Ro Khanna Introduces Bill Allowing States to Carve Path Toward Medicare for All
Congressman Ro Khanna received praise from progressive lawmakers and Medicare for All advocates on Tuesday after reintroducing a bill that would provide states with access to the federal funding and regulatory flexibility needed to implement universal healthcare programs.
"If the last year proved anything, it is that universal health coverage is not optional: it's urgent," the California Democrat, a member of the Congressional Progressive Caucus, said in a statement.
"As
we continue building the movement inside Congress to pass Medicare for
All nationwide, we must also support states that stand ready to provide
healthcare for all of their residents while ensuring they have the
resources necessary to do so."
—Rep. Pramila Jayapal
Proponents of the new legislation say it would advance the national movement for a single-payer system on a state-by-state basis, especially as the effort at the federal level has been stymied by the Biden administration's vocal opposition to supplanting the nation's for-profit system.
As Khanna's office explained, the State-Based Universal Health Care Act (pdf) would:
creat[e] a waiver to allow states to develop their own plans to provide access to healthcare for all their residents, via access to federal funding streams and regulations flexible enough to support affordable, universal healthcare plans. In order to apply for the waiver, participating states or groups of states must propose plans to provide healthcare coverage for 95% of their residents within five years. After that time, participating states would be required to demonstrate they reached coverage targets and provide a plan to cover the remaining five percent of their population. States that do not reach the 95% target after five years would have to revise their plan to achieve the targets, or risk losing their waiver. Federal technical assistance would be made available for states seeking help in developing and implementing these plans.
In addition, the bill "requires benefits provided under state plans be equal to or greater than what federal beneficiaries receive now." If a state's proposal is deemed acceptable after being evaluated by an independent panel of healthcare experts, the Secretary of Health and Human Services would then approve or reject the waiver application.
According to Khanna, "This is precisely how bold states like California can take the lead in making Medicare for All a reality."
While long-time Medicare for All advocates—including National Nurses United, the Labor Campaign for Single Payer, and Social Security Works—have endorsed Khanna's bill, expanding Medicare is not the only route to universal coverage outlined in the State-Based Universal Health Care Act.
Khanna's office noted that "states will have the freedom to devise their own individual state-based universal healthcare programs, as long as they meet the coverage breadth and depth requirements."
The legislation identifies a variety of possible funding and regulatory avenues that states can take, including: health benefit exchanges; cost-sharing reductions under the ACA; premium tax credit and employer mandate under the ACA; Medicare; Medicaid; CHIP; FEHBP; TRICARE; and ERISA pre-emption provision.
Khanna's attempt to forge ahead with universal healthcare at the state level is co-sponsored by Democratic Reps. Earl Blumenauer (Ore.), Suzanne Bonamici (Ore.), Jamaal Bowman (N.Y.), Peter DeFazio (Ore.), Mike Doyle (Penn.), Chuy Garcia (Ill.), Raúl Grijalva (Ariz.), Eleanor Holmes Norton (D.C.), Jared Huffman (Calif.), Pramila Jayapal (Wash.), Mondaire Jones (N.Y.), Barbara Lee (Calif.), Andy Levin (Mich.), Joe Neguse (Colo.), Ilhan Omar (Minn.), Chellie Pingree (Maine), Mark Pocan (Wisc.), Ayanna Pressley (Mass.), Jamie Raskin (Md.), Jan Schakowsky (Ill.), Adam Smith (Wash.), Mike Thompson (Calif.), Rashida Tlaib (Mich.), and Bonnie Watson Coleman (N.J.).
The bill elicited praise from many progressives, including Eagan Kemp, Public Citizen's healthcare policy advocate.
"Even before the pandemic, states like California and New York were leading the way in working to create state-based single-payer healthcare systems that would ensure that everyone in the state has access to the care they need," Kemp said in a statement. "The Covid-19 crisis has only increased the groundswell for state and federal action to fix our broken healthcare system by breaking down barriers to care and eliminating the ability of greedy corporations to profit off illness and disease."
"States should be given the authority and funds to create more efficient and equitable single-payer systems to demonstrate just how much better they are than our fragmented for-profit healthcare system," Kemp added. "This bill would do just that."
Last week, Medicare for All advocates debated the merits and drawbacks of sub-federal efforts like Khanna's in a pair of Common Dreams op-eds.
On the one hand, Dr. Ana Malinow, past president of Physicians for a National Health Program, and Kay Tillow, coordinator of the All Unions Committee for Single Payer Health Care, argued that there is no evidence that successful state-based reforms will be widely adopted nationwide. In fact, they wrote, the danger exists that if healthcare is left to the states, "the U.S. would become a nation of 50 different healthcare tiers, at war with each other over federal dollars."
