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The Health 202: CBO analysis shows single-payer health system would be messy

with Paulina Firozi


The highly anticipated analysis released yesterday by a nonpartisan organization on Medicare-for-all told us this much: Transitioning the United States to such a single-payer health-care system would be messy. Very messy.

In a 30-page report that laid out more questions than answers, the Congressional Budget Office detailed the pros and cons of moving the country’s health-insurance system — currently a patchwork of government programs, employer-sponsored coverage and subsidized private plans for individuals — into a unified single-payer system.

“The transition toward a single-payer system could be complicated, challenging, and potentially disruptive,” the CBO wrote in its report, which was requested early this year by House Budget Committee Chairman John Yarmuth (D-Ky.). Yarmuth said he’ll hold a hearing on the idea of a single-payer system later this month.

New York Times reporter Margot Sanger-Katz:

The CBO report only intensified an already heated debate over Medicare-for-all that’s been playing out on Capitol Hill this week, as Democrats weigh different ways to extend coverage to the remaining 29 million uninsured Americans. 

Medicare-for-all would set up a single-payer system in which private insurance would be abolished and the government would  provide coverage to Americans.

On Tuesday, the House Rules Committee held a day-long hearing on a sweeping plan by Rep. Pramila Jayapal (D-Wash.) that would scrap all private health coverage in favor of a generous but expensive government-backed set of medical benefits.

And yesterday, several Democrats jumped to reintroduce more-measured legislation which would allow people to keep their employer-sponsored plans but would make Medicare-like coverage available to those who wanted it.

Medicare for America, from Rep. Rosa DeLauro (D-Conn.) and Jan Schakowsky (D-Ill.), would gradually, over a six-year period, transition those in the Obamacare marketplaces and Medicaid into coverage that’s more comprehensive than what traditional Medicare plans currently cover. Any employer-sponsored plans would have to provide premium benefits, but employees could also put their employer’s health insurance contribution toward one of the new Medicare plans.

Choose Medicare, from Sens. Chris Murphy (D-Conn.), Jeff Merkley (D-Ore.) and Dianne Feinstein (D-Calif.), would preserve the marketplaces but supply them with a Medicare-type plan people could purchase with the help of Obamacare subsidies. Employers could also choose a new “Medicare Part E” plan to cover their workers instead of buying commercial coverage. Thirteen other Senate Democrats — including three running for president — have signed on to the measure.

The Democrats backing these types of plans say they’re a more realistic way of improving the U.S. health-care system than the dramatic overhauls suggested by Jayapal and Sen. Bernie Sanders (I-Vt.).

The CBO, in its report issued yesterday, didn’t give a specific estimate for the cost of Jayapal and Sanders’s bills, which would almost certainly cost tens of trillions of dollars over a decade. But it cautioned that several components of these measures — including covering long-term care for seniors and the elderly and virtually zero cost-sharing — would add heavily to the cost of any single-payer system.

Long-term care is a particular challenge to cover, the agency noted, because most of those services are currently provided by family members as unpaid labor. And a balance must be struck between requiring people to share in the cost of their care — to discourage overuse of medical services — and ensuring they don’t face heavy financial burdens when they need care.

The CBO also warned that lawmakers and policymakers would face a host of decisions about which medical benefits would be covered, how much doctors and hospitals would be paid and how prescription drug prices would be negotiated — all factors that play into the total cost of Medicare-for-all and the quality of health coverage Americans would get under it.

Here’s one way to think about it. Employers and households currently foot the bill for just under half of all national health-care spending — about $3.5 trillion in 2017. The government pays the rest, through programs such as Medicare and Medicaid. But under Medicare-for-all, the government would take on most of that spending.

“Shifting such a large amount of expenditures from private to public sources would significantly increase government spending and require substantial additional government resources,” the CBO wrote.

But the agency also acknowledged that total national health spending wouldn’t necessarily increase under Medicare-for-all — in fact, there's a possibility it might decrease depending on the services covered, provider payment rates and patient cost-sharing requirements (I discussed this question in this Health 202). It would almost certainly cost less to administer; the CBO noted that administrative costs average 6 percent of Medicare spending but 12 percent of private insurers’ spending.

The political hurdles to passing Medicare-for-all were quickly evident in Republican — and industry — reactions to the report, my Washington Post colleague Amy Goldstein reports. Chip Kahn, president of the Federation of American Hospitals, called a single-payer system “a high-stakes gamble.”

“Is it worth the risk of upending health care for every American when the law on the books already contains a road map to universal coverage?” Kahn said in a statement.


