To Whose advantage is Medicare Advantage? Part 2

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"They have to authorize this"

To whose advantage is Medicare Advantage? Part 1 of this inquiry overviewed the tradeoffs for enrollees and the primary payer -- the federal government. In this post, we'll hear from professionals who deal with MA enrollees and plans.

First, a recap of the issues overviewed in Part 1, based mainly on analysis from MedPAC, the Kaiser Family Foundation, and comments on MA recently solicited by CMS.

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Dear xpostfactoid subscribers: I would like to start publishing on Substack, which I gather has social media-ish characteristics that could be helpful. I've taken the liberty of porting the subscriber list to Substack (and accidentally sent one post already to the whole list -- apologies). If you will bear with me through a brief trial, a handful of posts will come through both subscription services, at which point I'll cut bait with one. I have no intention of charging a subscription fee, as Substack enables.  Thank you for your forbearance. 

Glory hallelujah, for a moment

 Last night I had what is for me a very rare thing -- a dream filled with joy. As always, it's hard to distinguish the dream itself from the interpretive memory of it immediately after -- and possibly later, too. But as best as I can manage...

I was lying flat on my back under the sky, possibly in a trench, as I had been reading a few pages about World War I in Brad DeLong's Slouching Toward Bethlehem before bed. I had a strong feeling of relief and release. We -- I and my family, or community, or possibly nation -- were safe and free. We had prevailed in some life-threatening struggle.

The sky was full of stars.  I thought of singing, but for some reason it seemed more appropriate, or feasible, to write across the sky, and I could do this with my finger, as you do on certain credit card touchpads. I was about to write, or maybe did write, Glory, or Gloria -- maybe Glory Hallelujah, or Gloria in excelcis deo (I seem to have been mulling this as I woke). I thought I would get something going among those around me, a kind of chorus of joy. Not sure whether I did get it started.

There may have been some undertone in this of the election -- fending off rising Republican fascism -- or of the Ukraine war. Maybe I injected those associations later. In any case, I relate it in case there was some intuitive hope that might be shared, as I imagined the "gloria' chorus might be.

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To whose advantage is Medicare Advantage? Part 1

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Note: Enrollment in Medicare Advantage plans is poised to surpass enrollment in traditional, fee-for-service (FFS) Medicare in 2023. MA's rapid growth raises major questions about the shape of Medicare coverage going forward. This is the first of two posts examining the pros and cons of Medicare Advantage. This post outlines the major issues as framed by MedPAC and select researchers, along with the basic economic tradeoffs for enrollees. Part 2 will report the experience of a hospitalist, brokers, and various stakeholders who responded to a CMS request for feedback about the MA program.

There is a slipknot quality to attempts to compare the value and utility of traditional, fee-for-service (FFS) Medicare and Medicare Advantage.

Medicare Advantage plans generally place bids to CMS far below CMS benchmarks, which are based on an adjusted estimate of what it costs to provide FFS Medicare to enrollees in the plan's geographic area. On average, according to the 2022 MedPAC report, MA plans spend 15% less to provide Part A and B benefits than FFS Medicare would spend.  But CMS pays Medicare Advantage plans an average of 104% of what it would pay for FFS Medicare coverage for the same enrollees. But MA plans use the excess payment to provide an estimated $2,000 per member in surplus benefits or out-of-pocket cost relief. But, according to MedPAC, the value of MA-furnished extra services as actually used by enrollees is elusive, because of inadequate reporting requirements, and the quality ratings that increase payments to MA plans do a poor job measuring quality.

With regard to outcomes, MA plans employ treatment protocols that do minimize some so-called low-value care and, in some cases at least, boost usage of preventive care that, according to some studies, can reduce cardiac events, foot amputations for diabetics, ER trips, hospital admittances, and other conditions and services. But there is also good evidence that MA plans inhibit or impede access to needed or high-value care, introduce expensive and sometimes dangerous bureaucratic hurdles to obtaining needed care, and drive enrollees with intense medical needs back to FFS. 