According to Malinow and Tillow, the U.S. Supreme Court's 2012 ruling on the constitutionality of the ACA, which held that Medicaid expansion should be "optional" for states, led to the "balkanization" of the ACA. With Khanna's bill, they argued, "we are about to see a similar balkanization of Medicare, the one national program that guarantees healthcare to everyone over the age of 65."
"The Covid-19 crisis has only increased the groundswell for state and federal action to fix our broken healthcare system."
—Eagan Kemp, Public Citizen
By failing to establish "single-payer as the model to achieve universal healthcare," Khanna's bill opens the door for states to "go the way of the ACA, a mishmash of employer and individual mandates, greater expansion of Medicaid, and more generous subsidies for the exchanges," the pair wrote, adding that this "would end Medicare as we know it."
Writing in response, Philip Caper, a physician and founding member of the National Academy of Social Insurance, agreed with Malinow and Tillow that "a uniform national program of Improved Medicare for All would be the best way to go, on the grounds of simplicity, efficiency, effectiveness, and political sustainability." However, he added, "I see no evidence that the Congress, as it is now constituted, has any appetite to enact anything close to Improved Medicare for All on a national scale anytime soon."
Noting that "there are ongoing efforts in over twenty states to enact universal healthcare," Caper wrote that "the idea of state-level universal healthcare, despite its shortcomings, is a powerful and compelling tool for education and for organizing the power of the people that will be absolutely necessary to overcome the power of the medical-industrial complex."
Caper's perspective was shared by Jayapal, who in March introduced the Medicare for All Act of 2021 and who is also a co-sponsor of Khanna's State-Based Universal Healthcare Act.
"As we continue building the movement inside Congress to pass Medicare for All nationwide," Jayapal said Tuesday, "we must also support states that stand ready to provide healthcare for all of their residents while ensuring they have the resources necessary to do so."
To Keep Their Son Alive, They Sleep in Shifts. And Hope a Nurse Shows Up.
A nursing shortage — driven by the pandemic — has made life miserable for parents with profoundly disabled children. “What if I’m so exhausted that I make a mistake?”
It was 9 a.m. on a Sunday in May, and Chloe Mead was already worn out.
In her living room, she cradled her 7-year-old son, Henry, supporting his head with one hand and helping him toss a ball with the other, careful not to disturb the ventilator that was keeping him alive. A nearby monitor tracked his blood-oxygen levels and a pump was at the ready should his tracheotomy tube need cleaning. In the corner, her 4-year-old daughter was building a pillow fort.
“I need, like, five extra arms,” she said.
Ordinarily, she wouldn’t be by herself. Since infancy, Henry, who has spinal muscular atrophy, a rare muscle-wasting disorder, has had intensive, round-the-clock nursing at home, with Ms. Mead and her husband serving as fallbacks when a nurse unexpectedly cancels a shift.
But the recent shortage of home-care nurses has forced the couple, who live in Queens, to handle longer and longer periods on their own — as many as 36 hours at a stretch. That morning, her husband, Andy Maskin, was catching up on sleep so he could take that night’s late shift, from 2 a.m. until 7 a.m., when he begins his own workweek.
About 4.5 million Americans with illnesses and disabilities are cared for at home by aides, therapists or nurses. Most of these patients are older, but hundreds of thousands are children with complex health needs, and that number that has climbed upward as medical advances allow more to survive into adulthood.
The families of these children have long struggled to find skilled help, but many say Covid-19 has made an already untenable situation even worse. Nurses left the work force to care for their own out-of-school children, or abandoned the profession permanently. And the surging demand for personnel at hospitals, testing sites and vaccination centers drew nurses away with as much as double the wages they earn caring for patients at home.
The easing of the pandemic may not improve conditions much. The shortage of nurses is longstanding and in the wake of a public health crisis that prompted 29 percent of health care workers to consider leaving the profession, many expect a wave of retirements.
“This is as bad as it’s ever been,” said Liz Wise, who works for the nationwide nonprofit Bayada Home Health Care, helping transition young patients from hospitals to homes. Her own daughter needed home-care nursing, so she feels it keenly when patients can’t get the coverage they need. “Disappointing families is enough to keep me up at night.”
Many had pinned their hopes on the Biden administration’s infrastructure plan, which would provide $400 billion to improve home and community-based care. But as the president and Republicans vie over the proposal’s size and scope, it’s unclear whether that part will survive.
