Note: This analysis was updated on May 22, 2019 to reflect the version of the bill introduced for the 116th Congress.

The Guttmacher Institute is evaluating how sexual and reproductive health and rights fit into U.S. health care reform efforts. Previous analyses have described people’s wide array of sexual and reproductive health needs and laid out a set of principles for how to address them within the health care system. This analysis applies those principles to one specific health care reform proposal. Evaluations of additional proposals can be found here.

Proposal name and bill number: Choose Medicare Act (S. 1261 and H.R. 2463, 116th Congress)

Proposal sponsor/author: Sen. Jeff Merkley (D-OR) and Rep. Cedric L. Richmond (D-LA)

Proposal version date: 5/1/2019

Summary of Proposal

An incremental approach to health reform that creates new public health plans (known as Medicare Part E plans) that would be available as options for people buying individual-market insurance plans on or off of the Affordable Care Act’s (ACA) health insurance marketplaces and for employers offering insurance to their employees. Also establishes a reinsurance program to control premium costs and expands ACA premium and cost-sharing subsidies

Ensure Comprehensive Insurance Coverage for Everyone

Provide coverage to all without cost or paperwork barriers: Provides new options for U.S. residents purchasing individual-market insurance, including through the ACA’s marketplaces, and for employers offering insurance to their employees. Requires patients to pay monthly premiums, but the ACA’s premium subsidies would be available for people buying coverage through the ACA marketplaces.

No explicit restrictions related to immigration status; however, "residency" would be defined by the U.S. Department of Health and Human Services (HHS), providing a hostile administration an opportunity to exclude many immigrants. In addition, keeps existing ACA rules blocking undocumented immigrants and Deferred Action for Childhood Arrivals (DACA) recipients from buying coverage through the ACA marketplaces or receiving ACA premium subsidies.

For the ACA marketplaces overall, increases premium subsidies and expands them to individuals with incomes below 600% of the federal poverty level (FPL), up from the current limit of 400% FPL. Also provides federal funding for state programs to reduce individuals’ out-of-pocket costs in the ACA marketplaces and for state-based reinsurance programs, which would protect individual-market insurance plans (on or off the ACA marketplaces) against unexpected costs and thereby lower premiums.

Cover the complete scope of sexual and reproductive health services without barriers: Requires coverage for all current Medicare benefits, the ACA’s 10 essential health benefits (which specifically includes maternity, contraceptive and some STI and reproductive cancer care, under current rules), and "abortions and all other reproductive services." HHS has authority to make policy on benefits covered, which leaves room for abuse. Includes language intended to override restrictions on the use of federal funds for abortion coverage and care (like the Hyde Amendment), explicitly overrides state laws that exclude abortion services from coverage, and includes a "sense of Congress" that all restrictions on reproductive health coverage in the private insurance market should end. Allows cost sharing (e.g., copays) for most services but expands the ACA’s subsidies to help patients afford cost sharing.

Build and Maintain a Robust Provider Network

Ensure that patients may seek care from any qualified provider: Allows access, with no apparent restrictions, to providers already in the Medicare network, as well as additional providers who choose to accept this coverage. Does not include any explicit protections for patients seeking care from reproductive health providers or providers seeking to participate in the network.

Fully reimburse providers and invest in their education, facilities and technology: Requires HHS to negotiate reimbursement rates with providers that are sufficient to maintain an adequate provider network and that are, in the aggregate, at least as high as Medicare rates and no higher than average rates in ACA marketplace plans.

Keep pace with emerging services and methods, such as telehealth: Not addressed.

Guarantee and Enforce Strong Patient Protections

Eliminate legal, cultural and safety-related barriers to care: Not addressed.

Respect patients’ privacy and autonomy and guard against coercion: Existing ACA protections would apply. Most notably, the ACA prevents the federal government from interfering with the principle of informed consent, patient-provider communication and patients’ timely access to care.

Fight discrimination and promote equitable health care access and experiences: Existing ACA provisions would apply, including its strong antidiscrimination protections for patients.

Overall Assessment

Strengths:

• Creates new insurance options to encourage competition, expands ACA premium and cost-sharing subsidies, and funds state-level reinsurance programs, all of which could lower insurance costs and expand coverage.
• Explicitly covers abortion and "all other reproductive health services" as a category, lifts federal restrictions on that coverage and overrides state restrictions on abortion coverage.
• Applies current ACA protections to the new public option, including subsidies, antidiscrimination rules, and coverage requirements for contraception, maternity care and other services.
• Under a supportive administration, would have strong potential to expand health insurance access to many immigrants and other groups whose coverage choices are currently limited.

Weaknesses:

• Under a hostile administration, many specific sexual and reproductive health services and the providers who offer them could be excluded from coverage.
• Maintains the ACA’s existing restrictions that exclude undocumented immigrants and DACA recipients from buying ACA marketplace coverage and receiving ACA subsidies, and under a hostile administration, many immigrants (who could be defined as not being U.S. residents) could be excluded from coverage entirely.

.