Most notoriously, by multiple accounts, MA plans often impede, block, limit options and reduce the duration of post-acute care. Comments about MA that CMS recently solicited from stakeholders detail these complaints (from physician and hospital associations, practitioners, acute care personnel, patients, brokers and others) again and again and again. A major strain in these complaints is from state employees forced into MA plans by retirement benefit packages.

This month, the Kaiser Family Foundation published a report, based on a literature review of 62 studies published since 2016, comparing "Beneficiary Experience, Affordability, Utilization, and Quality in Medicare Advantage and Traditional Medicare." The authors' conclusions are...inconclusive:

Will Medicaid's "great unwinding" when the PHE ends trigger a "great uninsuring"?

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During the pandemic, from February 2020 to May 2022, Medicaid enrollment increased by 18 million, or 29%, according to administrative data that CMS collects from states. That's mainly because of a moratorium on disenrollments that began in March 2020 and has yet to end. The moratorium will end when the federal government declares an end to the  Public Health Emergency, which will happen in mid-January 2023 at the earliest (the PHE has been extended repeatedly in 3-month increments). 

As noted in my last post, the disruption that may be triggered by the resumption of state "redeterminations" of Medicaid enrollees' eligibility, and subsequent disenrollment of some, is a focus of considerable angst -- and preparations, in states where Medicaid personnel are committed to keeping as many people insured as possible, to proceed with due deliberation and compassion. The Urban Institute has estimated that 15 million people may be disenrolled over the course of a year, the time period that CMS has asked states to devote to clearing the "redetermination" backlog. The Kaiser Family Foundation (KFF) estimates somewhat more modest losses, in a range from 5.3 million to 14.2 million.

This week the Census Bureau released its annual report on health insurance coverage in the United States. Based on the annual supplement to the Current Population Survey, the report shows a more modest increase in Medicaid enrollment from 2020 to 2021 -- 0.9% -- than CMS's administrative data would indicate.  According to CMS, Medicaid and CHIP enrollment increased by 6.6 million from December 2020 to December 2021. That's about 2% of the population.

The Census Bureau also released a second report, spotlighting health insurance changes over two years, and based on the American Community Survey. which interviews people throughout the year about their current insurance status (the CPS, conducted early in the year, asks respondents if they were insured at any point in the past year).  The ACS also shows a gap between Medicaid enrollment gains as reflected in administrative data compared to the survey data. According to the report, the percentage of the population insured by Medicaid increased by 1.3% over two years, from 2019 to 2021 (based, again, on surveys conducted throughout each year). The administrative data records an increase of 11.7 million enrollees from June 2019 to June 2021. That's about 3.5% of the population.

An analysis of the ACS data by KFF attempts to explain this gap. The explanation suggests to me that the disenrollments that will begin at the end of the PHE may not be as disruptive as "15 million disenrolled" might indicate -- at least in states that work in good faith and with due diligence to establish contact with all enrollees, accurately determine their status, and help them consider their options.  My emphasis via yellow highlight below (the bolded subhead is in the original):

Preparing for the great Medicaid unwinding: the case of New Jersey

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NJ FamilyCare end-of-PHE alert

The pending end of the Public Health Emergency declared by the federal government in March 2020 will trigger something of an earthquake among Medicaid enrollees.  

As of May of this year, enrollment in Medicaid and CHIP had increased by 18.3 million -- 26% -- since February 2020, the last month unaffected by the pandemic. Some 90 million Americans, well more than a quarter of the population, are now enrolled in Medicaid or CHIP.  That increase is mostly due to a moratorium on disenrollments enacted in March 2020 as part of the Families First Coronavirus Response act, which conditioned a 6.2% increase in the federal government's share of each state's Medicaid costs on implementing the moratorium (all states complied).  The Kaiser Family Foundation (KFF) estimates that 84% of the enrollment increase during the pandemic is attributable to the moratorium.

