Medicare For More or Medicare For Some

By Jill Zorn |

Note:  This is Part 3 of our Medicare For All Series.  Check out Part 1 here, and Part 2 here.

Congressional Democrats have proposed a range of bills to get us to universal health care.  In our previous blog post we wrote about Medicare for All and Medicare for Everyone Who Wants It.  These bills propose major improvements to Medicare, open the improved program up to everyone, and make huge changes to many other parts of the health care system.

This blog is about proposals that make less drastic changes and work more through existing structures. One set of bills allows more individuals, and in some cases employers, to purchase plans that are based on Medicare through the existing ACA marketplaces.  Two other bills allow some individuals – those 50 and over – to buy directly into Medicare.

Medicare for More

There are at least four versions of Medicare for More plans listed in this side-by-side comparison chart. We will focus on two bills, Choose Medicare Act (also known as Medicare E) and Medicare-X Choice Act.  Each of these has both a Senate and a House version and have at least 10 cosponsors in the Senate.

Title and Bill Numbers Chief Sponsor Number of Cosponsors Choose Medicare Act (Medicare E)

S 1261

HR 2463  

Sen. Jeff Merkley

Rep. Cedric Richmond  

14, including Sen. Chris Murphy and Sen. Richard Blumenthal

5 Medicare-X Choice Act of 2019

S 981

HR 2000  

Sen. Michael Bennet and

Sen. Tim Kaine

Rep. Antonio Delgado  


18, including Rep. John Larson

These plans are public options that add an additional choice for people to purchase through the ACA marketplaces.  They are not truly Medicare buy-ins. Instead, they are kind of a hybrid.  They look just like other Qualified Health Plans (QHPs) offered in the marketplaces – they cover the ten essential health benefits required of all ACA plans, including maternity care and pediatrics.  They follow ACA market rules and people buying them are eligible for subsidies, based on their income.  But they are tied to Medicare, too.  They use the existing Medicare provider networks and build off Medicare’s provider reimbursement rates, while perhaps setting rates somewhat higher.  And they each use the Medicare brand name:  Medicare E and Medicare-X.

These bills make one major change to Medicare itself- they require negotiation of prescription drug prices.  The Medicare E bill, which is the more comprehensive of the two, also establishes out-of-pocket limits for Medicare Parts A and B.  Right now original Medicare has no out of pocket maximums.

Another crucial difference from Medicare itself is how the plans are financed.  They do not rely on the Medicare Trust Fund.  Instead, a one-time allocation is made of $1-2 billion to cover start-up costs and to fund initial reserves.  After that, customers pay premiums which pay for the full cost of the coverage, including administration.

Anticipated savings from offering a Medicare-like public option, which would be less expensive than current QHPs on the exchange, are used to make important fixes to the ACA.  These enhancements include increasing premium subsidies to improve the affordability of all plans sold on the marketplaces.  The Medicare E bill also enhances cost sharing subsidies to help with out-of-pocket-costs.

The biggest difference between Medicare E and Medicare-X is how they treat employers.  Medicare E is intended to be an option that all employers, even large employers can choose.  Medicare-X is focused mainly on individuals, although after several years they allow small businesses to purchase plans, too, via the ACA SHOP exchanges which serve small groups.

Another important difference is that Medicare-X is silent on women’s reproductive health access, while Medicare E specifically states that Hyde amendment limitations on abortion access do not apply to Medicare E plans.  The bill also goes further to say that state efforts to restrict access to abortion or reproductive health services in any offering in the ACA marketplace are not permitted.

Medicare for Some

Title and Bill Numbers Chief Sponsor Number of Cosponsors Medicare at 50 Act

S 470 Sen. Debbie Stabenow 20, including Sen. Blumenthal Medicare Buy-In and Health Care Stabilization Act

HR 1346 Rep. Brian Higgins 45, including Rep. John Larson and Rep. Joe Courtney

These plans allow people 50 and over to simply buy into Medicare, both traditional Medicare and Medicare Advantage.  Plans are offered through the ACA marketplaces and are eligible for the same subsidies available for other QHPs.  The program is generally revenue-neutral, except enrollment assistance funding of $500 million per year is appropriated for the first four years.  As with all of the other bills, drug prices are negotiated, both for existing Medicare and the new plans.

The House bill is a bit more extensive than the Senate bill.  Here are a few key differences:

  • Allows for geographic variation of premiums (the Senate bill sets one national premium)
  • Makes improvements to the current ACA marketplaces
    • Enhances cost sharing reductions (CSRs) for all ACA plans, not just the Medicare Buy-In
    • Establishes a reinsurance program for the entire individual market and reinstitutes the risk corridor program – both of which protect insurers from against unpredictable losses
  • Establishes a new public option for Medigap supplemental insurance to serve both current Medicare beneficiaries and the buy-in option

To Learn More:

Medicare E Act

Medicare-X Choice Act

Medicare buy-In

Medicare basics

Articles and charts comparing bills