Analysis Law and Policy

‘Medicare-X’ Would Create a Public Option—Without Expanding Access to Reproductive Health Care

Ally Boguhn

Kaine and Bennet’s bill wouldn’t address reproductive health care beyond requiring essential health benefits be covered, unlike other versions of a public option introduced in Congress.

U.S. Sens. Tim Kaine (D-VA) and Michael Bennet (D-CO) last week re-introduced a “Medicare-X” bill to create a public plan for health insurance, but the legislation would do little to protect or expand access to reproductive health care at a time when it is increasingly imperiled.

The Medicare-X Choice Act of 2019, according to a summary of the legislation, would “build on the Medicare framework to establish a public option on the individual and small business exchanges.” In 2021, the plan would be “available in areas with one or fewer options on” the Affordable Care Act’s (ACA) marketplaces and in places “with a shortage of providers or a lack of plan competition.” By 2024, the public option would be available nationwide, and by 2025, it would also be available on the Small Business Health Options Program (SHOP) Exchange, which is run by the government to allow small businesses to offer health insurance options to their workers. The plan would be funded through premiums.

The bill text makes no explicit references to reproductive health care and abortion care. According to an analysis of the Medicare X bill from Guttmacher, provided exclusively to Rewire.News, this means “existing federal and state abortion coverage restrictions would apply. Depending on how those restrictions are interpreted and applied by the federal administration, abortion coverage would be banned either in at least half the states or in all states.”

The bill does, however, mandate that states with a Medicare X plan comply with the ACA’s required coverage of essential health benefits, a set of ten categories of services that all health insurance plans in the United States must cover. “Medicare-X would operate within the Affordable Care Act framework and it’s consistent with the ACA’s provisions with respect to women’s health and abortion,” a spokesperson for Kaine’s office told Rewire.News by email. “These essential health benefits also require coverage of preventive care without a copay or coinsurance—including breastfeeding support and contraception.”

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Guttmacher’s analysis of the Medicare-X legislation says this application of “current ACA protections to the new public option, including subsidies, antidiscrimination rules, and coverage requirements for contraception, maternity care and other services” is a strength of the proposal.

Adam Sonfield, senior policy manager at the Guttmacher Institute and co-author of the analysis, told Rewire.News that relying on the ACA to build out a public option isn’t a bad thing. “I don’t think that’s a knock against this bill or any of the other public option bills,” he said. “Building on the ACA is a completely reasonable strategy. … It makes a lot of sense.”

The Trump administration has tried to undermine access to reproductive health care through the ACA by seeking to expand religious and moral exemptions to some of its requirements, such as the birth control benefit. Those “have been held up in the courts, but if they ever went into effect you could have many more employers refusing to cover contraception or to cover certain contraceptive methods,” Sonfield said.

“One of the things we’ve been emphasizing is specificity in the law,” said Sonfield, who pointed to a set of principles recently outlined by Guttmacher to better address sexual and reproductive health in reform efforts. “We tried it this way, where you didn’t list out all the specific services that plans need to cover. You didn’t list all the specific protections the patients would have had, and the idea was that the administration would fill in those details and do it in good faith. Now what we’re seeing is that you can’t rely always on the good faith [in] the administration and that if it’s not spelled out in detail, a hostile administration can do a lot of damage.”

“That’s why we’ve been encouraging lawmakers to be more specific about reproductive health services in particular in their bills, because those are the services that are getting attacked,” said Sonfield.

Though Kaine and Bennet’s bill wouldn’t address reproductive health care aside from requiring essential health benefits be covered, other versions of a public option introduced in Congress do. Democratic Sen. Jeff Merkley’s (OR) 2018 “Choose Medicare Act” states that the plans it would create—“Medicare Part E” plans—would provide “coverage of abortions and all other reproductive services.” Recent versions of the House and Senate’s “State Public Option Act” sponsored by Sen. Brian Schatz (D-HI) and Rep. Ben Ray Lujan (D-NM) also require “comprehensive reproductive health care services, including abortion services.”

More sweeping “Medicare-for-All” bills cover abortion care—such as Sen. Bernie Sanders’ (I-VT) Medicare for All bill and Rep. Pramila Jayapal’s (D-WA) “Medicare For All Act of 2019.”

Public option proposals like Medicare-X would “establish a federal public plan option to build upon, rather than replace, the current blend of private insurance and public coverage,” according to a 2018 issue brief from the Kaiser Family Foundation. “In general, the bills aim to address some of the shortcomings in ACA marketplaces by giving individuals and employers a new option that may provide more affordable coverage.”

As Vox’s Sarah Kliff explained in 2017, “Medicare X and single-payer represent distinctly different views of the future of American health care and what role the federal government ought to play. Medicare X fits neatly into the system that exists right now. It slots into the Affordable Care Act’s marketplaces and Medicare’s doctor network,” she explained. “Single-payer, by contrast, is a much more radical change—one where a government health plan is not a choice but the only option available. It abolishes the Obamacare marketplaces as well as employer-sponsored coverage.”

Bennet, who has signaled interested in the Democratic presidential nomination, said his legislation was “a much more practical way to try to achieve the objective—which is universal coverage and a primary reduction of our expenditures on health care—than, frankly, any other proposal that’s been made since the Affordable Care Act was passed,” in a recent call with reporters, according to the Denver Post.

The Medicare-X bill is co-sponsored by Democratic Sens. Ben Cardin (MD), Patrick Leahy (VT), Tina Smith (MN), Debbie Stabenow (MI), Gary Peters (MI), and Dick Durbin (IL), as well as 2020 Democratic presidential contenders Sens. Cory Booker (NJ), Kamala Harris (CA), and Amy Klobuchar (MN).

Bennet’s office did not reply to a request for comment from Rewire.News.

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