AHH: The Trump administration wants $4.5 billion in emergency border funding, citing a record number of Central American families and children who are seeking to enter the United States.

The spending request the White House sent to Congress includes $3.3 billion for humanitarian assistance and $1.1 billion for border operations, money that would be in addition to the more than $8 billion the president called for in his 2020 budget request and the $6 billion in funding he requested when he declared a national emergency at the border this year, our Post colleagues Erica Werner, Maria Sacchetti and Nick Miroff report.

Administration officials said most of the requested funds would be used for the shelter and care for the influx of migrant families at the border.

White House acting budget director Russ Vought said the Department of Health and Human Services will run out of money for child welfare services in June. “If that happens, the agency will have to divert critical resources from other programs, will cancel or scale back any services not necessary for protection of human life, and will be forced to leave children in Department of Homeland Security detention facilities where they are not supposed to stay for longer than 72 hours,” our colleagues write.

“In the worst-case scenario, thousands of children might remain for lengthy periods of time in facilities that were never intended to be long-term shelters,” Vought wrote to lawmakers.

House Appropriations Committee Chairwoman Nita Lowey (D-N.Y.) said she would review the request but also slammed the administration, suggesting it “appears to want much of this $4.5 billion emergency supplemental request to double down on cruel and ill-conceived policies, including bailing out ICE for overspending on detention beds and expanding family detention.”

OOF: Humana CEO Bruce Broussard is the latest health insurance executive to weigh in on the Medicare-for-all debate, insisting the insurer would not support legislation that eliminates private coverage.

Broussard told investors on an earnings call yesterday that Humana “does not support any bill” that would “make private insurance illegal” or otherwise get rid of Medicare Advantage, which is private supplemental coverage for seniors covered by Medicare, CNBC’s Berkeley Lovelace Jr. reports.

UnitedHealth Group has been working to steer Democrats away from such a single-payer program, too. Our Post colleague Jeff Stein reported in April that an executive told employees at a company town hall meeting that the private health insurance giant has “done a lot more than you would think” in weighing in on the debate over Medicare-for-all.

“Wary of bringing unwanted political controversy to their companies, some private health-care firms have in part relied on advocacy groups and lobbyists in their fight against Medicare-for-all — joining the push without leaving too many company-specific fingerprints,” Jeff wrote.

Merlene Fredericks-James, chief medical officer of St. Lucia's Ministry of Health and Wellness, said a cruise ship was quarantined due to reports of measles. (Video: St. Lucia Ministry of Health and Wellness)

OUCH: Hundreds of people have been quarantined on a cruise ship in the Caribbean port of St. Lucia after a female crew member was confirmed to have a case of the measles.

The island has not seen a local outbreak of the measles since 1990, according to a statement from the acting national epidemiologist, Michelle Francois. But because of the record surge of the highly contagious disease in the United States, as well as in other areas with tourism links to St. Lucia, many have been preparing for such a spread, our Post colleague Reis Thebault reports.

“No one was allowed to leave the ship,” said St. Lucia’s chief medical officer Merlene Fredericks James in a statement. “Because of the risk of potential infection, not just from the confirmed measles case but from other persons who may be on the boat at the time, we thought it prudent to make a decision not to allow anyone to disembark.”

The latest quarantine comes as the number of measles cases in the United States hit a 25-year record in April, with at least 704 people who have been sickened this year by the potentially life-threatening disease.

Although health officials did not name the cruise ship now on lock down, Reis writes a sergeant with the St. Lucia Coast Guard told NBC the ship is associated with Church of Scientology.

— The Trump administration formally called on a federal appeals court to overturn the Affordable Care Act, arguing in new court filings that the law “should not be allowed to remain in effect.”

Justice Department officials laid out their argument in a brief filed with the U.S. Court of Appeals for the 5th Circuit, acknowledging that the administration reversed course after previously arguing that only certain parts of the health-care law should be invalidated, CNN’s Ariane de Vogue reports.

“Instead of rewriting the statute by picking and choosing which provisions to invalidate, the proper course is to strike it down in its entirety,” Assistant Attorney General Joseph Hunt wrote in the filing.

Senate Minority Leader Chuck Schumer (D-N.Y.) called the brief “heartless and wrong.” "This action only proves President Trump and his Department of Justice would rather make political points than defend our health care law that protects the 133 million Americans with pre-existing conditions, has provided tens of millions more Americans with health insurance coverage, and has lowered prescription drug costs for millions of seniors," Schumer said in a statement.

California Attorney General Xavier Becerra, who is leading a group of Democratic states to defend the ACA, said in a statement the “legal coalition will vigorously defend the law and the Americans President Trump has abandoned.”