Parents, meanwhile, continue to shoulder an unrelenting burden, increasingly alone.
The Pandemic Deepens a Pay Gap
A nurse caring for a medically fragile child at home has the same responsibilities he or she would in a hospital but no medical backup in case of emergency. It’s a high-wire act, and experts say that prevailing wages don’t reflect its difficulty.
Federal guidelines permit state Medicaid programs to cover in-home care for eligible children regardless of their families’ income, since the price of round-the-clock nursing would bankrupt almost anyone. But states generally pay home care nurses at much lower rates than they would for equivalent care in a hospital or other medical center.
“They effectively establish a benchmark of workers’ compensation that competitively disadvantages this field,” said Roger Noyes, a spokesman for the Home Care Association of New York State. In turn, state-certified home health agencies that provide families with nurses pay meager salaries and seldom offer health insurance or other benefits to the nurses they employ.
So, although home care is more appropriate for medically fragile children, hospitals receive about half of Medicaid spending on these cases compared with 2 percent for home care, studies show.
And Covid-19 generated competing demands for nursing that further diminished the home care work force. Surging with the pandemic, the state’s largest health care provider, Northwell Health, hired 40 percent more nurses in 2020 than the year prior and contracted with 1,000 additional temporary nurses once the local hiring pool was exhausted.
Robert Pacella, the chief executive of Caring Hands Home Care, the agency that staffs Henry’s case, noticed the change in January as nurses began declining opportunities to pick up shifts and new applicants dwindled.
“As recently as two years ago, we could easily interview 20 people a week who were qualified — now we’re lucky to get two to four,” he said. For the first time in his career, Mr. Pacella said, he had to turn new patients away.
The problem isn’t confined to New York. Thrive Skilled Pediatric Care says its eight-state operation received 53 percent fewer job applicants in March compared with the same month last year. Shortages of home care providers have been recently reported from New Hampshire to Michigan to Pennsylvania.
Jarred Rhatigan, a 31-year-old nurse from Nassau County, was once part of the home care work force: In addition to a full-time position in a hospital, he worked several days a week with Caring Hands for an hourly wage of around $40. But beginning last December, he dropped all those shifts to administer vaccines at sites across the greater New York area for up to $75 an hour.
“Home care definitely can’t compete with the rates,” he said. These earnings helped him pay off $8,000 of student loans this year, although it’s just a dent in the $62,000 he still owes.
For the last four years, Jen Semple, a registered nurse in South Carolina, has provided home care to a single patient, despite hourly pay that rose just $1 during all that time. When the pandemic began, she cut her home care hours to administer vaccines for a local health care system, at an hourly wage $7 higher than she had been earning. It is rewarding to contribute to the Covid recovery, she said, and the atmosphere is cheerful, with a stream of patients thrilled to get their doses. “But part of me does feel guilty because I know my private duty patient still has hours unfilled,” she said.
Between June and October 2020, Carolyn Foster, a researcher and pediatrician at the Ann and Robert H. Lurie Children’s Hospital of Chicago, surveyed parents of medically fragile children and found that half had lost home health care services during the pandemic. And patients with the most complex conditions often have the hardest time finding capable staff.
“The most vulnerable families were made all that more vulnerable,” she said.
‘We Have Nobody’
In the first months of the pandemic, two of Henry’s nurses fell ill and quarantined, and his parents cut back hours at their own jobs to take up the slack. After several months, they reassembled their nursing coverage, but by this spring, gaps reappeared. Ms. Mead said that when she called her home care agency, they responded, “We have nobody.”
Ms. Mead reached out to other agencies, contacted nurses who had formerly cared for Henry, and posted a plea on Facebook. To make matters worse, her daughter had recently been diagnosed with Type 1 diabetes, so the couple now had to look after two children with life-threatening conditions.
The recurrent all-nighters have stretched both parents thin. “I would like to believe that I’m always going to be 100 percent sharp, but what if I’m so exhausted that I make a mistake with something?” Ms. Mead asked. “It’s really frightening.”
For single parents, the difficulties are compounded. Sarin Morris, a 40-year-old mother in Clifton, N.J., has sole responsibility for her 4-year-old, Sam, whose rare neurological disorder has left him on a ventilator and prone to seizures. He is prescribed 20 hours a day of nursing care but has never had nurses to cover it all.
Ms. Morris and Sam’s father divorced before he was born and her parents live in Italy, so she has no family to assist her. If she can get a nurse, she works at Home Depot. Early in the pandemic she switched to the night shift, restocking shelves while the store is empty to reduce the risk she will contract the coronavirus and pass it on to her son. “But if I don’t have coverage, I can’t go to work,” she said. “And if I can’t go to work, I can’t have my bills paid on time.”
