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: Medicare for All Act (H.R. 1384, 116th Congress)

Proposal sponsor/author: Rep. Pramila Jayapal (D-WA)

Proposal version date: 2/27/2019

Related proposal: S. 1804, 115th Congress, Sen. Bernie Sanders (I-VT)

Summary of Proposal

Creates a federally run, nationwide health insurance program (often described as a "single-payer" program) to cover all U.S. residents, replacing existing private and public health insurance programs. (Also creates a temporary option for people to buy public coverage during the transition period to this new single-payer program. That temporary option is not analyzed here.)

Ensure Comprehensive Insurance Coverage for Everyone

Provide coverage to all without cost or paperwork barriers: Enrolls all U.S. residents in a new national health insurance program. Appears intended to include both documented and undocumented immigrants: Prohibits people from being excluded from the program on the basis of citizenship status, and asks the Department of Health and Human Services (HHS) to "ensure that every person in the United States has access to health care." Does not require premiums but would presumably require new federal taxes on individuals and companies.

Cover the complete scope of sexual and reproductive health services without barriers: Requires coverage for 14 categories of health benefits, including "comprehensive reproductive, maternity, and newborn care." A fact sheet from the bill’s sponsor says it includes abortion, though abortion and other specific reproductive health services are not listed in the bill itself. HHS has authority to make policy on benefits covered and what is "medically necessary or appropriate," 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). Prohibits cost sharing (e.g., copays) for all services and gives patients a legal right to coverage, which should limit barriers to care.

Build and Maintain a Robust Provider Network

Ensure that patients may seek care from any qualified provider: Allows patients to receive care from any provider that is qualified, as determined by HHS. Includes explicit protections for providers who offer reproductive health services (like Planned Parenthood) to ensure they may not be excluded for reasons other than their ability to provide care.

Fully reimburse providers and invest in their education, facilities and technology: Creates a national budget for the program to pay for patient health services, health professional education, investment in facilities and equipment, prevention and public health activities, and more. This budget would subsume many existing federal programs, possibly including the Title X national family planning program. Completely overhauls how institutional and individual providers will be funded; promising items include requiring the budget to allow for every participating provider "to meet the needs of their respective patient populations" and specifically investing in rural and medically underserved areas. Leaves numerous implementation decisions up to HHS.

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: Requires health care providers to "advocate for and to act in the exclusive interest" of their patients, and bars financial incentives (such as "pay for performance") that could undermine patient care. Requires HHS to protect patient privacy in studying health quality and outcomes. Does not include provisions to promote patients’ right to provide informed consent to care; guarantee that patients receive appropriate information, referrals or care; or address the potential harm of refusals of care by institutions or individuals.

Fight discrimination and promote equitable health care access and experiences: Includes anti-discrimination protections for patients "on the basis of race, color, national origin, age, disability, marital status, citizenship status, primary language use, genetic conditions, previous or existing medical conditions, religion, or sex, including sex stereotyping, gender identity, sexual orientation, and pregnancy and related medical conditions (including termination of pregnancy)." Requires data collection and reports on health inequities and disparities, and national goals and plans to improve services in underserved areas and for underserved populations.

Overall Assessment

Strengths:

• Designed to provide comprehensive, cost-free health insurance coverage for all U.S. residents, regardless of immigration status.
• Explicitly covers reproductive health services as a category and lifts federal restrictions on that coverage.
• Includes specific protections for providers who offer reproductive health services.
• Establishes strong anti-discrimination protections for patients, requires providers to act exclusively in their patients’ interest, and includes steps to address health inequities and reach underserved populations.
• Under a supportive administration, would have strong potential on multiple fronts to address sexual and reproductive health needs.

Weaknesses:

• The program’s overhaul of funding for providers could lead to major disruptions (e.g., the potential elimination of dedicated funding streams for sexual and reproductive health care, such as Title X), but has the potential to improve investment overall in providers that serve low-income and underserved populations.
• Does not include many important patient protections against coercion or address many current barriers to care.
• Under a hostile administration, many specific sexual and reproductive health services could be excluded from coverage (perhaps with the justification that those services could be covered under separate, privately purchased insurance plans).