Overview of Policy Options to Sustain Medicare for the Future

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1 Overview of Policy Options to Sustain Medicare for the Future Juliette Cubanski, Ph.D. Associate Director, Program on Medicare Policy Kaiser Family Foundation Medicare NewsGroup Journalism Workshop Covering Medicare: Care, Costs, Control and Consequences 7 May 2013

2 Exhibit 1 Why Medicare Proposals Are Under Discussion Medicare is now 16% of the federal budget, growing to 18% by 2020 Medicare was 3.6% of the economy in 2010, growing to 4.2% by 2020, 5.7% by 2030, and 7.1% by 2040 Medicare enrollment is growing from 50 million today to 88 million in 2040 Over the long term, total Medicare spending is projected to grow faster than the economy, due to retirement of baby boomers and rising health care costs (affecting all payers) 19% 17% Defense 19% Nondefense Discretionary 17% Other 2 13% Social Security 22% 22% Net Interest 6% Total Federal Spending, FY 2012: $3.5 Trillion Medicare 1 16% 15% Medicaid 7% NOTE: FY is fiscal year. 1 Amount for Medicare is mandatory spending and excludes offsetting premium receipts (premiums paid by beneficiaries, amounts paid to providers and later recovered, and state contribution (clawback) payments to Medicare Part D). 2 Other category includes other mandatory outlays and offsetting receipts. SOURCE: Kaiser Family Foundation based on Congressional Budget Office, Historical Budget Data, February 2013.

3 Exhibit 2 Medicare Part A Trust Fund Balance, Trust Fund Balance at beginning of year, as a percentage of annual expenditures: 120% 100% 80% 60% 40% 20% 0% SOURCE: Medicare Boards of Trustees 2012 Annual Report.

4 Exhibit 3 Medicare is projected to grow at about the same rate as the economy and slower than private insurance per capita 6.9% 6.9% Actual ( ) Projected ( ) 5.0% 3.9% 4.0% 2.9% 2.5% 2.1% Medicare spending per capita Private health insurance spending per capita GDP per capita CPI Medicare spending per capita* Private health insurance spending per capita GDP per capita CPI NOTE: *Assumes no reduction in physician fees under Medicare between 2012 and SOURCES: Kaiser Family Foundation analysis of data from Boards of Trustees, Bureau of Economic Analysis, Congressional Budget Office, Centers for Medicare & Medicaid Services, U.S. Census Bureau.

5 Exhibit 4 Challenges Facing Medicare A mismatch between projected revenues and spending that is projected to result in insufficient funds to support services that are paid for by the Hospital Insurance trust fund beginning in 2024 An outdated benefit design, with relatively high deductibles and cost-sharing requirements, no limit on out-of-pocket spending, and benefit gaps, that encourages beneficiaries to seek supplemental insurance and contributes to relatively high out-of-pocket spending Provider payments that reward volume, rather than value or patient outcomes, without adequate incentives to encourage providers to coordinate and manage patient care, particularly for high-need, high-cost beneficiaries A flawed physician payment formula that aims to constrain the growth in expenditures associated with physician services, but has led to frequent Congressional intervention to avoid sudden and severe reductions in doctors fees An ongoing struggle to constrain the growth in health care spending, while providing fair payments to providers and plans and high-quality, affordable medical care for beneficiaries

6 Exhibit 5 Several Medicare Savings Options are Currently Under Consideration Income-related premiums Raise the age of Medicare eligibility Premium support/defined contribution Place cap on Medicare spending Raise deductibles and/or cost-sharing for Medicare-covered services Require drug companies to provide rebates/discounts Reduce payments for providers and plans Accelerate delivery system reforms Modify IPAB Program integrity Revenues