Democrats have twelve years of healthcare accomplishment to run on

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Chuck Schumer tours Adirondack Medical Center

HuffPost reports that Priorities USA is urging Democrats to tout recent healthcare achievements:

In a memo set to be published Wednesday, Priorities USA says the most popular achievements of President Joe Biden’s tenure are giving Medicare the power to negotiate prescription drug prices, capping the price of insulin and continuing expanded subsidies for the Affordable Care Act.

Priorities USA recommends focusing on these issues while also attacking Republicans for working to restrict abortion rights in the wake of the Supreme Court decision overturning Roe v. Wade.

Amen. And below those top lines -- the healthcare provisions in the Inflation Reduction Act passed this month -- Democrats should also tout a long tail of recent accomplishments that have improved healthcare affordability and access. Their claim to be the party of healthcare bears not only recent but cumulative weight.

Healthcare was a potent issue for Democrats in 2018, with Republicans fresh off their failed attempt to repeal the ACA's core programs in 2017.  Because they failed, the ACA Medicaid expansion and subsidized marketplace survived to catch the newly uninsured when more than 20 million Americans lost their jobs in the first onslaught of the COVID-19 pandemic. 

Dem chorus rising: Don't let them take your freedom

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For most of the post-January 6 era, the U.S. has seemed to be sleepwalking toward autocracy. 

Republicans swiftly fell in all but unanimously behind Trump's Big Lie that he won the 2020 election; red states passed a raft of voter suppression laws; Trump acolytes positioned themselves to seize control of election administration and machinery; pardoned Team Trump criminals and the RNC encouraged thousands to sign up as poll workers; and diehard election deniers won Republican primaries for secretary of state, attorney general and governor in key states.

Meanwhile, inflation dominated headlines, Biden's approval rating sank to record lows for a first- and second-year president, courts upheld Republican gerrymanders and struck down Democratic ones, off-year elections swung heavily toward Republicans, and Republicans led in generic Congressional polling.

Then came the riveting January 6 Commission hearings in June and July, with Republican officials laying bare Trump's criminality and pathology -- and smack in the middle of that timeline, the intense shock of the Supreme Court ruling in Dobbs, overturning Roe v. Wade. Democrats woke up -- some Democrats, anyway. Gavin Newsom laid down a keynote in a July 4 ad aimed at Floridians ("inviting "them to move to California): freedom is under attack in your state...don't let them take your freedom.

Loony interlude

 

I wish the photo were better...

No healthcare this week, as we are in the Adirondacks, at a collection of Finnish (?!) huts on a small crystalline lake, with no motorboats allowed. On sunny Tuesday morning, in kayaks, we watched a family of loons (father, mother, adolescent) pursue and eat their breakfast. They sail along intermittently in tandem, with adults constantly diving for a minute or so at a time and coming up a few hundred feet away. After some time the female came up with a small silver fish, which she worked around in her beak for a long time, both as she swam back to the other two and as they circled together. At one point the male appeared to make a grab at it. Eventually she put it down the young one's throat. Then it was rinse, repeat: one of the adults (not sure which) caught another fish, worked it for a while, then swallowed it.

Widespread misconception of Medicare Part D enrollees' out-of-pocket exposure

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I object

Late last year, I took some pains to tease out the out-of-pocket (OOP) exposure of Medicare Part D enrollees up to the point where they reach the so-called "catastrophic threshold" of coverage. Beyond that point, they're responsible for a comparatively low 5% of subsequent costs until the end of the coverage year. 

The answer is no real mystery: it's well understood by involved professionals and scholars. It's just awfully hard to derive from general news coverage and even trade press coverage or scholarly coverage.

The exposure up to the catastrophic threshold in 2022 is $2,937, despite an often-cited cap of $7,050, referred to in the trade as the trOOP cap, or true out of pocket cap.