Weekends are the worst, she says. She has struggled to get any nursing coverage at all, and from Saturday night to Monday morning she is alone with her son, sometimes lying in bed beside him so his seizures will wake her if she dozes off. When a nurse finally relieves her, she rests a few hours before heading to work. “It’s a nightmare,” she said. “I don’t remember the last time I got a full night’s sleep in my bed.”
Out of desperation, Ms. Morris has considered enrolling in nursing school, in hopes of earning a living at her son’s bedside. State Medicaid programs typically bar people from getting paid as caregivers for relatives, but some of those restrictions were temporarily relaxed during the pandemic, and a few states have established permanent programs. In Colorado, for example, people can become paid certified nursing assistants for family members. But Ms. Morris is daunted by the tuition for the two-year nursing program at a nearby university, over $25,000. Her current job pays $13 an hour, and she has no savings.
Government Steps In, Lightly
To address the deficit of nurses, experts tick off recommendations including better incorporating home care into nursing education and creating financial incentives to enter the field — but most agree the problem can’t be truly addressed without narrowing the disparate pay between home care and medical facilities.
“Reimbursement rates need to be increased for home care, and also include health benefit packages, so that it becomes more of a valued health care role,” said Cara Coleman, the director of public policy and advocacy at Family Voices, a nonprofit that advocates for families and children with special needs.
Until recently, New York State’s Medicaid program paid less than most other states for registered nurses who care for medically fragile children. Last October, after years of advocacy by families and medical providers, the state carried out the first of several planned increases in reimbursement, and by April 2022 they will have risen by 45 percent.
“We were blown away they did it,” said Dr. Eddie Simpser, the president of St. Mary’s Healthcare System for Children, who pushed for the increase. But, he said, “hospital salaries are still strong competition.”
Since Medicaid programs receive significant federal funding, many advocates are looking to Washington for help. As part of the stimulus package, enacted in March, the Biden administration temporarily increased federal support for state Medicaid programs’ home and community-based services — but the measure lasts only one year, and states may balk at expanding programs that they will ultimately have to fund themselves. Biden’s infrastructure plan would go even further, sending states $400 billion over 10 years to beef up home care.
Dr. Foster, the researcher and pediatrician, said that this would be “a critically needed increase” in resources but that it isn’t a long-term solution. She pointed instead to a proposal by a group of Democratic lawmakers to permanently expand the entitlement for home and community-based services and standardize it nationwide, with the costs borne entirely by the federal government. Calling it “a once-in-a-generation opportunity,” she conceded it would carry a high price tag.
As the pandemic ebbs and testing and vaccination sites slow down, some nurses are expected to return to home care. But Ms. Mead has seen no sign of it: She lacks nursing coverage two nights this coming week, and expects to pass them, vigilant, caring for her son.
Labor Closed Door Negotiations Between New York City and Unions Representing City Workers Could Privatize Their Medicare Coverage
A hush-hush operation between New York City and the Municipal Labor Council (MLC) to essentially privatize the health care coverage for thousands of retirees has exploded into public view in the past several weeks. The internet has been buzzing with protests against the closed-door negotiations that would take retirees out of traditional Medicare and place them in a Medicare Advantage program run by private insurers, with all its traps and pitfalls.
The MLC is composed of the leadership of about 100 unions with members employed by the city. The city continues to pay for part of their health care coverage, under union negotiated contracts, after they retire.
“What they’re doing is using public money to subsidize a private operation,” said Norm Scott, who was an elementary school teacher in Brooklyn for 35 years. He is now active in Retiree Advocate, a caucus in the United Federation of Teachers, the New York affiliate of The American Federation of Teachers. “Ninety percent of the doctors in the United States take Medicare,” he pointed out, “but with these private insurers, you have to choose from their panel of doctors.” He noted that his wife, a hospital health care provider during her career, had spent countless hours on the phone hassling with companies who had turned down payments for patient treatments that doctors at her hospital deemed essential. “They’re just in it to save money so they can earn higher profits. This is not the rule with Medicare.”
According to the Kaiser Family Foundation, Medicare uses only 1.3 percent of the funds it collects on administrative costs (costs not related to medical reimbursements). Medicare Advantage insurance companies average nearly 15 percent on administrative costs, the result of hefty profits and seven and eight figure executive compensation packages.
Opposition to Privatization of Medicare Growing Among Retirees
The behind-the-scenes negotiations, which have been going on for some time, came to light only a few weeks ago and have aroused a storm of protest from rank-and -file union members who have heard about them. “More and more retirees are looking at it and talking about it on Facebook and other internet outlets,” declared Gloria Brandman, one of the leaders of Retiree Advocate, who taught in Brooklyn for more than 30 years.” We’re in a new world now and this issue has generated lots of concern among rank-and-file retirees.”
While the opposition took shape with teacher retirees in the UFT, retirees in other unions, like the Professional Staff Congress (PSC), representing the faculties of colleges in New York City, and District Council 37, representing other groups of city workers, are also raising deep concerns. The Delegates Assembly of PSC on April 15 unanimously (150 to 0) passed a resolution calling for a moratorium on any agreement between New York City and the Municipal Labor Committee (MLC) to move retiree healthcare coverage from traditional Medicare to Medicare Advantage and asking that the PSC bring the moratorium call to the MLC. The NYC Managerial Employees Association Executive Board adopted a similar motion on May 18.
And two weeks ago, retirees from several unions held a press briefing covered by some media outlets like New York’s Channel 11 and radio station WBAI and attended by about 150 retirees calling public attention to the issue.
Evading A Crucial Question
The growing opposition to the unfolding events compelled UFT President Michael Mulgrew to stage an online audio event, earlier this month, spending 45 minutes trying to assure his members that the union would not settle for any agreement that would reduce the benefits they now enjoy. He took a number of questions from listeners. But he evaded a question from one member who asked if he could keep his doctor under the new arrangement or would he have to switch to another doctor if his doctor was not on the insurance company’s panel.
A Feb. 21 article in The New York Times by Mark Miller vividly described why this question is vital to understanding a key aspect of the issue. Ed Stein, a retiree in Colorado who had been a newspaper editorial cartoonist, chose a Medicare Advantage plan over traditional Medicare when he turned 65. “The price was the same,” he recalled. “I liked the access to gyms, and the drug plan was very good. Never in my wildest dreams did I think I’d be facing a crisis like the one I’m having now.”
At 72, Stein was diagnosed with aggressive bladder cancer. He needed a complex surgical procedure and chemotherapy but the doctor in his area that he decided was best for the treatment was not on the panel of his Medicare Advantage plan. He tried to switch to traditional Medicare which would allow him to have a doctor of his choice but came up against a fact that is little known by the general public: the decision to choose Medicare Advantage is effectively irrevocable. “We were just shocked to learn this,” Stein recalled. In response to this issue, UFT President Mulgrew said that UFT retirees will be able to switch back to Medicare during the period of time a few weeks each year when retirees are allowed to switch their health plan coverage. But if they do so, they will have to pay for supplemental coverage.
Pushing Privatization While More People Lean Toward Medicare for All
Up until now, the UFT and most city unions were advising members approaching 65 to choose traditional Medicare, noting the traps and pitfalls of the Medicare Advantage plans run by private insurance companies. The motive of the city in these new proposals is clearly to try to save money at the expense of retirees. The motive of the unions who are basically changing their position is unclear.
At present, the city-MLC negotiations are at a stalemate with two insurance companies bidding for the goodies. A facilitator has been appointed to mediate between the two companies.
The Advantage plans around the country are growing, sparked by aggressive marketing campaigns that tout “extras” like gym membership and other incentives. Their growth has also been aided by quiet changes in federal law and regulation in recent years. And under the Trump administration, Medicare administrators have been tipping the scales improperly in favor of Advantage.
The aggressive campaign to essentially privatize health care and weaken Medicare comes at a time when more and more people are seeing the advantage of government run health care, as is the case in virtually all other developed countries. Medicare for all became an issue in the 2020 presidential campaign and currently, Massachusetts Senator Elizabeth Warren has introduced a bill in Congress that would establish a universal Medicare system. And in New York, a bill in the State Legislature which has majority support will make healthcare a right by establishing a universal single-payer healthcare system. Everyone would have quality healthcare regardless of age, employment, or immigration status. All healthcare would be covered (including dental, mental healthcare, long-term care and prescriptions). If it passes it would be a huge step towards health justice in New York and around the country.
Meanwhile, in New York City, the future of the issue is currently up in the air. It seems that the only barrier to the effort to turn city retirees’ medical coverage over to private insurers is a rising tide of opposition by members of city unions and perhaps the public at large.
Thanks for this timely and relevant overview. Homecare has been in crisis since the 70s. Meager pay for exhausting work. Having done this for a time early in my nursing career and again while caring for aging family members - I can attest to the emotional, physical, and financial drain this is for families and nurses alike.
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