Reading Elizabeth Warren’s Healthcare Plan, Part 1

Having written a fair amount about how to fix healthcare systems lately, I think looking at some current reform proposals will be fun. Maybe a good place to start is with Elizabeth Warren’s Medicare for All proposal–she’s got quite a few details out there.

This will be a two-part series because this week I read through all of her website’s pages that focus on healthcare (here, here, and here) and am really just using this post as my notebook of all the details I could find that are specifically about her vision of the structure of the healthcare system. I ignored all the details about how she would pay for it and how much it would cost (I’ve written about the cost of single-payer recently already). So, what follows is some extensive quoting.

In next week’s post, I’ll give my short summary of what I understand all of that to mean and give my assessment of how it will change the value delivered by our healthcare system over the long term.

• “Elizabeth supports Medicare for All, which would provide all Americans with a public health care program”
• “Everybody is covered. Nobody goes broke because of a medical bill.”
• “Everyone can see the doctor they need. Nobody goes broke. And your doctor gets paid by Medicare instead of fighting with an insurance company.”
• “allow the Department of Health and Human Services to step in where the market has failed. HHS would manufacture generic drugs in cases in which no company is manufacturing a drug, when only one or two companies manufacture a drug and its price has spiked, when the drug is in shortage, or when a medicine listed as essential by the World Health Organization faces limited competition and high prices”
• “Medicare should aggressively negotiate with drug companies. We should crack down on rampant abuse of the patent and regulatory system. And we should import drugs from countries that sell the same medicines and meet strong safety standards but that charge their citizens a fraction of our costs.”
• “hold insurers accountable for providing adequate mental health benefits and ensure Americans receive the protections they are guaranteed by law. She has also worked to hold the Department of Health and Human Services accountable for improving insurers’ compliance with mental health parity laws through an online consumer portal”
• “invest $100 billion in federal funding over the next ten years in states and communities to fight [the opioid] crisis — because that’s what’s needed to make sure every single person gets the treatment they need. It gives directly to first responders, public health departments, and communities on the front lines of this crisis — so that they have the resources to provide prevention, treatment, and recovery services for those who need it most”
• “[demand] states use Medicaid to its fullest to tackle the [opioid] crisis, expanding access to medication-assisted treatment, and ensuring treatment programs and recovery residences meet high standards”
• “create a new Medicare designation for rural hospitals that reimburses them at a higher rate and offers flexibility of services to meet the needs of their communities”
• “strengthen antitrust protections to fight hospital mergers”
• “increase funding for Community Health Centers by 15 percent per year over five years and establish a $25 billion dollar capital fund to support a menu of options for improving access to care in health professional shortage areas”
• “grow the current health workforce in rural communities by lifting the cap on medical residency placements, targeted in underserved areas, by 15,000 over the next five years and increasing the National Health Service Corps and Indian Health Service loan repayment programs to full loan repayment”
• “Medicare for All is the best way to cover every person in America at the lowest possible cost because it eliminates profiteering from our health care and leverages the power of the federal government to rein in spending”
• “ensure that Americans have access to all of the coverage they need – not just what for-profit insurance companies are willing to cover – including vision, dental, coverage for mental health and addiction services, physical therapy, and long-term care for themselves and their loved ones”
• “pursue comprehensive anti-corruption reforms to rein in health insurers and drug companies”
• “reverse Donald Trump’s sabotage of health care, protect individuals with pre-existing conditions, take on the big pharmaceutical companies to lower costs of key drugs for millions of Americans, and improve the Affordable Care Act, Medicare, and Medicaid”
• “create a true Medicare for All option that’s free for tens of millions”
• “give every American over the age of 50 the choice to enter an improved Medicare program, and I’ll give every person in America the choice to get coverage through a true Medicare for All option”
• “Coverage under the new Medicare for All option will be immediately free for children under the age of 18 and for families making at or below 200% of the federal poverty level (about $51,000 for a family of four). For all others, the cost will be modest, and eventually, coverage under this plan will be free for everyone.”
• “a boost of $100 billion in guaranteed, mandatory spending for new NIH research over the next ten years to radically improve basic medical science and the development of new medical miracles for patients”
• “fight to pass legislation that would complete the transition to full Medicare for All”
• “supplemental private insurance that doesn’t duplicate the benefits of Medicare for All would still be available”
• “I will act immediately to lower the cost of prescription drugs, using every available tool to bring pressure on the big drug companies. I’ll start by taking immediate advantage of existing legal authorities to lower the cost of several specific drugs that tens of millions of Americans rely on.”
