Comparing HR676 Medicare4All to Our Medicare4All Blueprint

HR676 is out!

Let’s take a look and see how it stacks up to our ideal system.

TL;DR: Is HR676 good? Yes, quite. A few tweaks and it would cover everything we talked about in the last post.

1. Negotiate Prescription Costs

HR676 fully authorizes MMS to get the best price it can for our medications

(a) Negotiated Prices. — The prices to be paid each year under this Act for covered pharmaceuticals, medical supplies, and medically necessary assistive equipment shall be negotiated annually by the Program.

Recommended update to HR676:

  1. Allow MMS to survey the top 20 advanced nations to see what prices they are paying for the top 50 prescribed medications and use this to negotiate prices.

2. Add Mental Health, Dental, Vision and Home Healthcare to Medicare Coverage

HR676 adds coverage for all of the above with excellent quality standards built in.

Here is the coverage:

(a) In General. — The health care benefits under this Act cover all medically necessary services, including at least the following:
(1) Primary care and prevention.
(2) Approved dietary and nutritional therapies.
(3) Inpatient care.
(4) Outpatient care.
(5) Emergency care.
(6) Prescription drugs.
(7) Durable medical equipment.
(8) Long-term care.
(9) Palliative care.
(10) Mental health services.
(11) The full scope of dental services, services, including periodontics, oral surgery, and endodontics, but not including cosmetic dentistry.
(12) Substance abuse treatment services.
(13) Chiropractic services, not including electrical stimulation.
(14) Basic vision care and vision correction (other than laser vision correction for cosmetic purposes).
(15) Hearing services, including coverage of hearing aids.
(16) Podiatric care.

Mental healthcare services are also established:

c. Mental Health. — The Director shall appoint a director for mental health who shall be responsible for administration of this Act and ensuring the availability and accessibility of high quality mental health services.

The act also favors community based care as the preferred option to deliver mental health services

(a) In General. — The Program shall provide coverage for all medically necessary mental health care on the same basis as the coverage for other conditions.
(b) Favoring Community-Based Care. — The Medicare For All Program shall cover supportive residences, occupational therapy, and ongoing mental health and counseling services outside the hospital for patients with serious mental illness. In all cases the highest quality and most effective care shall be delivered, and, for some individuals, this may mean institutional care.

Home healthcare is also provided:

(1) IN GENERAL. — The Medicare For All Program, through its regional offices, shall pay each institutional provider of care, … home care agencies, ….


(b) Regional Budgets. — Each region shall provide a global budget to local long-term care providers for the full range of needed services, including in-home, nursing home, and community based care.

and, like mental care, community based care is preferred over institutional care (also in Sec 203):

(d) Favoring Non-Institutional Care. — All efforts shall be made under this Act to provide long-term care in a home- or community-based setting, as opposed to institutional care.

Services are highly portable:

(b) Portability. — Such benefits are available through any licensed health care clinician anywhere in the United States that is legally qualified to provide the benefits.

And the best part:

c. No Cost-Sharing. — No deductibles, copayments, coinsurance, or other cost-sharing shall be imposed with respect to covered benefits.

Recommended updates to HR676: None.

3. Tune Medicare’s Mission

In our original post we suggested that Medicare focus it’s mission on Preventative Integrative Medicine. This seems to be covered in this section:

(2) SYSTEM SAVINGS AS A SOURCE OF FINANCING. — Funding otherwise required for the Program is reduced as a result of —
C. improved access to preventive health care.

and here:

It is the intent of this Act that the Program at all times stress the importance of good public health through the prevention of diseases.

Recommended updates to HR676:

  1. Add extra funding for preventative and integrative healthcare research.
  2. Direct Medicare to prioritize preventative and integrative techniques.
  3. Add funding for education and training in preventative and integrative techniques

4. Nutrition IS Healthcare

This one seems to be lacking in HR676. The only reference to “nutrition” or “diet” is here:

(2) Approved dietary and nutritional therapies.

Recommended updates to HR676:

  1. Direct all agricultural agencies to change their priorities to protect public healthcare and soil health instead of protecting industry profits.
  2. Combine all funds from all nutrition assistance (SNAP, TANF, WIC, etc) and combine it into M4All
  3. Give everyone a stipend for healthy, nutritious food (starting at $100/mo) and going up based on income (see Nutrition is Health section for example table)
  4. Created subsidies and grants for all farmers to revitalize their land back to optimal health.
  5. Direct Dept of Ag to work with soil microbiologists to find out how to measure the health of the soil and use that to heal the farm land that we have poisoned.

5. Allow Medicare to build/purchase hospitals

HR676 doesn’t specifically state that MMS can build or purchase hospitals and turn it into one system. Much of the language in the bill allows for ACOs which are Accountable Care Organizations. Instead of buying out the hospital and placing everyone on salary, this allows hospitals to operate in a non-profit manner, place everyone on salary and get a bulk monthly payment to pay for all services rendered. This is definitely better than the “fee-for-service” model that we have now which turns doctors into sales reps, but this doesn't give us the highest effectiveness or efficiency possible since it doesn't unite the system under one umbrella. It will be hard to encourage patient collaboration or research collaboration across this fragmented system.

This part is mostly covered under


Part (a) of this establishes the lump-sum payment methods for healthcare institutions:

(1) IN GENERAL. — The Medicare For All Program, through its regional offices, shall pay each institutional provider of care, including hospitals … or pre-paid group practices, a monthly lump sum to cover all operating expenses under a global budget.

