Democrats Discuss Ideas for Expanding US Health Coverage

Kerry Dooley Young

March 30, 2022

Democrats this week sought to draw attention to proposals for expanding US access to medical care, with the White House unveiling its priorities in a new budget request and members of a House committee revisiting the "Medicare-for-all" approach.

President Joe Biden's budget request for fiscal 2023, which begins October 1, asks Congress to expand funding for mental health services and programs to treat people with opioid use disorder. Members of Congress have been able to find bipartisan agreement on these two issues in recent years, making the Biden proposals seem feasible.

In the weeks ahead, Congressional committees will dig into the details of Biden's request, which was unveiled March 28.

The House Appropriations Committee on March 31 will hold a hearing on the proposal for the Department of Health and Human Services (HHS). Members of this committee likely will delve deeply into the White House's plans for funding federal agencies, including the National Institutes of Health and the Centers for Disease Control and Prevention. On April 5, the House Ways and Means Committee, which oversees Medicare and Medicaid, wiill hold its hearing on the HHS budget. Members of this committee likely will raise issues about rules on physician payment and operations of private insurance plans.

Debating Medicare for All

Separate from the consideration of the Biden budget request, though, are continued efforts by some Democrats to press for a major overhaul of how the US pays for healthcare.

The House Committee on Oversight and Reform on Tuesday held a hearing to draw attention to obstacles that prevent many people in the US from receiving medical care. Highlighted at the hearing was the Medicare for All bill offered by Rep. Pramila Jayapal (D-WA).

Jayapal's bill would establish a national government-run health insurance program and limit use of private insurance to items not covered by the new federal plan. Under her bill, the creation of a new federal insurance program would not affect coverage provided through the Department of Veterans Affairs or the Indian Health Service.

Other Democrats have offered a less radical plan, known informally as Medicare for all who want it. Officially titled the Medicare-X Choice Act, this bill from Rep. Antonio Delgado (D-NY) would create a federal health plan to compete on insurance exchanges with offerings from private insurers such as UnitedHealth and Blue Cross.

Objecting to Jayapal's bill at the hearing was a witness called by the Republican members of the committee. Grace-Marie Turner, president of the nonprofit Galen Institute, noted that implementing Jayapal's bill would lead to major upheaval.

"While the promises of Medicare for All sound utopian, what about the large portion of at least 173 million people who don't want to give up their job-based insurance? What if 64 million seniors like their current Medicare and Medicare Advantage plans and don't want the program abolished and replaced?" Turner asked in her testimony. "And what about union members who have made significant sacrifices in wages to earn their rich health benefit packages?"

Democrats' chances of successfully creating a sweeping single national medical insurance program seem decidedly slim — at least in the near term. Jayapal's bill has attracted the support of only about half of her fellow House Democrats and no Republicans.

Porter Counts the Costs

Democrats used Tuesday's House Oversight hearing to point out how private health plans take money given to them by consumers for medical treatment and spend it on items like promotions.

A government-run system would be more efficient because it would eliminate this waste, Democrats said.

Rep. Katie Porter (D-CA) asked a panel witness, Sarah R. Collins, PhD, vice president for healthcare coverage and access at the nonprofit Commonwealth Fund, to review the difference in administrative costs between Medicare and private plans. Medicare's administrative costs consume about 3% to 5% of the giant federal program's budget, compared with 17% to 18% for private insurers, Collins said.

Noted for her whiteboards and other tools she uses to try to explain complex issues at House hearings, Porter in this case had a stack of $1 bills handy. She counted out $17 and then put down about 14 bills and held up $3 to show the potential savings of a government-run plan.

Rep. Katie Porter counts out $1 bills in a demonstration of how private insurers utilize more administrative costs than federal health plans.

Porter then reviewed with Collins some of the ways private plans spend their customers' money, in addition to applying the bulk of premiums to medical costs. These include stock buybacks for shareholders, Porter noted. She also noted that private insurers spend more on executive pay.

"Does Medicare spend money on marketing? Private insurance likes to put its name on stadiums and PGA tournaments. Is there a Medicare arena?" Porter asked rhetorically.

The St. Louis Post Dispatch last month reported that Centene Corp had entered a 15-year deal for naming rights for a stadium in that city. "Centene will have its name emblazoned on the outside of the 22,500-seat facility, the scoreboard, and other signage," the newspaper says, adding that the terms of the deal were not disclosed. Centene's business model rests heavily on profiting while managing care of people covered by the government-funded Medicaid and Medicare programs.

Another example is the Kaiser Permanente Arena in Santa Cruz, California, named for a giant nonprofit insurer.

Opting for the sleeker administrative style of government-run Medicare would leave money free for expanding benefits, Porter said.

"We could spend that money to let patients see dentists. We could spend that money to let patients pay for hearing aids, to help older adults afford eyeglasses, to bring down the cost of prescription drugs, to finally pay mental health professionals for the work they do," Porter said. "Instead, all this money is wasted."

Dropping the Term "Abuse"

Biden's fiscal 2023 budget requests seeks $42.5 billion for various efforts to address drug addiction, a $3.2 billion increase from current annual spending.

In addition, the budget request proposes changing the name of the National Institute on Drug Abuse to the National Institute on Drugs and Addiction and to change the name of the National Institute on Alcohol Abuse and Alcoholism to the National Institute on Alcohol Effects and Alcohol-Associated Disorders.

"Individuals do not choose to 'abuse' drugs and alcohol; they suffer from a disease known as addiction," HHS said in a budget document, calling for an end to "outdated and stigmatizing language that is harmful to the individuals and families that suffer from addiction."

The Biden budget also calls for what it describes as full parity between physical healthcare and behavioral healthcare, which includes mental health and substance use disorder care. The budget includes a request for $697 million in the new 988 bill and Behavioral Health Services initiative. The National Suicide Prevention Lifeline is readying for a transition from a 10-digit number to 9-8-8 in July 2022.

Other proposals in the Biden budget request include the following:

  • $7.5 billion for a new mental health transformation fund, to be allocated over 10 years to expand access services, including plans to develop "non-traditional health delivery sites" and the integration of quality mental health and substance use care into primary care settings;

  • $4.1 billion for a permanent extension of funding for community mental health centers;

  • $1.2 billion to strengthen consumer protections and increase access to behavioral health services in the private insurance market, including a proposal to require coverage of three behavioral health visits with no enrollee cost-sharing;

  • $3.5 billion to improve Medicare mental health coverage, including plans to cover three behavioral health visits per year without cost-sharing and to eliminate the 190-day lifetime limit on psychiatric hospital services; and

  • $35.4 billion to improve mental health access in Medicaid, including plans to establish a performance fund to improve behavioral health and to encourage utilization of clinically appropriate criteria for Medicaid covered behavioral health services.

Kerry Dooley Young is a freelance journalist based in Washington, DC. She is the core topic leader on patient safety issues for the Association of Health Care Journalists. Young earlier covered health policy and the federal budget for Congressional Quarterly/CQ Roll Call and the pharmaceutical industry and the Food and Drug Administration for Bloomberg. Follow her on Twitter at @kdooleyyoung.

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