• “bypass [pharmaceutical] patents (while providing “reasonable and entire compensation” to patent holders) using “compulsory licensing authority.””
• “require re-licensing of certain patents developed with government involvement when the contractor was not alleviating health or safety needs”
• “fix our broken generic drug market by stepping in to publicly manufacture generic drugs”
• “launch a full-scale effort to enforce [the mental health parity] requirements”
• “The Trump administration has abandoned its duty to defend current laws in court, cheering on efforts to destroy protections for pre-existing conditions, insurance coverage for dependents until they’re 26, and the other critical Affordable Care Act benefits. In a Warren administration, the Department of Justice will defend this law. And we will close the loopholes created by the Trump administration, using 1332 waivers, that could allow states to steer healthy people toward parallel, unregulated markets for junk health plans. This will shut down a stealth attack on people with pre-existing conditions who would see their premiums substantially increase as healthier people leave the marketplace. “
• “The Trump administration has expanded the use of junk health insurance plans as an alternative to comprehensive health plans that meet the standards of the ACA. These plans cover few benefits, discriminate against people with pre-existing conditions, and increase costs for everyone else. And in some cases they direct as much as 50 percent of patient premiums to administrative expenses or profit. I will ban junk plans.”
• “re-fund the Affordable Care Act programs that help people enroll in ACA coverage”
• “reverse the Trump administration rule that artificially reduced premium tax credits for many people, making coverage less affordable – and instead will expand these credits”
• “prohibit restrictive and ineffective [Medicaid] policies like work requirements – which have already booted 18,000 people in Arkansas out of the program – as well as enrollment caps, premiums, drug testing, and limits on retroactive eligibility that can prevent bankruptcy”
• “reverse the Trump administration’s terrible proposed rule permitting health plans and health providers to discriminate against women, LGBTQ+ people, individuals with limited English proficiency, and others”
• “roll back the Trump administration’s domestic and global gag rules, which deny Title X and USAID funding to health care providers who provide abortion care or even explain where and how patients can access safe, legal abortions. And I will overturn the Trump administration’s embattled proposed rule to roll back mandatory contraceptive coverage.”
• “Because of something called the “family glitch,” an entire family can lose access to tax credits that would help them buy health coverage if one parent is offered individual coverage with a premium less than 9.86% of their family income. I’ll work to make sure that a family’s access to tax credits is based on the affordability of coverage for the whole family”
• “extend eligibility for ACA tax credits to all people who are legally present, including those eligible for the Deferred Action for Childhood Arrivals program”
• “require employers to pass along the full value of the [medical loss ratio] rebate directly to employees”
• “expand the medically necessary dental services Medicare can provide”
• “Medicare payments to [Medicare Advantage] plans for each enrollee are supposed to reflect the cost of covering that person through traditional Medicare, but overwhelming evidence shows that these private plans make their enrollees appear sicker on paper than they actually are to earn inflated payments at the expense of taxpayers. Some suggest that this adds $100 billion or more to Medicare spending over ten years. My administration will put an end to this fraud.”
• “With the approval of the federal government, states can use Section 1115 demonstration waivers to expand coverage to people who aren’t otherwise eligible for Medicaid. Currently, however, states can only obtain these waivers if projected federal spending under the new program will not be higher than without the waiver. While I pursue legislative reforms to expand coverage, I’ll also change this administrative restriction”
• “Some states take [Medicaid] coverage away if someone misses just one piece of mail or forgets to notify the state within 10 days of a change in income. These kinds of harsh policies help explain why more than a million children “disappeared” from the Medicaid and CHIP programs in the past year. I will eliminate these kinds of unfair practices, and instead work with states to make it easier for everyone – families, children, and people with disabilities – to maintain this essential coverage.”
• “roll back the Trump administration’s proposed changes to rules regulating Medicaid managed care plans, which would dilute important standards, such as requiring health plans to maintain adequate provider networks guaranteeing access to care for Medicaid enrollees.”
• “I will appoint aggressive antitrust enforcers who recognize the problems with hospital and health system consolidation to the Department of Justice and Federal Trade Commission. My administration will also conduct retrospective reviews of significant new mergers, and break up mergers that should never have taken place.”
