"Medicare for all who want it" raises the kludge question

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Given the "triple veto" imposed on legislators by the U.S. Constitution, U.S. policy is doomed to kludge. Policy design that's logical and internally coherent often can't survive the legislative process.

On the healthcare front, it's been evident since the early aughts that the logical, feasible, appropriately incremental way to improve access and control costs without throwing multiple healthcare industries into chaos and swiftly transitioning 150 million people out of employer-sponsored insurance is to offer a public plan on affordable terms to both employers and employees -- leaving employer insurance to either compete effectively or die on the vine.

Early iterations of such a "public option" included Helen Halpin's CHOICE program (2003), Rep Peter Stark's Americare bill (2006),and Jacob Hacker's Health Care for America plan (2007). All of these enabled any individual to buy in on an income-adjusted basis regardless of whether her employer offered insurance, and gave employers the option of paying into the public plan (e.g., via a payroll tax) rather than offering their own plans.  Instead we got the ACA -- with subsidy eligibility limited to those without access to employer insurance deemed "affordable" (by dubious standards), inadequate subsidies, and dependence on the whims, pricing, negotiated provider payment rates and plan designs of private insurers.

Now we're back to the future with the Medicare for America Act, introduced in late 2018 by Reps Rosa DeLauro and Jan Schakowsky and reintroduced last month. Medicare for America offers a revamped "Medicare" on affordable terms to any citizen or legally present noncitizen who opts in.

The kludge question: Does offering a truly comprehensive and affordable plan on affordable terms to anyone who wants it necessarily entail ending our existing mammoth and Byzantine public health insurance programs, Medicaid and as-currently-structured Medicare? Medicare for America's creators answered "yes."

Folding Medicaid into Medicare for America: Will states pay their share?

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One of the many sweeping transformations of U.S. healthcare mandated by the Medicare for America Act is the absorption of all Medicaid programs -- currently serving some 72 million Americans -- into a revamped Medicare serving all ages. That would occur six years after enactment.

Medicare for America would be available to Americans of all ages and incomes -- and free to everyone in a household with an income below 200% of the Federal Poverty Level (FPL). That's far above the eligibility threshold for Medicaid programs -- with the exception CHIP in some states, for which children in families with incomes as high as 400% FPL may be eligible. Families with incomes between 200% and 400% FPL would have to pay a percentage of income -- probably not higher than 4% -- to insure the whole family. The new program would include comprehensive disability services and 100% coverage for the medically frail and for chronic disease treatment, as well as dental, vision and hearing services.

State governments -- many of them sure to be deeply hostile -- would be subject to two major requirements: 1)  cede control of service for their Medicaid populations, and 2) reimburse the federal government with "maintenance of effort" payments equivalent to their current Medicaid responsibilities, adjusted annually for inflation. Those requirements are certain to be challenged in court, as was the ACA Medicaid expansion.

Seniors' costs under Medicare for America, continued

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In my last post I noted that while the revamped and expanded Medicare available to all under the Medicare for America Act of 2019 would serve most Americans very well, some people who turn 65 after full enactment would pay more in premium than they would today for traditional Medicare Parts B and D, or comparably priced Medicare Advantage.

They would get far more for the money -- most notably, long-term care insurance, dental, visual and hearing coverage, and 100% coverage for a host of vital services like chronic disease management, addiction and mental health treatment, and care for the medically frail. Still, higher premiums for seniors with incomes above about $50,000 for an individual or $80,000 for a couple is a political problem that needs to be thought out.  Here, I have a bit more data to sketch in.

If Medicare for America passes, some seniors would pay more (and get more) than at present

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Medicare for America,  the bill that would allow anyone at any age to buy into a revamped Medicare at an income-adjusted price (e.g., $0 for the bottom 30% of the income distribution), would be a clear benefit to anyone under 65. Even for those who continue to get insured through their employers, it would offer the true freedom from job-lock that the ACA promised and largely failed to deliver.

Most seniors who turn 65 after the new program would come into full effect (2023 were it to pass this year) would be gainers too (those enrolled in current Medicare before the new program launches would have the option of continuing to pay their then-current premiums). A fair number of new enrollees, however, would pay far more in premium than they would for existing fee-for-service Medicare or a Medicare Advantage plan. They would get more for their money. But the expectation that when you turn 65 you can get reliable insurance for under $200 per month is pretty hard-wired into Americans, I suspect. Violating that expectation for a substantial subset of the 3-4 million people who age into Medicare in year one (and every year following) is a political problem to be reckoned with.

