House Panel Digs In on Medicare for All, Other Insurance Options

Kerry Dooley Young

June 13, 2019

WASHINGTON — Lawmakers on Wednesday tussled over approaches for making healthcare more affordable and accessible for people in the United States, including a proposal to replace private insurance with a nationwide Medicare-for-all plan.

Lasting more than 4 hours, a House Ways and Means Committee hearing on possible paths for expanding access to medical care served as a preview of debates likely to dominate the 2020 election cycle and the next session of Congress.

For the remainder of the 116th session (January 2019 to January 2021), though, it is unlikely that Congress will attempt any major overhaul of American healthcare, with Democrats holding the House and Republicans having control of the Senate.

Still, citizens' concerns about paying for healthcare will keep lawmakers in both parties deeply engaged in this issue. Even people with private insurance sometimes struggle with medical bills and the costs of medicines.

A recent poll indicates that about one fourth of all insured Americans have difficulty paying their premiums, deductibles, and copays for physician visits and prescription drugs, Tricia Neuman, ScD, a senior researcher at the nonprofit Kaiser Family Foundation, told the Ways and Means Committee. Neuman, a key witness at the hearing, also said research shows that annual deductibles have increased eight times as fast as wages since 2008.

Beyond these statistics is the toll of continual anxiety many people have about being unable to obtain care for a serious illness, lawmakers said at the hearing.

"People can go through their entire life wondering if they are just going to be lucky and not happen to get sick," said Rep. Dan Kildee (D-MI) at the hearing. "In the wealthiest country on Earth, that's a crime."

The Ways and Means hearing put on display diverging ideas by Democrats about how to expand coverage. Republicans remain strongly united in opposition to plans that would increase the government's role in care.

At the hearing, Republican lawmakers referred to waiting times for care in countries that have broad national health plans, such as Canada. Canadians may wait 4.3 weeks for a CT scan, 10.6 weeks for an MRI scan, and 3.9 weeks for an ultrasound, according to the Fraser Institute, a self-described Canadian think tank.

Rep. Kevin Brady of Texas, the ranking Republican on Ways and Means, said the Democrats' plan would undo a system of private insurance that many Americans favor. About 158 million people who are now covered through employer-sponsored insurance could someday find that "Medicare-for-all canceled your good plans and forced you into a one-size-fits-all plan run by Washington politicians," Brady said.

"Since doctors and hospitals lose money on nearly every treatment they provide in Medicare, experts predict that Medicare for all will cause a chronic shortage of doctors, and hospital overcrowding will be an epidemic," Brady added.

Democrats countered that the current system forces many Americans to skimp or forgo medical care.

"To say that everything is peachy keen and everybody has access is missing the point," Rep. Jimmy Gomez (D-CA) said.

The first witness at the hearing was Rebecca Wood of Massachusetts, who spoke about how her family has coped with the high costs of medical care for her daughter, Charlie, who was born prematurely.

To preserve funds for therapy for her daughter, Wood put off her own dental care, which led to an infection that spread through her mouth and jaw. She told Ways and Means about having all of her teeth pulled and parts of her jaw scraped away in a 6-hour procedure under local anesthesia, because she could not afford general anesthesia.

"I sobbed the entire ride home afterwards. I don't know what the worst part is. The excruciating pain I live with every day, how I worry whether I'm drooling when I smile, how eating is awkward and challenging, or how I love jazz but will never play the trumpet again," Wood told the committee.

Medicare Proposals

The Medicare-for-all legislation, backed by Rep. Pramila Jayapal (D-WA) and Sen. Bernie Sanders (I-VT), would add dental coverage to the federal program's services, along with vision care and institutional and community-based long-term services and supports, Neuman said.

"Benefits would be far more comprehensive than those that are typically offered by most private insurance plans and the current Medicare program — with no premiums, deductibles, or cost sharing," she said in testimony to the committee.

To constrain spending, Medicare-for-all would establish payment rates for hospitals, physicians, and other clinicians. Under the current system, these are negotiated separately by private insurers and public programs.

Another approach developed by Democrats is the Medicare for America proposal, offered by Reps. Rosa DeLauro (D-CT) and Jan Schakowsky (D-IL). Their proposal would expand Medicare but allow an opt-out option for people who choose qualified coverage under an employer plan.

Schakowksy is a sponsor for one of several Democratic bills seeking to create a federal public option based on Medicare, which would compete with private insurance.

Democratic bills have been introduced to allow consumers to buy into Medicare and Medicaid.

"There are different options to a path to full coverage" of people in the United States for healthcare, said Ways and Means Chairman Richard E. Neal (D-MA).

Neal urged his Republican colleagues to take advantage of what he termed a "bipartisan opportunity" to make improvements to the Affordable Care Act of 2010.

Neal urged use of this law, which has withstood several attempts by Republicans to repeal it, as a vehicle to lower medical costs and improve the quality of care for Americans.

One Physician's Perspective

While Republicans continue to endorse a rollback of the Affordable Care Act, many of them say they support a key provision of the measure — its mandate that insurers cover people who have preexisting conditions.

"I would say, candidly, that everyone here is in favor of coverage for preexisting conditions," said Rep. Brad Wenstrup, DPM (R-OH). "We supported it, all of us, both sides of the aisle."

He spoke of his family's own struggles with medical conditions, including his sister's leukemia when she was in her 20s. She had to fight her insurance company for coverage of a procedure that helped save her life.

"I understand the anxiety that comes when people don't know if they are going to be covered or if they're going to be able to afford it," Wenstrup said.

But he also sought to bring to the discussion the view of a physician trying to keep his small business afloat.

"Medicare and Medicaid are the lowest payers," Wenstrup said. "That makes it challenging in private practice."

He recalled a case in which Medicaid denied coverage for an MRI he wanted for a patient.

"In a private plan, I had the same situation, and I got it because the patient was able to say, 'We're going to drop you as our insurer.' They have some clout" with private insurers, but not the large government plan, Wenstrup said.

In many ways, the disagreements between Democrats and Republicans over healthcare boil down to differing perceptions of the role and value of insurance companies.

Speaking as a witness at the hearing, Donald M. Berwick, MD, MPP, who led the Centers for Medicare & Medicaid Services during the Obama administration, presented testimony in favor of a broad Medicare expansion.

In his testimony, Berwick sought to counter Republican objections to this idea, including what he characterized as claims that "Medicare for all would unacceptably disrupt people's current relationships with their healthcare insurers.

"Indeed, Medicare for all would give every American not now covered by Medicare a new insurer — a public insurer. Whether this threat to existing bonds between people and commercial insurers in fact troubles Americans I find doubtful," Berwick said. "I suspect that what most Americans value is their bond with clinicians, not with insurers."

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