— Actor Ben Stiller appeared before the Senate Foreign Relations Committee yesterday to testify about the humanitarian crisis in Syria.

Stiller, who is a goodwill ambassador for the Office of the U.N. High Commissioner for Refugees, told lawmakers about his recent visit to refugee camps, including in Berlin, Jordan and Lebanon where he met Syrian families, among them a family whose friend suggested they sell their newborn to “help make ends meet." “The suggestion sheds light on the family’s desperate circumstances,” Stiller said.   

Stiller, who acknowledged the United States remains UNHCR’s largest donor, called for continued support for host countries to create long-term infrastructure that will help with growing refugee populations. “We need to help them ensure that their health services, education systems and livelihood opportunities are available to refugees,” he said. “And also that the needs of their own citizens are addressed, so that both groups are able to thrive.”

— A House Appropriations subcommittee this week advanced by a voice vote a more than $200 billion spending bill for the departments of Labor, Health and Human Services, Education, and other related agencies. No Republicans on the subcommittee voted for the measure, which includes provisions meant to block the Trump administration’s efforts to impose family planning restrictions on abortion providers as well as funds for the National Institutes of Health and the Centers for Disease Control and Prevention to conduct gun violence research.

“The bill would provide substantial funding increases to the departments it funds, setting a high bar for spending as House Democrats begin working on fiscal 2020 appropriations,” CQ’s Andrew Siddons writes. “HHS would receive $8.5 billion in new funding. The bill would provide HHS with $99 billion, but that doesn’t include the Food and Drug Administration or the Indian Health Service, which each have budgets in the $5 billion-to-$6 billion range. Those divisions are funded in spending bills that have not yet been released.”


— The Kansas state Senate failed by one vote yesterday to advance a bill to expand Medicaid, a blow for Gov. Laura Kelly (D), who has made the issue a priority.

"Democrats tried to use a procedural motion to override Senate leaders and keep expansion alive in the waning days of the legislative session,” the Kansas City Star’s Andy Marso and Jonathan Shorman report. “But the 40-member chamber needed 24 votes and the motion failed 23-13 after Senate majority leader Jim Denning, a Republican from Overland Park, voted ‘pass’ rather than ‘aye’ or ‘nay.’ ”

Kelly criticized Denning and the state Senate’s Republican president in a statement following the vote.

“There are only two senators — Susan Wagle and Jim Denning — who are preventing a vote on this bill,” Kelly said. “There are two senators who are preventing 150,000 hardworking Kansans from having access to health care.”

The governor added: “It is very clear that a strong majority in the Kansas Senate support Medicaid expansion and want the opportunity to debate and vote on it this year.”

From Kelly: 


— In a new op-ed in USA Today, health-care access expert Ted Slafsky writes that a repeal of the ACA would disrupt health care in many of the rural areas that backed President Trump in the 2016 presidential campaign.

“President Trump remains very popular in small town America,” writes Slafsky, former president and chief executive of 340B Health, a group representing hospitals and health systems. “That makes his recent decision to go full monty on repealing the Affordable Care Act that much more puzzling and politically unwise.”

Slafsky pointed to the ACA's expansion of a drug discount program to more hospitals, many in rural areas. “If the ACA is repealed, lower-priced pharmaceuticals go away in rural America,” he writes.

— And here are a few more good reads: 

Texas SNAP recipients may face ban on junk food and sugary drinks (Laura Reiley)

Sanders criticizes Biden health plan: 'It doesn't go anywhere near far enough' (The Hill )


Trump says the border crisis is about criminals and gangs. His administration says it is about families and children. (David Nakamura)

Trump’s claim of ‘amazing’ success in cutting opioid prescriptions (Glenn Kessler)


Doctors, health officials push to end restrictions on key addiction treatment (Stat)


CMS, Treasury want more ideas to boost state uptake of ACA waivers (Modern Healthcare)


Alex Trebek on his cancer: ‘My oncologist says I’m doing well, even though I don’t always feel it’ (Deanna Paul and Sonia Rao)

Like ‘Uber for Organs’: Drone Delivers Kidney to Maryland Woman (New York Times)


‘They’re doing it on the backs of patients,’ one cancer center warns Congress about robocalls (Tony Romm)



  • The House Veterans Affairs Subcommittee on Health holds a hearing on women veterans’ access to health care.

Coming Up

  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on the 21st Century Cures Act on May 7.

From The Post's Fact Checker:Trump’s claim of ‘amazing’ success in cutting opioid prescriptions:

Trump suggests he reached a three-year goal in one year. But the trend started under President Obama. (Video: Meg Kelly/The Washington Post)