United States National Health Care Act

The **United States National Health Care Act** or **Expanded and Improved Medicare for All Act** is a bill first introduced in the United States House of Representatives by former Representative John Conyers (D-MI) in 2003, with 25 cosponsors. As of October 1, 2017, it had 120 cosponsors, a majority of the Democratic caucus in the House of Representatives, and the highest level of support the bill has received since Conyers began annually introducing the bill in 2003.

The act would establish a universal single-payer health care system in the United States, the rough equivalent of Canada's Medicare and Taiwan's Bureau of National Health Insurance, among other examples. Under a single-payer system, most medical care would be paid for by the federal government, ending the need for private health insurance and premiums, and recasting private insurance companies as providing purely supplemental coverage, to be used when non-essential care is sought.

The national system would be paid for in part through taxes replacing insurance premiums, but also by savings realized through the provision of preventative universal healthcare and the elimination of insurance company overhead and hospital billing costs. An analysis of the bill by Physicians for a National Health Program estimated the immediate savings at $350 billion per year. Others have estimated a long-term savings amounting to 40% of all national health expenditures due to preventative health care. Preventative care can save several hundreds of billions of dollars per year in the U.S., because for example cancer patients are more likely to be diagnosed at Stage I where curative treatment is typically a few outpatient visits, instead of at Stage III or later in an emergency room where treatment can involve years of hospitalization and is often terminal.

During the 2009 health care debates over the bill that became the Patient Protection and Affordable Care Act, H.R. 676 was expected to be debated and voted upon by the House in September 2009, but was never debated.

On September 13, 2017, Senator Bernie Sanders introduced a parallel bill in the United States Senate with 16 cosponsors. The act would establish a universal single-payer health care system in the United States.

In 2019, the original 16 year old proposal was renumbered and Pramila Jayapal (D-WA) introduced a broadly similar but more detailed as HR 1384 for the 116th United States Congress.

## Elements

The laws proposed are not necessarily identical year-over-year.

### 116th Congress (2019-2020)

In 2019, the House Medicare for All Act of 2019 by Jayapal was broadly similar but more detailed than the original Conyers proposal, but the "parallel" proposal by Sanders had significant differences, including a "global budget" system for hospitals. Both the proposals include expansive coverage including long-term care and dental care with no cost-sharing such as coinsurance, deductibles, or premiums, which as of 2019 is unprecedented in the world.

Under the House version, funding for institutions such as hospitals would be negotiated with regional directors, while individual providers would be paid a fee-for-service. Value-based pay for performance incentives would not be allowed. HHS would have administrative authority to set various details.

The Senate proposal sets out a four-year transition plan and the House proposal is two years.

As of April 2019, the Senate proposal did not include details on how to completely pay for the plan, but Sanders had released a paper listing ideas.

### 111th Congress (2009-2010)

The summary of the National Health Care Act as proposed in the 111th Congress (2009-2010) includes the following elements, among others:

1. Expands the Medicare program to provide all individuals residing in the 50 states, Washington, DC, Puerto Rico, and territories of the United States with tax-funded health care that includes all medically necessary care. That would include primary and preventive care, prescription drugs, emergency care, long-term care, mental health services, dental services, and vision care.
2. Prohibits an institution from participating unless it is a public or nonprofit institution. Allows nonprofit health maintenance organizations (HMOs) that deliver care in their own facilities to participate. On the whole, private insurance would be replaced with the new nationalized system for all basic, major care.
3. Gives patients the freedom to choose from participating physicians and institutions, which, given the coverage of the new national system, would be any institution or clinic in the United States receiving any degree of public funding (the vast majority).
4. Prohibits a private health insurer from selling health insurance coverage that duplicates the benefits provided under this Act. Allows the private insurers to sell benefits not medically necessary, such as cosmetic surgery benefits.
5. Sets forth methods to pay institutional providers of care and health professionals for services. Prohibits financial incentives between HMOs and physicians based on utilization.
6. Establishes the USNHC Trust Fund to finance the Program with amounts deposited: (1) from existing sources of government revenues for health care; (2) by increasing personal income taxes on the top 5% of income earners; (3) by instituting a progressive excise tax on payroll and self-employment income; and (4) by instituting a small tax on stock and bond transactions. Transfers and appropriates amounts that would have been appropriated for federal public health care programs, including Medicare, Medicaid, and the State Children's Health Insurance Program. Taxes would be paid instead of insurance premiums, as the government (instead of private insurance companies) would be paying for the care under the single-payer health care.
7. Establishes a program to assist individuals whose jobs are eliminated (such as within insurance companies) by the simplified single-payer administrative process.
8. Requires creation of a confidential electronic patient record system.
9. Establishes a National Board of Universal Quality and Access to provide advice on quality, access, and affordability.
10. Provides for the eventual integration of the Indian Health Service into the Program and evaluation of the continued independence of Department of Veterans Affairs (VA) health programs.
11. The bill covers treatments starting on the first day of the year that follows one year after the date of passage.
12. Compensation continues for 15 years to owners of converting for-profit providers for reasonable financial losses.

