As the debate over the future direction of our health care system heats up leading into the 2020 Presidential election, several Democratic proposals to create a single, federal, universal health insurance program known as Medicare-for-all have garnered significant attention. These proposals would replace most current public and private health insurance with a new federal program that would guarantee health coverage for all or nearly all U.S. residents. However, many details about how a new public program would be implemented and financed are not yet known. While much attention has focused on the implications of ending private insurance and Medicare, the debate has largely ignored the effects on the low-income and vulnerable populations covered by Medicaid and the broader implications for states of eliminating the Medicaid program. Key changes related to Medicaid under current proposals include: (1) Medicare-for-all proposals would generally eliminate current variation in eligibility, enrollment and renewal processes, benefits, and payment and delivery systems that are part of the current structure of Medicaid where states have considerable flexibility to design programs within broad federal rules. (2) Proposals would extend coverage for certain Medicaid services important to vulnerable populations (such as comprehensive benefits for children and non-emergency medical transportation) to other populations. The proposals would continue Medicaid protections against high out-of-pocket costs. (3) One of the most fundamental changes under Medicare-for-all would be uniform coverage of community-based long-term care services for all Americans. Medicaid is the primary payer for these services today, with substantial state variation in eligibility and coverage. Under current Medicare-for-all proposals, these services would be required and explicitly prioritized over institutional services. Medicare-for-all proposals vary as to whether they would include institutional long-term care, such as nursing homes, or instead continue the current Medicaid coverage of these services, locking in state spending, variation in benefits across states, and limited access to populations beyond Medicaid. (4) Some proposals would have the federal government assume all or a significant share of the nearly $222 billion in state spending on Medicaid, leading to significant state savings, while other proposals call for a maintenance of effort for all or some current state Medicaid spending. (5) The proposals would shift responsibility for designing and implementing much of health policy from states to the federal government, in contrast to states' role under Medicaid today.
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