Would Medicare for America phase out employer-sponsored insurance?

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It's often regarded as an open question whether the Medicare for America Act, were it to become law, would lead to a phase-out of private insurance. The bill makes a revamped Medicare available to anyone of any age who wants or needs it, with premiums adjusted by income even if the enrollee has access to employer-sponsored insurance.

The revamped "Medicare" is free to anyone whose household income is below 200% of the Federal Poverty Level (FPL) -- about 30% of the population. For those with incomes over 600% FPL, the premium is 8% of income. Those in the 200-600% FPL range will pay a sliding scale, topping out at 8%. Newborns are auto-enrolled, as are the uninsured. Employers can either pay an 8% payroll tax and direct their employees to the public program, or continue to offer their own health plans. Medicare Advantage continues alongside the public program.

I do not think the bill would kill of employer-sponsored insurance, though it would likely shrink the market to a kind of blue-chip perk for well compensated employees. ESI is likely to persist for several reasons:

• The bill stipulates that medical providers have to accept "Medicare" payment rates (not identical to current rates, but based on them) from private insurers.


• The employer tax exemption for health benefits persists. In fact, the ACA's "Cadillac Tax" on especially generous plan (long postponed) is repealed.


• Most importantly, the 8% of income that affluent people would pay for the revamped "Medicare" is considerably more than many pay out-of-pocket for employer-sponsored insurance.

The average premium for family coverage in ESI was $19,616 in 2018, according the Kaiser Family Foundation's Employer Health Benefits Survey, with the employee footing $5,547, or 28%.  For a couple with one child earning $125,000 -- a shade over 600% FPL -- that's 4% of income.

A major fix in Medicare for America 2.0

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Medicare for America, the sweeping healthcare reform bill that allows anyone to buy into a revamped Medicare at an income-adjusted premium, has the potential to transform U.S. healthcare into either an all-payer or a single-payer system.

The bill, first introduced by Reps Rosa DeLauro and Jean Schakowsky in December 2018 and reintroduced on May 1 this year, allows both Medicare Advantage and employer-sponsored insurance to continue, and stipulates that healthcare providers must accept (revised) Medicare payment rates from those private programs.  But because employees can opt into "Medicare" on an income-adjusted basis even if their employers offer compliant private insurance, private insurance will have to establish a real competitive advantage if it's to survive alongside the generous public program.

The headline change in the reintroduced bill is elimination of deductibles, which were modest enough in the original bill (topping out at $350 individual/$500 family). But a more significant change improves the bill's financing and provides ballast for the competition between public and private sectors.

Benefit cliffs in the ACA marketplace

Dave Anderson highlights an important weakness in the subsidy structure for the ACA marketplace. As income rises, the enrollee's share of the premium for a benchmark silver plan is subject to sudden and irregular bump-ups, which Anderson compares to jolts in marginal tax rates.  Take the case of a couple looking to buy a benchmark silver plan:

From $17,000 to$20,000 this couple pays an extra $2 per month for every thousand dollars more they earn a year.  Annually this is about a 2% marginal tax rate on the additional income.  And then there is a huge bump from $20,000 to $21,000.  The benchmark premium suddenly becomes $256 more expensive.  This is a 25% marginal rate...

And then the marginal rate drops again when the family increases their earnings from $21,000 to $22,000.  The marginal rate for this slice is now about 11%.  The marginal rate for couples earning under 300% FPL is in the mid-teens, and then there is a drop in the marginal rate to just under 10% for 300% to 400% FPL and then a potential massive spike as soon as someone earns over 400% FPL.

The spikes in out-of-pocket (OOP) costs this couple is exposed to as income rises are even more sudden -- and, I think, potentially damaging to family finances -- than the premium spikes. The main benefit cliff is formed by the sudden fadeaway of Cost Sharing Reduction (CSR) subsidies at 201% FPL, where the actuarial value of a silver plan drops from 87% to 73%.  CSR disappears entirely at 251% FPL, and the coverage offered by a benchmark silver plan with no CSR, which has an AV of 70%, is clearly underinsurance for those without significant financial resources.

