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-X Choice Act (S. 981 and H.R. 2000, 116th Congress)

Proposal sponsor/author: Sen. Michael F. Bennet (D-CO) and Rep. Antonio Delgado (D-NY)

Proposal version date: 4/2/2019

Summary of Proposal

An incremental approach to health reform that establishes a public option for individual and small-group plans to be sold on the Affordable Care Act’s (ACA) health insurance marketplaces. Maintains ACA coverage and eligibility standards, and uses Medicaid and Medicare provider networks. More generally, establishes a reinsurance program to control premium costs and expands ACA premium subsidies.

Ensure Comprehensive Insurance Coverage for Everyone

Provide coverage to all without cost or paperwork barriers: Provides new public options for U.S. residents already eligible to purchase private insurance through the ACA’s individual or small-group marketplaces. Consistent with the existing ACA rules, blocks undocumented immigrants and Deferred Action for Childhood Arrivals (DACA) recipients from coverage. For the ACA marketplaces overall, increases premium subsidies for individuals with incomes below 400% of the federal poverty level (FPL) and expands subsidies to people above 400% FPL. For individual-market health insurance on or off the ACA marketplaces, establishes a nationwide reinsurance program, which would protect insurance plans against unexpected costs and thereby lower premiums.

Cover the complete scope of sexual and reproductive health services without barriers: Requires coverages for the ACA’s 10 essential health benefits (which specifically include maternity, contraceptive and some STI and reproductive cancer care). Does not directly address abortion care, but existing state- and federal-level restrictions on ACA marketplace plans would apply; the end result would be no abortion coverage in most or all states. ACA marketplace cost-sharing rules and subsidies would apply.

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 Medicaid and Medicare networks (though providers may opt out), 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: Offers providers Medicare reimbursement rates, which are generally lower than rates under private insurance, and elevated reimbursement for providers in rural areas.

Keep pace with emerging services and methods, such as telehealth: Allows innovative payment mechanisms and delivery system reforms intended to improve health outcomes and health care quality. Establishes processes and grants to integrate medical care with other social services (e.g., housing and transportation) and requires telehealth tools to be integrated into medical care.

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: Requires innovative payment mechanisms to address health disparities (including racial and ethnic disparities) and geographic variation in the provision of care. Otherwise, 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 subsidies and funds a nationwide reinsurance program, all of which could lower insurance costs and expand coverage.
• Applies current ACA protections to the new public option, including subsidies, antidiscrimination rules, and coverage requirements for contraception, maternity care and other services.
• Provides new investments in delivery system and payment reform, including efforts to reduce health disparities, expand the use of telehealth and integrate health care with programs addressing social determinants of health.

Weaknesses:

• Omits any provisions specifically designed to address sexual and reproductive health.
• 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.
• Maintains the ACA’s existing restrictions that exclude undocumented immigrants and DACA recipients from buying coverage, with or without government subsidies.