Budget analysts at the Congressional Budget Office (CBO) have implied, in a new report on Medicare for All proposals and other single-payer health care system proposals, that they can’t assume would-be health policymakers in Washington know much about how the U.S. health finance system works now, or how the health finance system works in other countries.
The CBO is an arm of Congress that helps members of Congress understanding programs and proposals that could affect federal spending, or federal revenue.
The House Rules Committee held a hearing Tuesday on H.R. 1384, a bill introduced by Rep. Pramila Jayapal, D-Wash., that would eliminate all private health insurance, dental insurance, vision insurance and long-term care insurance. The bill calls for the U.S. Health and Human Services secretary to ensure that “no cost-sharing, including deductibles, coinsurance, copayments, or similar charges, is imposed on an individual for any benefits provided under this Act.”
CBO analysts have released a new document with the title, “Key Design Components and Considerations for Establishing a Single-Payer Health Care System.”
The document does not include any systematic analyses of how much various proposals for expanding the role of the government in health finance might affect government spending, government revenue or U.S. health system performance.
Instead, the analysts have focused on trying to help readers understand the various components of the U.S. health care finance system, how other systems work, and how U.S. systems and non-U.S. systems seek to balance the demand for high-quality care with the need to hold down costs.
‘C’ Is for Fun With Cost-Sharing
The authors include, for example, a table comparing the universal coverage systems in Australia, Canada, Denmark, England, Sweden Taiwan.
The table shows that all of the health care systems other the Canadian system require patients to pay part of the costs for prescription drugs, dental care and vision care, and that the Canadian and English systems have no caps on patients’ out-of-pocket spending.
Enrollment Is Something Health Care Systems Do
The CBO primer authors have included a section on the fact that single-payer health care systems still need to have ways to enroll people in coverage and verify eligibility for coverage.
“A single-payer system would need a way to verify eligibility and enroll participants in the system,” according to the primer. “Verifying eligibility would be easier than it currently is for public programs, such as with Medicaid’s income verification, because the single-payer system would have fewer eligibility exclusions. A verification and enrollment system could build on the current Medicare Part A enrollment system. People could also be automatically enrolled when they were issued Social Security numbers, newborns could be enrolled in hospitals at birth, and other eligible individuals could be enrolled when they sought medical care.”
But policymakers would still have decisions about eligibility to make, according to the primer.
“Policymakers designing a single-payer system would need to determine whether the entire U.S. population would be eligible to participate and whether the system would allow for any opt-outs among the eligible population,” according to the primer. “To ensure that everyone eligible for the single-payer system received coverage, the system would need to establish an infrastructure to verify eligibility and enroll participants… Under a state-administered single-payer system, states could establish their own residency and eligibility requirements, such as providing coverage for noncitizens who are not lawfully present. However, the federal government might impose certain conditions in exchange for providing matching funds.”
The CBO analysts don’t refer to insurance agents, brokers, navigators, enrollers or exchange programs in the primer.
Long-Term Care Costs Money
The CBO analysts note that “long-term services and supports,” or LTSS, including home health services as well as nursing home care, and that Medicaid now pays for nursing home care for people with low income and low asset totals.
“Public spending would increase substantially relative to current spending if everyone received LTSS benefits,” the CBO analysts explain to would-be health policymakers. “Currently, much of LTSS is unpaid (or informal) care provided by family members and friends. If a single-payer system covered LTSS with little or no cost sharing, a substantial share of unpaid care might shift to paid care. That effect could be particularly large if the single-payer plan covered home- and community-based services.”
Government Health Care Programs Say ‘No,’ Too
The CBO analysts point out that, like U.S. private managed care plan managers, government health programs in countries with single-payer systems often “use various forms of utilization management.”
“In Canada’s single-payer system, some provinces make lower payments to specialists when a patient has not been referred by a primary care physician,” according to the primer. “In England, access to specialists generally requires a referral from a primary care provider. Taiwan monitors use of services and costs in near-real time through its IT system to identify wasteful spending and inappropriate care.”
A copy of the CBO single-payer health care system primer is available here.
— Read ACA Debaters Should Define Their Terms, on ThinkAdvisor.