Monday, April 22, 2019

Medicare at Will

I have posited repeatedly (here, here, here) that the gateway to real healthcare system transformation (and cost control) is a buy-in to a strong public option that's open to employees as well as employers. A strong public option is one that pays providers at Medicare rates or some adjusted variation, and that all providers who accept Medicare are required to accept.

The public plan must set premiums and out-of-pocket costs at affordable levels for all comers and must be truly available to all, including those whose employers offer private insurance. It should be the baseline against which private coverage must compete, setting a de facto all-payer rate (unless those offering and buying top-drawer coverage want to pay above that baseline).

The Medicare for America bill does all this and also a great deal more -- transforming existing Medicare, including long-term care, folding in Medicaid, auto-enrolling all newborns four years after enactment. I'm not sure the U.S. political system can handle all that mandated transformation at once: in my view the buy-in for employers and employees is the essential core.

This kind of public option, which dates back to the early 2000s in basic concept, has a branding problem. "Medicare for All" has been a dominant watchword and battlecry since 2016, courtesy of Bernie Sanders. "Medicare for America" does not differentiate itself conceptually.  "Medicare for All Who Want or Need It" is...ugh.  Articles such as this one put the buy-in concept under the rubric of Medicare for All, where it doesn't fit.

So I'm here today just to float a name and creed: Medicare at Will. The public plan should  be an affordable option that anyone can choose, with premiums and OOP adjusted to income even if other insurance is available.  Medicare at will is in syllabic balance with Medicare for All. It incorporates the "if you like your plan you can keep it" meme without making any unsustainable promises. In fact it's all about a promise kept: Medicare is always there if you want it or need it.

#MedicareAtWill, friends.

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1 comment:

  1. You are on a good track here. Let me pose a few key issues that would come up:

    1. Initial pricing

    Would the premium be $1,000 a month, which is about what Medicare costs for seniors?
    Or would the cost be scaled down every 5 years, something like that? What would be charged for kids?

    2. Renewal pricing

    Every federal health program in history has had higher than expected costs in the first years. This one will be no exception. Medicare will appeal to those who burn through their deductible each year, and those who want to visit the Mayo Clinic and cannot do so on their current plan.

    Will premiums be raised actuarially, as private insurers do, or will they be raised politically as Medicare does?

    3. Interaction with the employer market

    I assume that employers with stingier plans (high deductibles, narrow networks, not covering spouses) will lose the most participants to Medicare.

    Which is probably fine with them. However the taxpayers might get restless. The subsidies will be large in some cases, as money which used to come from employers now comes from the government.