## Cost

An analysis of the bill by Physicians for a National Health Program estimated the immediate savings at $350 billion per year. Others have estimated a long-term savings amounting to 40% of all national health expenditures due the extended preventive healthcare and the elimination of insurance company overhead costs.

A study by Harvard University and the Canadian Institute for Health Information estimated the 1999 costs of U.S. health care administration at nearly $300 billion, accounting for 30.1% of health care expenses, versus 16.7% in Canada. This study estimated the U.S. per-person administrative cost at $1,059.

Charles Blahouse, who worked as George W. Bush's economic advisor and as a public trustee for medicare and social security, wrote a Mercatus Center study of the 2017 proposal It claims that Sander's M4A plan will increase federal spending by at least $32 trillion but that the savings on administrative and other costs could save $2 trillion in healthcare costs. However, Blahouse stresses that these savings rely on multiple generous assumptions and that the plan will likely cost significantly more.

A 2019 analysis was critical of Sanders bill for allowing accountable care organizations and failing to include a provision to negotiate budgets with hospitals.

## Version history

The House single-payer law was proposed under the same HR 676 number since 2003 until the 116th Congress in 2019 when it was changed because it was introduced later, but similar laws were not always proposed in the Senate. In 2009, Senator Sanders introduced the American Health Security Act of 2009, which was the first single-payer bill in the Senate since the 1990s, when a similar law was proposed by Senator Paul Wellstone. It was more similar to HR 1200, The American Health Security Act of 2009, than HR 676.

### 115th Congress (2017)

On 13 September 2017, in the aftermath of his 2016 presidential campaign in which single-payer healthcare was among the core tenets of his platform, Sen. Bernie Sanders introduced the "Medicare-for-all Act of 2017" S. 1804], a parallel bill to the "United States National Health Care Act" (H.R. 676) that was introduced by Rep. John Conyers in the House.

Notably, Sanders had introduced a similar version of the bill in 2013, but no other Senators cosponsored it. This time, his 2017 version attracted sixteen Democratic cosponsors besides himself:

* Sen. Tammy Baldwin from Wisconsin
* Sen. Richard Blumenthal from Connecticut
* Sen. Cory Booker from New Jersey
* Sen. Al Franken from Minnesota
* Sen. Kirsten Gillibrand from New York
* Sen. Kamala Harris from California
* Sen. Martin Heinrich from New Mexico
* Sen. Mazie Hirono from Hawaii
* Sen. Patrick Leahy from Vermont
* Sen. Ed Markey from Massachusetts
* Sen. Jeff Merkley from Oregon
* Sen. Brian Schatz from Hawaii
* Sen. Jeanne Shaheen from New Hampshire
* Sen. Tom Udall from New Mexico
* Sen. Elizabeth Warren from Massachusetts
* Sen. Sheldon Whitehouse from Rhode Island

Sanders explains the rationale for the bill in terms of per-capita healthcare costs in the United States compared to other countries:

> Despite so many uninsured and under-insured, the United States spends far more per capita on health care than any other nation. According to the OECD, in 2015, the U.S. spent almost $10,000 per person for health care, while the Canadians spent $4,644, the Germans $5,551, the French $4,600, and the British $4,192 even though all of these other countries guarantee health care to all of their people. Despite this huge expenditure, life expectancy in America is lower than most other industrialized countries and our infant mortality rates are much higher.
>
> — Bernie Sanders, Press Release, September 13, 2017
>

He argues that the universal healthcare systems in other countries are responsible for their decreased costs and urges that the United States follow suit.

### 116th Congress

In 2019 Bernie Sanders introduced the Medicare for All Act of 2019 as S. 1129. According to Robert Moffit, per section 303 of the legislation, if any doctor provides any private service outside of the government plan, the doctor may not bill the government for any service for any reason for one year. Sanders proposed new taxes to pay for Medicare for All, including progressive taxes on workers.

The House version is HR 1384, sponsored by Representative Japayal with 112 consponsors.