Policymakers, including candidates in the 2020 presidential campaign and members of Congress, have proposed a variety of options to address the shortcomings of the current health care system. These range from improvements to the Affordable Care Act to robust single-payer reform.
There are numerous challenging trade-offs when choosing an approach to health care reform, including covering the uninsured, improving the affordability of health care, and raising the government funding required to implement them. The public and policymakers alike need more information about the potential effects of various health reform proposals.
This study, funded by the Commonwealth Fund, analyzes eight health care reforms and their potential effects on health insurance coverage and spending. Each of the analyzed reform proposals makes health insurance considerably more affordable by reducing people’s premiums and cost sharing. Some reforms also reduce US health care costs, and all require additional federal dollars.
Within the existing public-private health care system, near universal coverage and improved affordability could be achieved with moderate increases in national health spending. Under one of the plans modeled in the report, which proposes a mix of private and public health insurance, everyone in the US could be covered except for undocumented immigrants. The plan would enable workers to opt for subsidized nongroup coverage instead of their employer’s insurance plan. It would also improve the ACA’s subsidies to help people afford coverage, cover people in states that have not expanded Medicaid, require everyone to have insurance with an auto-enrollment backup, offer a public insurance option, and cap provider payment rates. Coverage and costs: This reform plan achieves universal coverage for people legally present in the US, covering 25.6 million people who would otherwise be uninsured. However, the plan leaves 6.6. million undocumented immigrants without coverage. National spending on health care would decrease modestly, by $22.6 billion or 0.6 percent, compared with current law in 2020. Federal government spending would increase by $122.1 billion in 2020, or $1.5 trillion over 10 years.
One single-payer approach would leave no one uninsured and largely eliminate consumers’ out-of-pocket medical costs but would require much greater federal spending to finance. The modeled “enhanced” single-payer system would cover everyone, including undocumented immigrants. The reform would include benefits more comprehensive than Medicare’s—including adult dental, vision, hearing, and long-term services and supports—with no premiums or cost sharing. All current forms of insurance for acute care would be eliminated, including private insurance, Medicaid, and Medicare, and everyone residing in the US would be covered by a new public insurance program. Providers would be paid rates closer to Medicare’s. Health spending by employers would be eliminated, and household and state health spending would decline considerably while federal spending would increase significantly Coverage and costs: This reform option covers the entire US population. National spending on health care would grow by about $720 billion in 2020. Federal government spending would increase by $2.8 trillion in 2020, or $34.0 trillion over 10 years.
A second single-payer approach can be constructed with lower federal and system-wide costs. In addition to the enhanced single-payer plan above, researchers examined a single-payer “lite” plan that is similar to the enhanced version but includes cost-sharing for out-of-pocket expenses based on income, adds fewer new covered benefits, and only covers legally residing US residents. Single-payer “lite” lowers total national health spending, decreasing health spending by households, employers, and state governments and increasing federal government spending by less than the enhanced single-payer reform. Coverage and costs: This reform plan achieves universal coverage for people legally present in the US, covering 25.6 million people who were uninsured. However, the plan leaves all 10.8 million undocumented immigrants without coverage (due to the elimination of private insurance). National spending on health care would decrease by $209.5 billion, or 6 percent, in 2020. Federal government spending would increase by $1.5 trillion in 2020, or by $17.6 trillion over 10 years.
The analysis demonstrates that there is more than one effective approach to achieving universal health care coverage in the United States and highlights the trade-offs of different reform strategies.