Take a hike, xpost

I neglected to mention that I'm on vacation this week. I'll be back early next. I've been reluctant to spoil my frame of mind with news of our latest spasms toward oligarchy, authoritarianism and/or war, so I'm pretty out of it.  I gather Trump has taken a stand against balance billing. Does he know what it is?  I have long suspected that balance billing is the one healthcare abuse so egregious that even Americans won't tolerate it indefinitely. But watch our pols bipartisanly give away the store to providers.

What if a candidate took voters' stated healthcare priorities literally?

In its low-key way, the Kaiser Family Foundation has been warning Democrats for some time that the electorate is not strongly demanding Medicare for All, or sweeping healthcare system change generally.

With about 90% of the population insured (and perhaps a third underinsured), Drew Altman noted a month ago that voters' main overall healthcare priority is lowering their own out-of-pocket costs. The latest Kaiser tracking poll, conducted this month, fleshes this out:

Drug costs. Surprise bills. Access to affordable insurance if you get sick (e.g., if you lose your job). Underlying these concerns, Altman pointed out, is the poll finding that half of people who are sick have trouble paying their medical bills. With deductibles soaring, 43% said it was hard to pay their medical bills before the deductible kicks in.

Secondarily, there is broad support for expanding financial help to more people who need to buy health insurance in the individual market. There's majority support, in theory, for Medicare for All, but Kaiser's January tracking poll found that that support collapses collapses from 56% to 37% when people are asked if they would support a program that raises most people's taxes or eliminates private health insurance companies.

Meeting voters where they are on healthcare

These responses raise the question: what would a healthcare platform that aims to give voters what they say they want look like?  Addressing voters' stated wishes piecemeal may not be optimal policy: systemic change might be needed to address core concerns. Most fundamentally, reducing individuals' out-of-pocket costs requires bringing down the underlying cost of care, if the cost is not simply to be shifted to the tax burden.

At the same time, a candidate who floats a plan that would leave the current core elements of our health insurance sources intact -- preserving employer-sponsored insurance, existing Medicare, Medicaid and the ACA marketplace -- might have some running room to impose reforms that pinch healthcare industry revenues.

Providers would fight a strong balance billing ban and a strong public option in the ACA marketplace -- but they might ultimately  settle for these reforms that don't radically shrink the employer insurance cash cow. Ditto for insurers. They will fight a public option in the ACA marketplace -- but it's less of a threat than Medicare for All, or a public option that's affordably open to pretty much anyone. As for pharma...let's assume for the sake of argument here that it's possible to take on one healthcare industry head-on if you're not taking on all at once.

So, here's the hypothetical platform:

Strong balance billing protection. Balance billing is the one form of abuse in the U.S. healthcare system that's so egregious, even Americans may not stand for it much longer -- hence the bipartisan draft legislation introduced in the Senate to provide relief. Vox and Kaiser Health News have been doing God's work exposing shocking-but-routine instances of price-gouging. As cited in a Brookings analysis, some 20% of emergency room episodes, 9% of scheduled procedures and 50% of ambulance services result in out-of-network bills for patients

A strong solution would ban balance billing for a) people brought to an out-of-network ED in an emergency, b) people who get emergency care at an in-network facility, and c) people who schedule a procedure with an in-network primary provider at an in-network facility. A viable solution should also not drive up the cost of care by requiring insurers to pay billed costs at huge multiples of Medicare rates, as do some proposals and state bills that mandate arbitration, or use billed costs as a benchmark..

A strong solution put forward in the Brookings analysis would a) cap all out-of-network billing at 125% Medicare and b)  ban independent billing for targeted specialties, e.g.,  emergency, ancillary clinician, hospitalist, and neonatology services delivered at an in-network facility.  That puts the onus on hospitals to negotiate rates acceptable to those specialists.

Prescription drug relief. Medicare should negotiate rates not only for Medicare Part D but for the whole nation -- joining virtually every other wealthy country in having the national government negotiate uniform rates for prescription drugs for all payers. Medicare should also be empowered to create a formulary, i.e. not cover every drug, i.e. have the power to walk away when there's a viable alternative.  This is not going to happen. But in the proposal phase, go big here to balance the moderation of the overall package. Fallbacks might include a) empowering Medicare to negotiate for Part D plans only; b) creation of a drug oversight board empowered to flag and punish or roll back price-gouging as defined by statute; and c) various current bipartisan initiatives to encourage generic production and competition.

