Becerra supports Medicare for All and could help states get there

Xavier Becerra has long supported the United States’ transition to a Medicare for all system. As President-elect Joe Biden’s choice to lead Health and Human Services, he may have opportunities to accelerate such a transition.

The Secretary of Health and Human Services oversees a range of waivers that states can use to cover new groups or provide different types of health plans. Since these exemptions do not require Congressional approval, they could become a crucial policy-making tool for the Biden administration if Republicans retain control of the Senate.

“Without a Senate majority, it will be difficult to advance some of the cornerstones of the government’s plans,” said Katherine Hempstead, senior policy advisor at the Robert Wood Johnson Foundation. “This is where the power to waive becomes important.”

The future of health care was a major dividing point in the Democratic presidential primary. President-elect Biden has supported the idea of ​​a public option: a government-led health plan that all Americans could participate in — but not the Medicare-for-all system proposed by Vermont Senator Bernie Sanders, which would eliminate private coverage and would move all Americans into a public plan.

Some of the exemptions may work through the Medicaid program, which has the power to allow states to cover additional groups or provide expanded health care services.

Others may peruse the Affordable Care Act, which includes a section that allows states to pool their various sources of funding for health care laws — such as dollars as a lump sum to fund a different type of health care system. States must meet certain requirements: they can’t increase the uninsured rate, and their plan can’t require additional federal money.

The types of waivers approved often depend on the policy preferences of the administration and the Secretary of Health and Human Services. The Trump administration has typically approved waivers that tighten eligibility for public health programs, such as

The waivers approved by Mr. Becerra as part of the Biden administration would most likely be different and could reflect his long track record of supporting single-payer health care. He endorsed the idea as a first-term congressman in 1994 and sponsored Medicare four times during his 12 terms in Congress for all legislation. In 2017, he reiterated that he “absolutely” supports policies that would move all Americans towards a government-led health plan.

“He’s been known as a supporter since his time in the House,” said Rep. Ro Khanna, a California Democrat and a prominent supporter of Medicare for All. “He sponsored this at a time when it wasn’t very popular to support it .”

Most observers expect Mr. Becerra and the Biden administration to be open to waivers that expand health coverage in ways big and small.

“Waivers are at the discretion of the secretary,” said Patricia Boozang, senior managing director of consulting firm Manatt Health. “There are many innovative ideas that states have to expand coverage and make it more affordable.”

Illinois, for example, applied in November 2019 for a one-year postpartum waiver from Medicaid coverage for mothers of newborns. The Trump administration has defaulted on the request, but some observers expect it will get a fresh look and faster approval after Mr. Becerra takes over the health agency.

States will also have the opportunity to pursue more experimental and larger coverage expansions. Many experts believe Mr Becerra’s waiver power would easily allow a public option to be pushed forward at the state level. Nevada, Colorado and Connecticut have all pondered the idea in recent years, and President-elect Biden backed the idea in his 2020 campaign.

“I think a lot of states are dusting the cobwebs off some old plans and thinking about how we can use these waivers,” Ms Boozang said.

An enterprising health minister working with a state could go even further. Some experts believe that a combination of Medicare, Medicaid, and Affordable Care Act exemptions could allow a state to use all of its federal healthcare dollars to build a payer plan.

Vermont planned this in the early 2010s and identified exemptions to create a state health plan that covers all Vermonters. The state held monthly meetings with the Obama administration to work out how to use federal waivers to build its new healthcare system.

“They gave us all the waivers we needed to get it done,” said Peter Shumlin, the former Vermont governor who led the state’s effort. “I hope the Biden administration will also work with states to innovate.”

However, the state’s plan foundered when it concluded that the tax increases needed to create the program were politically unfeasible.

This speaks to a weakness of much of the waiver process: although states can use their federal funds in new ways, they typically do not receive additional money. Any extra dollars they need would have to come from either tax increases or other budget cuts.

In the case of Vermont, the small state estimated that it would need an additional $2.5 billion in funding to build a single-payer health care system — an amount larger than its annual budget.

“When health care costs are often increasing two or three times faster than income, there is no magical way to pay for the system,” Mr. Shumlin said. “That’s what we found.”

The hardest part of moving forward with payer healthcare in this way might be finding a state willing to try again. The coronavirus has placed a significant strain on national budgets; Many states are now considering cuts to their Medicaid programs instead of considering ways to expand coverage.

“The math is very difficult,” said Ms. Hempstead.

Some states have shown at least some interest in addressing the issue, but none are willing to seek a federal waiver.

In its 2018 session, the New York State Assembly passed a bill creating a depositor system, but the effort died in the Senate. In California, Governor Gavin Newsom ran his latest campaign on a single-payer platform and established a commission on the issue in January. One of his first acts as governor was to write a letter to President Trump trying to determine what federal flexibility existed for states wanting to provide universal coverage.

But Gov. Newsom has had to focus on fighting the coronavirus pandemic this year and has scaled back budget proposals aimed at expanding coverage to more Californians — a sign of how challenging major healthcare reform can prove if states continue to oppose fighting a public health crisis.

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