• Medicare eligibility expansion to people starting at age 55 is the most likely option if Democrats sweep 2020, says a former CMS administrator.
  • Existing Medicare expansion bills would pay Medicare FFS rates.
  • Limited Medicare expansions are the most popular among Democratic coverage proposals.

April 26—If everything goes right for Democrats in the 2020 election, the most likely Medicare expansions are not the ones getting the headlines now, says a former Medicare administrator.

Tom Scully, JD, administrator of the Centers for Medicare & Medicaid Services (CMS) under President George W. Bush, said a Democratic sweep of the White House and both congressional chambers would be most likely to result in a 10-year expansion of the start of Medicare eligibility and a so-called public option based on Medicare.

"They’ll put out a Medicare Advantage-like plan and say, 'If you’re between 55 and 65 or various other people, you can buy into local Medicare Advantage [MA] plans,'" Scully said in an interview this week. "I don’t think Republicans will like it, but that’s the only thing that’s going anywhere." 

Various types of proposals in play

Among the eight Democratic bills introduced so far to expand Medicare in various ways — or to use it as the nominal basis for a single-payer system — the Medicare buy-in approach was the focus of two bills. Companion bills sponsored by Rep. Brian Higgins (D-N.Y.) and Sen. Debbie Stabenow (D-Mich.) were introduced in February. However, those bills would differ in key ways from the sort of legislation Scully envisions.

These "Medicare at 50" bill provisions would:

  • Allow buy-in starting at age 50
  • Add the option of Medicare Parts A, B and D, or an MA plan to Affordable Care Act (ACA) marketplaces
  • Use Medicare payment rates
  • Include Medicare limits on balance billing

The bills also include provisions allowing the secretary of the U.S Department of Health and Human Services to negotiate drug prices.  

The bills differ from the "Medicare X Choice Act" sponsored by Sen. Michael Bennet (D-Colo.) — and a companion bill by Rep. Antonio Delgado (D-N.Y.) — in many ways. For instance, the Bennet bill would use "Medicare’s network of doctors and providers," but its benefits would mirror not those of Medicare but the very different mandatory coverage requirements for ACA marketplace plans.

 The Medicare public-option bills have had a much lower profile than "Medicare for All" proposals, such as the one from Sen. Bernie Sanders (I-Vt.). However, the Stabenow bill has been co-sponsored by 20 Democratic senators, including several running for president, which indicates its appeal in that party.

Similarly, Higgins’ bill, the "Medicare Buy-In and Health Care Stabilization Act of 2019", has 34 co-sponsors.

Medicare buy-in approaches seem popular

Medicare buy-in approaches are among the most popular of the Democratic proposals, said Karen Pollitz, a senior fellow at the Henry J. Kaiser Family Foundation (KFF). The latest KFF polling found 77% "strongly or somewhat favor" a Medicare buy-in option starting at age 50. Only 18% oppose it.

"And it is very bipartisan. 'Medicare for All' is mostly [Democrats] versus [Republicans]," Pollitz said in an interview.

Among the KFF poll findings:

  • 56% support single-payer options
  • 42% oppose single-payer options
  • 81% of Democrats support single-payer bills
  • 23% of Republicans support single-payer bills

However, a Reuters/Ipsos poll found that even Democratic voters' support for a "Medicare for All" system would collapse if it raised their taxes or did not deliver the same quality of care.

Another complicating factor in the push for Medicare expansion is that a majority of Democrats (51%) prefer that Congress focus on bolstering the ACA rather than move toward a single-payer option (38%), according to the KFF poll.

Other approaches that could be in play

A Democrat-dominated federal government also would be most likely to launch "a big push" to get any states that have not undertaken Medicaid eligibility expansion, as allowed under the Affordable Care Act, (ACA) to do so, Scully said.

The coverage-expansion approach that Scully backs would open eligibility nationally to the Federal Employee Health Benefits program, which provides a subsidy to federal workers to buy coverage from private plans. However, no current legislation exists to create such a system.

If President Donald Trump and Republicans triumph in 2020, Scully expects them to return with some version of the repeal-and-replace legislation that narrowly failed in 2017. Scully backed that bill’s use of per-capita caps for Medicaid, with funding allowed to increase when enrollments surge during recessions.

"The reason for per-capita caps is that the Medicaid structure is broken because states have all of these bizarre ways, such as intergovernmental transfer, where a lot don’t put any money in Medicaid," Scully said. "A per-person cap is a way to fix the Medicaid program economically, get it to work better."


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Friday, April 26, 2019