7 Exhibit 6 Comparison of Medicare Provisions in Recent Proposals Raise age of Medicare eligibility EXHIBIT 15 Increase premiums; restructure/ increase cost sharing Prohibit/ discourage supplemental coverage Premium support President s FY 2014 budget No Yes Yes No Ryan FY 2014 Budget Yes Yes No Yes Bipartisan Policy Center 2013 No Yes Yes No Simpson-Bowles 2013 Yes Yes Yes Maybe

8 Exhibit 7 Raise the Age of Medicare Eligibility from 65 to 67 Why do it? Beneficiaries have longer life expectancy now than in 1965 The full retirement age for Social Security benefits is increasing to 67, so why not for Medicare? Medicare saves money by covering somewhat fewer people Why not? Earlier studies documented potential for large increase in uninsured 65 and 66 year olds if they were no longer eligible for Medicare Why revisit the issue now? Health reform law will change the coverage landscape in 2014 (if fully implemented as passed) People who lose access to Medicare would have access to other sources of coverage (e.g., Medicaid, employer, exchange)

9 Exhibit 8 Raising the age of Medicare eligibility to 67 is expected to reduce costs for some, but increase costs for most 65 and 66 year olds (Assuming full implementation of higher age and health reform in 2014) No change in out-of-pocket spending 3% Average reduction = $2,300 31% would pay LESS out of pocket 66% would pay MORE out of pocket Average increase = $2,200 Total Number of Full-Year Equivalent Medicare Beneficiaries Affected = 5.0 million SOURCE: Kaiser Family Foundation, Raising the Age of Medicare eligibility: A Fresh Look Following Implementation of Health Reform, July 2011.

10 Exhibit 9 Raising the Medicare age of eligibility to 67 would reduce Medicare spending, but result in net increase in total health costs (Assuming full implementation of higher age and health reform in 2014) In billions: Employers State Medicaid $1.1 Medicare $7.0 Federal Medicaid $8.9 Federal Exchange $9.4 Individual OOP $22.9 $4.5 SPENDING INCREASES $58.3 billion Federal Medicaid $0.6 State Medicaid $0.4 Medicare $30.5 Individual OOP $16.7 SPENDING DECREASES $52.6 billion NET INCREASE: $5.7 BILLION NOTES: Estimates do not reflect individual changes in out-of-pocket spending, but rather the average change for each group of individuals, based on new source of health insurance. SOURCE: Actuarial Research Corporation analysis for the Kaiser Family Foundation.

11 Exhibit 10 Public supports raising premiums for higher income Medicare beneficiaries, but few know this is current law Opinion Knowledge 59% of Americans support requiring higher-income seniors to pay higher Medicare premiums 80% of Americans are currently unaware that Medicare already requires Higher-income seniors to pay more for coverage SOURCE: Kaiser Family Foundation, The Public's Policy Agenda for the 113th Congress, January 2013 (conducted January 3-9, 2013).

12 Exhibit 11 Under current law, higher-income Medicare beneficiaries now pay higher Medicare Part B and Part D premiums My income is.. Less than $85,000 $85,001 - $107,000 $107,001 - $160,000 $160,001 - $214,000 $214,001 or more My monthly Part B premium in 2013 is $105 $147 $210 $273 $336 Share of Part B beneficiaries in this income level 95% 2% 2% 1% 1%. SOURCE: Kaiser Family Foundation illustration of Income-Related Medicare Premiums for Part B, 2013; premiums from 2012 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplemental Medical Insurance Trust Funds.

13 Exhibit 12 Implications of Freezing the Income Thresholds until 25% of Beneficiaries Pay Higher Medicare Premiums If income thresholds remain fixed beyond 2019, a growing number and share of beneficiaries will pay the higher Medicare premiums Share paying higher premiums: Current law Proposal 25.8% When fully phased in (~2035), beneficiaries with incomes of $85,000 or more per individual or more would be subject to the higher premium 8.9% 5% 5% $85,000 in 2035 is equivalent to $47,000 for an individual in inflationadjusted 2012 dollars SOURCE: Kaiser Family Foundation, Income-Relating Medicare Part B and Part D Premiums Under Current Law and Recent Proposals: What are the Implications for Beneficiaries?, February 2012.