Augmented ACA.  Improvements to the ACA should a) make individual market coverage affordable, including via affordable out-of-pocket costs, for anyone at any income level who lacks affordable access to other insurance (e.g., affordable employer insurance or Medicaid); and b) control underlying costs, so that the improved subsidies required by a) are affordable to the Treasury.

A bill that might fit the, um, bill would

a) Raise the benchmark plan in the ACA marketplace, for which enrollees pay a fixed/sliding percentage of income, from 70% actuarial value to 80% AV, i.e. from silver level to gold in the current marketplace scheme. 80% AV is near the average for employer-sponsored insurance.

b) Erase the current subsidy cliff, which renders coverage extremely expensive for many who are just beyond the income threshold for subsidies (400% of the Federal Poverty Level, or roughly $49,000 for an individual/$100,000 for a family of four). Cap premiums for the benchmark plan at 8.5% of income for anyone otherwise eligible with an income over 400% FPL.

c) Improve premium and cost sharing subsidies at incomes below 400% FPL, requiring a lower percentage of income to pay the benchmark premium and providing higher AV for benchmark plans.

d) Create a strong public option, paying Medicare rates to providers (with some adjustments for rural hospitals and primary care) and requiring providers who accept Medicare to accept the public plan. This would also push down the rates that commercial marketplace insurers pay providers, and remove providers' incentive to refuse to accept the commercial marketplace plans, most of which would probably pay more than the public option.

e) Enable people whose employers offer insurance to access subsidies for marketplace coverage if the employer plan a) costs more than 8.5% of income, including for family coverage if the employee has a family, and/or b) offers less than 80% AV coverage.

Point e) does not open the sluice gates to the public plan as wide as does the Medicare for America bill, soon to be reintroduced by Reps Rosa De Lauro and Jan Schakowsky, which allows anyone to buy into the public plan at no more than 10% of income (and much less at lower incomes, including $0 for people with incomes up to 200% FPL).  Because the public option in Medicare for America is free to people with incomes up  200% FPL (with zero out-of-pocket costs as well), it also entails folding Medicaid into the new public plan -- and existing Medicare, with long-term-care added. It also auto-enrolls newborns as of 2022 (or probably 2023 in the upcoming update).

Medicare for America opens a plausible path either to Medicare for All (albeit with out-of-pocket costs for most enrollees) or to a de facto all-payer system, since the bill stipulates that providers must accept the public plan's payment rates from commercial insurers (in employer insurance and Medicare Advantage). It's a coherent set of measures for major system transformation.

The plan above is much more limited. It's also a much lighter lift. But it does cram an awful lot of systemic reform into the Overton Window  opened by Medicare for All and Medicare for America -- while leaving a candidate like Elizabeth Warren free to propose spending trillions on education, childcare and other priorities .

Let's call it 160% Medicare...Washington state public option

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[Updates at bottom: bill is on the Governor's desk]

A few days back, I noted that the state public option bill working its way through the Washington legislature provides an object lesson in how hard it is to expand the pool of people in health plans paying Medicare rates.  An early iteration of the bill had the public plan paying Medicare rates, but a version that passed the House on April 10 had upped the maximum aggregate payment rate to 150% Medicare. The Senate declined to pass this bill, and it went to conference.

Now a new version (ESSB 5526) has emerged from Senate-House conference (kindly flagged for me by Amy Lotven of Inside Health Policy, who will have a story up about it later today). And guess what -- the maximum aggregate payment rate* is up to 160% Medicare.  For reference, commercial payment rates to hospitals average 188% Medicare nationally, according to a 2017 CBO report, and about 128% Medicare for physicians, according to MEDPAC.

Further, the director of the state Health Care Authority can waive the rate cap if she "determines that selective contracting will result in actuarially sound premium rates that are no greater than the qualified health plan's previous plan year rates adjusted for inflation." The director can also waive the rate cap if a carrier contracted to provide the public option can't form a provider network that meets the stipulated network adequacy standards, or if the carrier can offer premiums 10% lower than those of the previous plan year without conforming to the rate cap.

100% Medicare, 150%, 160%.... I am reminded* of the accounting approach of Rabbit, Winnie the Pooh's friend: