Urban Institute's 'Healthy America Program'

The Healthy America Program: Building on the Best of Medicare and the Affordable Care Act

By Linda J. Blumberg, John Holahan, Stephen Zuckerman
Urban Institute, May 14, 2018


Since efforts to “repeal and replace” the Affordable Care Act (ACA) have failed, and bipartisan attempts to improve the law have stalled, some policymakers are now looking beyond incremental fixes. In this paper, Urban Institute researchers present a set of policy ideas that would provide universal access to comprehensive coverage but would also allow people to keep their employer-sponsored coverage, would offer a range of insurer options and ensure broad pooling of health care risk, would not have an employer mandate, would provide income-related federal assistance, and would create a more flexible individual incentive to remain insured than that under the ACA.

The proposal builds on components of the Medicare program and the ACA Marketplaces. However, it simplifies the current health insurance system by integrating Medicaid acute care for nonelderly people and the Children’s Health Insurance Program (CHIP)—while preserving access to their benefits—with coverage for people enrolled in private nongroup insurance and people currently uninsured. This large new Medicare-style marketplace, featuring a public plan and private insurer options, would contain costs by fostering competition among many insurers, capping provider payment rates, and addressing prescription drug pricing. This proposal is less ambitious than a single-payer system (i.e., Medicare for All), but it would get close to universal coverage with much lower increases in federal spending and less disruption for people currently enrolled in employer coverage or Medicare.

They estimate that the plan would result in 15.9 million fewer uninsured people and reduce total health care spending by $28.9 billion in its first full year of implementation.

Healthy America Compared with Other Proposals 

See Table 4 in the full article for other proposals - only Healthy America (HA) and Medicare for All by Sanders (MfA) are included here.

Who is eligible for the new program?

HA - All lawfully present people younger than 65

MfA - All US residents

What’s in the program?

HA - New public plan option, restructured private nongroup insurance market, enhanced premium and cost- sharing subsidies, new incentive to remain insured

MfA - Single-payer system enrolling all US residents in a single plan

Does the separate Medicaid program continue?

HA - Medicaid acute care program ends, with enrollees folded into other programs; long- term services and supports program continues as under current law

MfA - No

Are states required to make maintenance-of- effort contributions?

HA - Yes, but only for spending on acute care for the nonelderly

MfA - No

Does the separate Medicare program continue?

HA - Yes

MfA - No

Does the private insurance market remain?

HA - Yes, for group and nongroup private insurers; no firewall between employer coverage and new program

MfA - No

What benefits are offered?

HA - ACA essential health benefits

MfA - All medically necessary acute care and dental, vision, and hearing care; long-term services and supports stay the same as under current Medicaid program

How much are household premiums?

HA - Premiums range from 0 to 8.5% of income; premium subsidies are tied to 80% actuarial value plan

MfA - None

What are the cost-sharing requirements?

HA - Cost-sharing subsidies increase actuarial value above 80% for people with incomes up to 300% of FPL; cost- sharing options with actuarial value below 80% also available

MfA - None

Are people automatically enrolled?

HA - Only SNAP and TANF enrollees, who face no premiums, are autoenrolled; others without premiums can enroll in public plan at any time

MfA - Yes

Do individuals face a penalty for remaining uninsured?

HA - Yes, structured as loss of a tax benefit, which can be partially refunded if people enroll in coverage later

MfA - No, all are enrolled in a single plan

Are there limits on provider payment rates?

HA - Yes, for nongroup insurance markets

MfA - Yes

Do employers face a penalty for not insuring workers?

HA - No

MfA - No

Are there minimum standards for employer coverage?

HA - No

MfA - Not applicable; employer insurance eliminated

Does the program provide universal coverage?

HA - Close to universal for legal residents (not for undocumented people)

MfA - Yes

From the Discussion

Several proposals are being put forward to fix the ACA or to fundamentally reshape the US health insurance system. Proposals of significant restructuring are necessarily more complex than those focused on making the ACA work better. In Healthy America, we try to strike a balance by retaining Medicare and employer-sponsored insurance while significantly changing Medicaid and nongroup health insurance. Our goals are to keep what people like, change what is not working, and limit the increase in new federal costs.

Full Report (24 pages):



By Don McCanne, M.D.

Those looking for solutions other than a single payer improved Medicare for all may find Urban Institute's Healthy America Program to be an attractive incremental approach since it leaves Medicare and employer-sponsored plans intact while making adjustments to Medicaid and the nongroup health insurance market. For single payer advocates, merely reading the comparisons between the two proposals is enough to show that the Urban proposal falls intolerably short of the reform goals of single payer.

A detailed critique of the full proposal could be prepared, but if you merely skim though the full report, it's obvious that it is not worth the effort since they leave in place most of our highly flawed health care financing infrastructure.

Read the full report if you want to, but if you are primarily interested in refreshing in your mind what actually will work, spend your time reading once again the Physicians’ Proposal for Single-Payer Health Care Reform:

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