14 Exhibit 13 Restructure Medicare s Benefit Design Why do it? Medicare has a relatively outdated cost-sharing structure Separate deductibles for Part A and Part B Cost-sharing requirements for covered services vary No limit on out-of-pocket spending Nearly 90 percent of Medicare beneficiaries have supplemental insurance which helps cover these costs (and many pay premiums for this coverage) Concern that supplemental coverage leads to overutilization Medicare could save money (depending on the structure of the new design) CBO has modeled a restructuring option One deductible = $550 Uniform coinsurance for all Medicare-covered services = 20% Annual limit on out-of-pocket spending = $5,500

15 Exhibit 14 Under new cost-sharing rules, most beneficiaries would face somewhat higher costs; a small share would save a lot $550 deductible, 20% coinsurance for all services, $5,500 cost-sharing limit Among 5%, average reduction = $1,570 Among 71%, average increase = $180 Spending reduction 5% No/nominal change 24% 71% Spending increase Total Medicare FFS Beneficiaries, 2013 = 40.8 million SOURCE: Kaiser Family Foundation, Restructuring Medicare s Benefit Design: Implications for Beneficiaries and Spending, Nov 2011.

16 Exhibit 15 Prohibit or Discourage First-Dollar Medigap Coverage Why do it? Some research shows those with Medigap have higher total spending than others Roughly 5 million of 9 million Medicare beneficiaries with a Medigap policy have firstdollar coverage Medigap pays their Part A and B deductibles and coinsurance Medicare would save money through higher cost sharing and reduced utilization Why not? Supplemental Medigap coverage protects policyholders from unpredictable costs Equity issues in limiting the generosity of one source of supplemental coverage and not others One option Require Medigap enrollees to pay the first $550 in cost sharing, followed by 50% of cost sharing up to a limit on out-of-pocket spending

17 Exhibit 16 Prohibiting first-dollar Medigap coverage would reduce costs for many, but one in five are expected to pay more Medigap premiums are expected to decline because Medigap would cover a smaller share of claims Medicare spending declines mainly because policyholders are expected to use fewer services when faced with higher cost sharing Reforms would disproportionately and negatively affect enrollees in relatively poor health, those with inpatient stays, and those with modest incomes Cost REDUCTION Cost INCREASE 79% 21% 36% 14% 7% 8% 6% 8% 21% > $1,000 decrease $500-$999 decrease $250-$499 decrease $1-$499 increase > $1,000 increase $1-$249 decrease $500-$999 increase SOURCE: M. Merlis for Kaiser Family Foundation, Medigap Reforms: Potential Effects of Benefit Restrictions on Medicare Spending and Beneficiary Costs, July 2011.

18 Exhibit 17 EXHIBIT 11 Premium Support, Broadly Defined Under current law, Medicare beneficiaries are entitled to a defined benefit package Most beneficiaries get that defined benefit through traditional fee-forservice Medicare; roughly one-quarter through private plans (Medicare Advantage) Under premium support, Medicare beneficiaries would be entitled to a defined federal contribution to be used towards the purchase of a health plan Some proposals would keep traditional FFS Medicare as a competitor to private plan offerings

19 Exhibit 18 EXHIBIT 12 Illustrative Effect of Premium Support Proposal If Federal payments are based on 2 nd least expensive plan In areas with relatively high In areas with relatively low Medicare FFS spending Medicare FFS spending Defined contribution: Second-least expensive plan, or FFS Medicare Medicare FFS spending Secondleast expensive plan cost Medicare FFS spending Plan cost Beneficiaries likely to pay higher premiums for traditional FFS Medicare (unless Medicare FFS is further subsidized) Private plan enrollees could face higher premiums/ fewer benefits, and/or plans may withdraw (unless plans are further subsidized) NOTE: Federal payments would be based on or tied to the second-least expensive plan, or fee-for-service, whichever is least expensive.

