The Congressional Budget Office published a much-awaited paper about the possible design of a single-payer or “Medicare for all” system in the United States.
The budget office most often provides detailed estimates about the cost of legislation. But anyone looking for many numbers in Wednesday’s long report would be disappointed.
Instead, the nonpartisan office noted the many ways that legislators could devise such a system, outlining the cost and policy effects of a wide range of difficult choices. It also noted that such a system would be so different from the country’s current situation that any hard estimates would be difficult, even with all the specifics laid out.
As such, the report has convenient snippets likely to be deployed by both single-payer devotees and detractors. Within minutes of its release, congressional news releases began pouring out, noting how the report had confirmed this or that position.
A change to single-payer, which a substantial number of Democratic presidential candidates and members of Congress have called for, would amount to the largest domestic policy change in decades. It would have broad implications not only for health care and the federal budget, but also for the broader economy.
“The magnitude of such responses is difficult to predict because the existing evidence is based on previous changes that were much smaller in scale,” the paper said.
Democrats in Congress have been writing bills that would bring the country closer to a single-payer system. And on Tuesday a House committee held the first hearing in more than a decade on the merits of a single-payer approach. Bills sponsored by Bernie Sanders, the independent senator from Vermont, and Pramila Jayapal, a House Democrat from Washington, would create a so-called Medicare for all. In that system, Americans would be covered by the same government insurer for a wide range of medical benefits, without the need to make any payments to doctors or hospitals when they receive health care.
Democrats have also introduced other bills recently, including two this week, proposing more modest changes in how health care is delivered. One, called the Choose Medicare Act, would allow more Americans to opt into the existing Medicare system. Another, called Medicare for America, would automatically enroll more Americans in the government system, and give others a choice between government and private insurance.
The single-payer proposals have broad — though not majority — support among Democratic lawmakers so far, meaning they are unlikely to become law in the immediate future. That’s in part why John Yarmuth, the chairman of the House Budget Committee, who supports single-payer health care, asked for a report of this type. Medicare for all is likely to have a high price, and many Democrats would prefer to postpone contending with the politics of such a number until there is a plausible path forward.
But as the C.B.O. report highlighted, the expansive approach Mr. Sanders and Ms. Jayapal have embraced is not the only way to devise a single-payer system. Congress could opt to provide all Americans with coverage more similar to what people 65 and older currently receive under Medicare, with more limited benefits and a requirement that they pay some deductibles and co-payments. A single-payer system could preserve some role for private insurance, either to cover certain benefits or to pay for private care outside the standard system. Such decisions could have a big effect on the overall cost.
When it came to particulars of those costs, however, the budget office said little. “Government spending on health care would increase substantially,” the paper noted at one point. But it never said by how much. The amount matters because it will influence how much tax revenue will be needed to pay for the program. Supporters of a single-payer plan note that, even though government spending would increase, there could be substantial reductions in the other ways individuals and employers pay for health care now through premiums, out-of-pocket spending and state taxes.
The budget office may still provide firm estimates for a proposal if one gets closer to a floor vote in the House or the Senate. The office is charged with developing estimates for legislation, and it produces them even when doing so involves a fair bit of speculation. In past years, for example, the budget office was asked to provide cost estimates for a federal terrorism reinsurance program, which required it to gauge the likelihood of terrorist attacks and the possible expense of their damages.
The cost of a single-payer system is not as unpredictable as that of terrorism insurance, but the report’s many caveats and questions highlight how the effects of Medicare for all will depend on a multitude of legislative decisions — and then a larger set of management decisions by the government that runs the system.
Would government insurance cause shortages of doctors or waits for care? It depends on how well the system pays clinicians, how individuals respond to more generous health coverage, and how the Medicare system adapts over time.
“If the number of providers was not sufficient to meet demand, patients might face increase wait times,” the report noted. But it said such problems were not inevitable under a government-run system: “In the longer run, the government could implement policies to increase the supply of providers.”
Would the government eliminate the denials and other red tape that annoy Americans about the private health insurance system? Maybe, or maybe not. The paper notes that requiring patients to see a primary care doctor before a specialist; denying a treatment that is unusual; or requiring patients to try less expensive drugs before more expensive alternatives would all be possible under single-payer, and are limitations with such systems in other countries.
Would patients see new and expensive treatments and drugs? That would depend on the government’s approach to approving new therapies. The existing bills provide little detail on how the government would make such decisions.
The many questions and nuances are all reminders that single-payer is more complicated than the campaign talking points on either side might suggest. It might not cause rationing. It might not create seamless care.
For now, legislators can take their pick of a set of third-party estimates of the cost of the Sanders plan. They range widely, underlining the budget office’s point that precision will be a challenge.