• “ramp up the enforcement against information blocking by big hospital systems and health IT companies, and I will appoint leaders to the FTC and DOJ who will conduct a rigorous antitrust investigation of the health records market, especially in the hospital space.”
• “I view good health plans negotiated through collective bargaining as a positive achievement for working people, and I will seek as part of the first phase of my plan the elimination of the excise tax on those plans.”
• “fund a true Medicare for All option. The plan will be administered by Medicare and offered on ACA exchanges.”
• “benefits of the true Medicare for All option will match those in the Medicare for All Act. This includes truly comprehensive coverage for primary and preventive services, pediatric care, emergency services and transportation, vision, dental, audio, long-term care, mental health and substance use, and physical therapy.”
• “offer coverage at no cost to every kid under the age of 18 and anybody making at or below 200% of the federal poverty level (about $51,000 for a family of four) – including individuals who would currently be on Medicaid, but live in states that refused to expand their programs.”
• “States will be encouraged to begin paying a maintenance-of-effort to the Medicare for All option in exchange for moving their Medicaid populations into this plan and getting out of the business of administering health insurance. For states that elect to maintain their Medicaid programs, Medicaid premiums and cost sharing will be eliminated, and we will provide wraparound benefits for any Medicare for All option benefits not covered by a state’s program to ensure that these individuals have the same free coverage as Medicaid-eligible people in the Medicare for All option.”
• “This plan will begin as high-quality public insurance that covers 90% of costs and allows people to utilize improved ACA subsidies to purchase coverage and reduce cost sharing. There will be no premiums for kids under 18 and people at or below 200% of the federal poverty level. For individuals above 200% FPL, premiums will gradually scale as a percentage of income and are capped at 5.0% of their income. Starting in year one, the plan will not have a deductible — meaning everyone gets first dollar coverage, and cost sharing will be zero for people at or below 200% FPL. Cost sharing will scale modestly for individuals at or above that level, with caps on out-of-pocket costs. In subsequent years, premiums and cost sharing for all participants in this plan will gradually decrease to zero.”
• “The Medicare for All option will have the ability to negotiate for prescription drugs using the mechanisms I’ve previously outlined“
• “Anyone who is uninsured or eligible for free insurance on day one, excluding individuals who are over 50 and eligible for expanded coverage under existing Medicare, will be automatically enrolled in the Medicare for All option. Individuals who prefer other coverage can decline enrollment.”
• “Workers with employer coverage can opt into the Medicare for All option, at which point their employer will pay an appropriate fee to the government to maintain their responsibility for providing employee coverage. In addition, unions can negotiate to include a move to the Medicare for All option via collective bargaining during the transition period, with unionized employers paying a discounted contribution to the extent that they pass the savings on to workers in the form of increased wages, pensions, or other collectively-bargained benefits.”
• “I have identified cost reforms that would save our health system trillions of dollars when implemented in a full Medicare for All system. The more limited leverage of a Medicare for All option plan will accordingly limit its ability to achieve these savings – but as more individuals join, this leverage will increase and costs will go down. Provider reimbursement for this plan will start above current Medicare rates for all providers, and be reduced every year as providers’ administrative and delivery costs decrease until they begin to approach the targets in my Medicare for All plan. The size of these adjustments will be governed by overall plan size and the progress of provider adjustment to new, lower rates.”
• “any person over the age of 50 will be eligible for expanded coverage under the existing Medicare program”
• “critical benefits like audio, vision, full dental coverage, and long-term care benefits will be added to Medicare, and we will legislate full parity for mental health and substance use services”
• “Identical to the Medicare program, enrollees will pay premiums in Part B and D, with a $300 cap on drug costs in Part D. Plugging a huge hole in the current Medicare program, out-of-pocket costs will be capped at $1,500 per year across Parts A, B, and D, eliminating deductibles and reducing cost sharing. In subsequent years, premiums and cost sharing will gradually decrease to zero.”
• “Identical to the Medicare for All option, workers 50-64 can opt into expanded Medicare, at which point their employer will pay an appropriate fee to the government to maintain their responsibility for providing employee coverage.”
• “The expanded Medicare program will receive the ability to negotiate for prescription drugs using the mechanisms I’ve previously outlined, helping to drive down costs for patients. And we will create a publicly run prescription drug plan that is benchmarked off the best current Part D plan.”
• “Every person without health insurance over the age of 50 will be automatically enrolled in the expanded existing Medicare program.”
