patients receive appropriate information, referrals or care; or protect patient confidentiality.

Fight discrimination and promote equitable health care access and experiences: Applies the Affordable Care Act’s antidiscrimination protections for patients on the basis of race, color, national origin, sex, age or disability to Medicare for America and all employer-sponsored plans. Does not include specific provisions to address health inequities and disparities.

Overall Assessment

Strengths:

  • Establishes a national program to offer comprehensive, affordable coverage to most people in the United States.
  • Explicitly covers a comprehensive package of reproductive health services, lifts federal restrictions on that coverage (like the Hyde Amendment), and includes specific protections for providers who offer reproductive health services (like Planned Parenthood).
  • Overrides refusal of care laws and prohibits providers from denying covered services due to religious objections.

Weaknesses:

  • Maintains existing restrictions that exclude undocumented immigrants and DACA recipients from coverage.
  • Does not include many important patient protections against coercion, address many current barriers to care or specifically address health inequities and disparities.