Part (b) covers the 3 types of payment mechanisms available for M4All:

A. Fee for service payment under paragraph (2).
B. Salaried positions in institutions receiving global budgets under paragraph (3).
C. Salaried positions within group practices or non-profit health maintenance organizations receiving capitation payments under paragraph (4)

We need to slowly move away from fee for service. As stated above, that system turns doctors into sales reps by forcing them to figure out how to care for a patient inside a monetarily controlled list or based on some patient quota. We should free all doctors from this burden by making them salaried. This will allow them to care for the patient as they see fit and not as a fee-list determines or some arbitrary quota designed to aid in gaining profits. The top hospitals in the country all follow the salaried doctor template for delivering healthcare.

Recommended updates to HR676:

  1. Give HHS the ability to purchase and build hospitals and clinics. The hospitals in this system will all have fully salaried staff and be part of one system. The staff should be encouraged to research and collaborate across the entire network.
  2. Use the salary schedule from the top 10 hospitals (Mayo, Cleveland Clinic, Mass General, UCLA Med, Johns Hopkins, etc) to create a template salary schedule for the new system.
  3. Provide funds to encourage patient collaboration, research collaboration and training/continual-learning across the entire system. Including medical and research conferences that are broadcast system-wide and recorded.
  4. Provide funds to create a GI-like scholarship program for doctors and nurses and provide free education for those that wish to staff these hospitals.

6. Add QoS Feedback Mechanism

HR676 adds some quality control mechanisms to Medicare:

The Director shall appoint a director for an Office of Quality Control. Such director shall, after consultation with State and regional directors, provide annual recommendations to Congress, the President, the Secretary, and other Program officials on how to ensure the highest quality health care service delivery. The director of the Office of Quality Control shall conduct an annual review on the adequacy of medically necessary services, and shall make recommendations of any proposed changes to the Congress, the President, the Secretary, and other Medicare For All Program officials.

and also in:


The duties of the board are listed as:

(b) Duties. —
(1) IN GENERAL. — The Board shall meet at least twice per year and shall advise the Secretary and the Director on a regular basis to ensure quality, access, and affordability.
(2) SPECIFIC ISSUES. — The Board shall specifically address the following issues:
A) Access to care.
B) Quality improvement.
C) Efficiency of administration.
D) Adequacy of budget and funding.
E) Appropriateness of reimbursement levels of physicians and other providers.
F) Capital expenditure needs.
G) Long-term care.
H) Mental health and substance abuse services.
I) Staffing levels and working conditions in health care delivery facilities.

and in section 3 where the “UNIVERSAL, BEST QUALITY STANDARD OF CARE” is established:

(3) ESTABLISHMENT OF UNIVERSAL, BEST QUALITY STANDARD OF CARE. — The Board shall specifically establish a universal, best quality of standard of care with respect to —
A) appropriate staffing levels;
B) appropriate medical technology;
C) design and scope of work in the health workplace;
D) best practices; and
E) salary level and working conditions of physicians, clinicians, nurses, other medical professionals, and appropriate support staff.

Qualifications to serve on the board ensures that every American is represented:

(2) QUALIFICATIONS. — The appointed members of the Board shall include at least one of each of the following:
A) Health care professionals.
B) Representatives of institutional providers of health care.
C) Representatives of health care advocacy groups.
D) Representatives of labor unions.
E) Citizen patient advocates.

Recommended updates to HR676:

  1. Allow Medicare to be reviewed by every patient for every visit and by the providers, medical staff and by Medicare personnel itself and use the constant feedback as a continuous improvement process that keeps tightening the efficiencies of healthcare delivery and increasing patient, provider, staff and MMS personnel quality and satisfaction

7. Make the Medicare taxes progressive

HR676 creates several avenues for Congress to fund Medicare4All.

C) Funding. —
(1) IN GENERAL. — There are appropriated to the Medicare For All Trust Fund amounts sufficient to carry out this Act from the following sources:
A) Existing sources of Federal Government revenues for health care.
B) Increasing personal income taxes on the top 5 percent income earners.
C) Instituting a modest and progressive excise tax on payroll and self-employment income.
D) Instituting a modest tax on unearned income.
E) Instituting a small tax on stock and bond transactions.

We believe that our progressive payroll tax would be the best option because it’s a single channel of revenue that would be easier to maintain, monitor and audit. Here is the example table we created in the last post:

*NOTE: These numbers have not been calculated yet and will definitely need to be tuned. They should be used as a template for a starting point.

8. Make Medicare completely independent of politics

HR676 doesn’t go in depth about the independence of Medicare and the agency that is in charge of running it. The only part we found that covers this is Sec 305 (a) (4)

(4) PROHIBITION ON CONFLICTS OF INTEREST. — No member of the Board shall have a financial conflict of interest with the duties before the Board.

This part only covers the National Board of Universal Quality and Access.

Recommended updates to HR676:

  1. Separate MMS from politics and create a council of physicians and a council of nurses that advise MMS on all medical related problems (including expenditures)
  2. Separate the funding for MMS from politics by ensuring all tax funds for medicare go into an account/trust that can only be accessed by MMS
  3. MMS leadership should be drawn from professional experience in healthcare only.
  4. There should be no political appointments for this position. An independent commission should be created to find top level candidates and present them to Congress directly for an up or down vote.
  5. Congress should only have oversight powers over MMS and that power must be in the form of an independent IG or commission free from politics.


HR676 is an excellent piece of legislation. It helps to cover ALL Americans with excellent, high quality coverage and encourages preventive and integrative medical techniques which will help to drastically bring down the overall costs. In short, we would be very happy if HR676 was passed as written, even without our recommended updates.