• “Provider reimbursement for new beneficiaries will start above current Medicare rates for all providers, and be reduced every year as providers’ administrative and delivery costs decrease until they begin to approach the targets in my Medicare for All plan. It will be a new condition of participation that providers who take Medicare or other federally subsidized insurance also take the Medicare for All option. We will also adopt common sense reforms to bring down bloated reimbursement rates, including reforms around post-acute care, bundled payments, and site neutral payments.”
• “lift the upper limit on eligibility for Premium Tax Credits, allowing people over 400% of the federal poverty level to purchase subsidized coverage”
• “allow any person or family to receive ACA tax credits and opt into ACA coverage, regardless of whether they have an offer of employer coverage. If an individual currently enrolled in qualifying employer coverage moves into an ACA plan, their employer will pay an appropriate fee to the government to maintain their responsibility for providing employee coverage.”
• “Right now, people may pay up to 9.86% of their income before they get subsidies. Under my plan, this cap would be lowered – and to make sure those tax credits cover more, we will benchmark them to more generous “gold” plans in the Marketplace. And we will increase eligibility for cost sharing reductions, ensuring that more individuals can get into an affordable exchange plan immediately.”
• “Right now, if someone’s income goes up, they can be forced to repay thousands of dollars in back premiums. We will change this and base tax credits on the previous year’s income. And if someone’s income goes down, they will get the higher subsidy for that year.”
• “To help states try out different payer arrangements and pilot programs, we will allow states to receive passthrough funding to expand or improve coverage via the ACA’s Section 1332 waivers. Combined with Medicaid waivers, these changes will allow interested states to start experimenting immediately with consolidating public payers and move towards a single-payer system.”
• “boost medical research by investing an additional $100 billion in guaranteed, mandatory spending in the NIH over ten years, split between basic science and the creation of a new National Institute for Drug Development that will help take the basic research from the other parts of NIH and turn it into real drugs that patients can use”
• “invest $100 billion in federal funding over the next ten years in states and communities to fight [the opioid] crisis – providing resources directly to first responders, public health departments, and communities on the front lines of this crisis”
• “To cut down on time wasted on paperwork, we will create single standardized forms for things like prior authorizations and appeals processes to be used by all insurers (private and public), and we will establish uniform medical billing for insurers and doctors.”
• “Right now, there are so many middlemen in health care that no one knows for certain how much we pay for different services across the whole system. A centralized repository of de-identified claims data will help the government, researchers, and the market better understand exactly what we pay for health care and what kind of quality it gets us.”
• “ban non-compete and no-poach agreements and class action waivers across the board, while making it easier for private parties to sue to prevent anti-competitive actions. I’ll work with states to repeal Certificate of Public Advantage, or COPA, statutes that shield health care organizations from federal antitrust review and can lead to the creation of large monopolies with little to no oversight. And I’ll also push to ensure our antitrust laws apply to all health care mergers.”
• “end the practice of surprise [out-of-network] billing by requiring that services from out-of-network doctors within in-network hospitals, in addition to ambulances or out-of-network hospitals during emergency care, be treated as in-network and paid either prevailing in-network rates or 125% of the Medicare reimbursement rate, whichever is lower”
• “dramatically scaling up apprenticeship programs to build a health care workforce rooted in the community”
• “lift the cap on residency placements, allowing 15,000 new clinicians to enter the workforce”
• “expand the National Health Service Corps and Indian Health Service loan repayment program to allow more health professionals – including physicians, physician assistants, registered nurses, nurse practitioners, and other licensed practitioners – to practice in underserved communities”
• “provide grants to states that expand scope-of-practice to allow more non-physicians to practice primary care”
• “push to close the mental health provider gap in schools”
• “fight to pass legislation to complete the transition to the Medicare for All system defined by the Medicare for All Act by the end of my first term in office”
• “Moving to this system would mean integrating everyone into a unified system with zero premiums, copays, and deductibles”
• “for unions that seek specialized wraparound coverage and individuals with specialized needs, a private market could still exist”
• “allow private employer coverage that reflects the outcome of a collective bargaining agreement to be grandfathered into the new system to ensure that these workers receive the full benefit of their bargain before moving to the new system”
• “Medicare for All will sharply reduce administrative spending and reimburse physicians and other non-hospital providers at current Medicare rates”
• “rebalance rates in a budget neutral way that increases reimbursements for primary care providers and lowers reimbursements for overpaid specialties“
• “While private insurance companies pay higher rates, this system would be expected to continue compensating providers at roughly the same overall rate that they are currently receiving. Why? This is partially because providers will now get paid Medicare rates for their Medicaid patients – a substantial raise. But it’s also because providers spend an enormous amount of time on billing and interacting with insurance companies that reduces their efficiency and takes away from time with patients.”
