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What Medicare for All Could Mean for Chronic Illness, Disability and Mental Health


On Wednesday, Vermont Sen. Bernie Sanders and 2020 presidential hopeful released a formalized outline of what his idea of health care reform would look like. He’s not the first to propose a new way of doing health care in the U.S. and as we head into the next big election, he certainly won’t be the last.

No matter your politics, ideas like “Medicare for All” or “Medicare buy-in” health care are driving the debate about health policy heading into the 2020 presidential election. To find out what this could mean for people who live with chronic illness, disability and mental health conditions, we spoke to three health policy experts.

What Kind of Health Care Do We Have Now?

Health care in America is complicated, so let’s start with a brief overview of the major health care and health insurance systems we have now for adults. These range from completely self-funded to paid for by the government: 

  • Private insurance: Health care coverage through employers or purchased independently from a private health insurance company
  • Medicaid: A state and government-sponsored health care program available to low-income U.S. residents, including people with disabilities
  • Affordable Care Act exchange insurance: Health insurance purchased through a private company in a government-subsidized marketplace enacted under President Barack Obama in 2010

What New Plans Are Politicians Proposing?

While politicians on the campaign trail and currently in office throw around many terms for potential health care reform like “Medicare for All” and “Medicare buy-in,” so far there hasn’t been a concrete plan proposal that’s likely to become law. Partly this is because health care in the U.S. is incredibly complicated. However, health policy experts see a few common threads in proposed health care change ideas.

Nancy Nielsen, M.D., Ph.D., senior associate dean for health policy at University of Buffalo’s Jacobs School of Medical and Biomedical Sciences, highlights that health care reform could take various forms, including:

  • Medicare for All: A single national health insurance program for all U.S. residents
  • Medicare buy-in: The ability to buy in (or pay to opt-in) earlier to the current Medicare system (beginning at age 50 or 55)
  • New public plan option: Care plans similar to the current version of Medicare for individuals and/or employers through the Affordable Care Act insurance marketplace

Gerald Kominski, Ph.D., professor of health policy and management and senior fellow at the UCLA Center for Health Policy Research, explained why trying to enact any one of these plan ideas can be so complicated, especially from a financial perspective. He told The Mighty:

The one thing Medicare for All will guarantee is that no one will ever have to worry again about losing their insurance or whether they’ll be able to afford to pay their medical bill. … The disadvantage is that the current system works well for some people so they’re going to be reluctant to give up something that currently is serving them well for something that they’re not sure will be better for them.

John Rother, J.D., president and CEO of the National Coalition on Health Care, pointed out one plan that has the most bipartisan support because it may be less disruptive — Medicare Advantage for All. Currently, under Medicare Advantage, private insurance companies manage your health insurance but the terms are approved by the government-run Medicare program. Rother told The Mighty:

One [idea] that might have some bipartisan appeal would be Medicare Advantage for All…. You enroll in any private plan that manages your total care and that’s proven very successful.

Medicare Advantage for All [would] actually give a bigger role to private insurance in terms of managing care for a larger number of people. Private insurers today actually do administer the Medicare program. They do so under federal rules but the actual process of claims and reimbursements is done under private insurance.

What Change Could Mean if You Have a Chronic Illness

If you live with a chronic illness, new health care options and rules would likely guarantee insurance companies have to cover pre-existing conditions, just like insurance companies that must provide insurance through the Affordable Care Act now. In theory, you should have an easier time getting health care services and your out-of-pocket costs might be less, depending on the changes and protections of a new health care policy.

What Change Could Mean if You Have a Disability

However, Nielsen said that depending on health care reform, Medicaid might get cut completely. For people with disabilities and other chronic conditions, losing Medicaid without a new provision to make up for those costs, like long-term care in a facility or some medical equipment, may mean you actually end up with less coverage and more out-of-pocket costs. In-home care and personal care attendants are not covered by Medicare or any form of private insurance, so a new plan would have to explicitly add this coverage. 

“Medicaid also picks up the 20 percent remaining of Medicare medical bills,” Nielsen said, adding:

For example, Medicare only pays for home services and durable medical equipment if a person is homebound, whereas Medicaid helps those in need of such services such as transportation, a wheelchair for use outside the home, etc. Medicare does not cover long-term care, vision, hearing or dental care, whereas Medicaid does.  

What Change Could Mean if You Have a Mental Health Condition

Making sure mental health care is covered under a new health care policy could be tricky as well. Under the Affordable Care Act now, the law requires health insurance must cover mental health and substance abuse treatment. However, switching to a Medicare-based program as is without updates might limit the types of mental health professionals your plan will pay for.

“Current Medicare pays for medically necessary mental health services by clinical social workers, psychiatrists and psychologists, but not from counselors and therapists,” Nielsen said. “‘Access to’ mental health services does not assure’“availability of’ those services. Scarcity of providers and uneven geographic distribution are problems now, and would probably worsen.”

According to U.S. Department of Labor statistics, in 2011 there were nearly 552,000 licensed mental health professionals working in the United States. Of these, only 59 percent are licensed clinical social workers, psychologists with a doctorate degree or psychiatrists with a medical degree. These are the only professionals that would be covered by a Medicare-only plan unless the health care rules are updated when creating a new system.

What You Can Do

If health care policy or health care reform is important to you, especially going into the 2020 presidential election, Nielsen recommends really taking a close look at what politicians are proposing and asking for details.

“Politicians mean different things when they propose or oppose Medicare for All, so digging deeper with questions to them is important,” Neilsen said. “A key question to pose is this: Would your proposed Medicare for All replace or supplement current health plans and employer-based insurance? And what would happen under your plan to Medicaid?”

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