20 Exhibit 19 Most beneficiaries projected to pay higher Medicare premiums unless they switch plans; effect varies across states One in four beneficiaries projected to see Medicare premiums rise by more than $100 unless they switch plans NOTE: Assumes all private plans reduce bids by 5%. Assumes full implementation in SOURCE: Kaiser Family Foundation, 2012

21 Exhibit 20 Majority of the public expresses opposition to most deficit-reducing changes to Medicare I m going to read you some changes to the Medicare program that have been discussed as ways to reduce the federal budget deficit. Please tell me whether you would generally favor or oppose each one. Strongly favor Somewhat favor Somewhat oppose Strongly oppose Requiring drug companies to give the federal government a better deal on medications for low-income people on Medicare 68% 17% 6% 7% Requiring only high income seniors to pay higher Medicare premiums 32% 27% 17% 21% Gradually raising the age of eligibility for Medicare from 65 to 67 for future retirees 26% 22% 12% 39% Reducing payments to hospitals and other health care providers for treating people covered by Medicare 23% 23% 21% 30% Increasing the payroll taxes workers and employers pay to help fund Medicare 16% 27% 22% 33% Requiring all seniors to pay higher Medicare premiums 3% 10% 24% 50% 61% NOTE: Don t know/refused answers not shown. SOURCE: Kaiser Family Foundation/Robert Wood Johnson Foundation/Harvard School of Public Health, The Public s Health Care Agenda for the 113 th Congress (conducted January 3-9, 2013)

22 Exhibit 21 Half of Medicare beneficiaries have incomes below $22,500 5% have incomes above $88,900 50% have incomes below $22,500 25% have incomes below $14,000 NOTE: Total household income for couples is split equally between husbands and wives to estimate income for married beneficiaries. SOURCE: Urban Institute analysis of DYNASIM for the Kaiser Family Foundation.

23 Exhibit 22 By 2030, Medicare beneficiaries are unlikely to have much greater capacity to absorb rising health care costs, except for the wealthiest Per capita total income (in 2012 dollars) $120,000 $100,000 $88,936 95th percentile $110,455 $80,000 $60,000 $40,000 $20,000 $22,502 50th percentile (Median) $28,588 $ NOTE: All incomes are adjusted to 2012 dollars. SOURCE: Urban Institute / Kaiser Family Foundation analysis, Year

24 Exhibit 23 Key Questions in the Debate about Medicare s Future How much can Medicare absorb in additional savings, and over what period of time, without negatively affecting patient care? How should efforts to sustain Medicare be distributed among providers, plans, beneficiaries, and taxpayers? What are the most promising strategies for reducing inefficiencies and promoting high-quality care: accelerated delivery system reforms; greater plan/provider competition; stronger financial incentives to encourage care management? Should Medicare s basic entitlement be changed from a program that guarantees a defined set of benefits to one that provides a defined contribution for the purchase of insurance? Should reform efforts focus specifically on Medicare or be broadened to address the growth in health care spending across all payers?

25 Exhibit 24 Kaiser Family Foundation Medicare Resources Policy Options to Sustain Medicare for the Future The Budget Control Act of 2011: Implications for Medicare Raising the age of Medicare Eligibility Transforming Medicare into a Premium Support System: Implications for Beneficiary Premiums How much Skin in the Game is Enough? Health Care on a Budget Projecting Income and Assets Side-by-side comparison of Medicare provisions in Deficit and Debt Reduction Proposals Income-relating Medicare Part B and Part D Premiums Under Current Law and Recent Proposals Key Issues in Understanding the Economic and Health Security of Current and Future Generations of Seniors Side-by-side Comparison of Medicare Premium Support Proposals Repealing the Affordable Care Act: Implications for Medicare Spending and Beneficiaries The Story of Medicare: A Timeline For more information, visit

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