• “reimburse hospitals at an average of 110% of current Medicare rates, with appropriate adjustments for rural hospitals, teaching hospitals, and other care providers with challenging cost structures”
• “my Medicare for All program maintains these base rate adjustments for geography and other factors. In my plan for Rural America, for example, I have committed to creating a new designation under Medicare for rural hospitals due to the unique challenges health systems face in rural communities. That’s why my plan allows for adjustments above the 110% average rate for certain hospitals, like rural and teaching hospitals, and below this amount for hospitals that are already doing fine with current Medicare rates.”
• “Today, for example, insurers can charge dramatically different prices for the exact same service based on where the service was performed. Under Medicare for All, providers will receive the same amount for the same procedure”
• “We can also make adjustments to things that we know Medicare currently pays too much for – like post-acute care – by adjusting those payments down slightly while accounting for the patient’s health status”
• “We build on the success of value-based reforms enabled by the Affordable Care Act, including by instituting bundled payments for inpatient care and for 90 days of post-acute care.”
• “Under Medicare for All, hospitals won’t be able to force some patients to pay more because the hospital can’t agree with their insurance company. Instead, because everyone has good insurance, providers will have to compete on better care and reduced wait times in order to attract more patients.”
• “I will appoint aggressive antitrust enforcers to the Department of Justice and Federal Trade Commission and allow hospitals to voluntarily divest holdings to restore competition to hospital markets. I’ve also previously committed to strengthening FTC oversight over health care organizations, including non-profit hospitals, to crack down on anti-competitive behavior. And I will direct my FTC to block all future hospital mergers unless the merging companies can prove that the newly-merged entity will maintain or improve care.”
• “Under Medicare for All, the federal government would have real bargaining power to negotiate lower prices for patients. I will adopt an altered version of the mechanism outlined in the Lower Prescription Drug Costs Now Act which leverages excise taxes to bring manufacturers to the table to negotiate prices for both branded and generic drugs, with no drug exceeding 110% of the average international market price, but removes the limit of the number of drugs Medicare can negotiate for and eliminates the “target price” so Medicare could potentially negotiate prices lower than other countries.”
• “If negotiations fail, I will use two tools – compulsory licensing and public manufacturing – to allow my administration to ensure patient access to medicines by either overriding the patent, as modeled in the Medicare Negotiation and Competitive Licensing Act, or by providing public funds to support manufacturing of these drugs, as modeled in my Affordable Drug Manufacturing Act.”
• “incentivize pharmaceutical companies to develop the drugs we need – like antibiotics, cancer cures, and vaccines”
• “Medicare for All covers each patient for their entire lifespan. There’s no perverse incentive to deny the prescriptions they need today because the long-term benefits to their health won’t benefit their current private insurance company”
• “if [healthcare spending] growth rates exceed this [projected average 10-year GDP growth of 3.9%], I will use available policy tools, which include global budgets, population-based budgets, and automatic rate reductions, to bring it back into line”
• “Over the next ten years, individuals will spend $11 trillion on health care in the form of premiums, deductibles, copays, and out-of-pocket costs. Under my Medicare for All plan, that amount will drop from $11 trillion to practically zero.”
• “instead of [American] companies sending those payments to private insurance companies, they would send payments to the federal government for Medicare in the form of an Employer Medicare Contribution.”
• “People who are self-employed would be exempt from making Employer Medicare Contributions unless they exceed an income threshold.”
• “Small businesses – companies with under 50 employees – would be exempt from this [Employer Medicare Contributions] requirement too if they aren’t paying for employee health care today. When either new or existing firms exceed this employee threshold, we would phase in a requirement that companies make Employer Medicare Contributions equal to the national average cost of health care per employee for every employee at that company.”
• “Employers currently offering health benefits under a collective bargaining agreement will be able to reduce their Employer Medicare Contribution if they pass along those savings to workers in the form of increased wages, pensions, or other collectively-bargained benefits. New companies or existing companies who enter into a collective bargaining agreement with their employees after the enactment of Medicare for All will be able to reduce their Employer Medicare Contributions in the same way. Employers can reduce their contribution requirements all the way down to the national average health care cost per employee.”