Medicare-E(veryone) is a great slogan.
I think it is a good animating vision for a desired end point.
It is not serious policy yet.
Medicare-E instead of managed competition is a debate about means. I want to assume that I share the same desired end of most Medicare-E/single payer advocates (namely making sure everyone in this country has access to affordable, competent and effective health care.) I am assuming that is a shared end goal. But I have a hard time seeing how the end goal is achieved by an attractive slogan that has minimal policy back-up support.
I understand the desire to use Medicare as the basic structure of a national single payer system as it is a pre-exisiting program whose skeleton is strong enough to build on. However that skeleton has some odd deformities to it, and a lot of trade-offs have been built into Medicare that would need to be re-examined if we were to massively expand Medicare’s scope. I have a big series of questions that Medicare-E advocates would need to answer to transform a slogan into a policy program as Medicare E is not a matter of simply printing up new ID cards and mailing them to everyone in the country with a start date three months from the mail date.
- Why Medicare-E when there are numerous other examples of universal or near universal coverage that are provided by non-single payer systems (Netherlands, Germany, Switzerland as relevant examples)?
- We are currently closer to the Swiss model of managed competition than single payer. How do we managed the transition?
- If Medicare-E was an easy sell, we should have seen Vermont go forward with a single payer plan. Please explain why Vermont decided that it would not apply for a Section 1332 Waiver to transition the PPACA programs into single payer?
- How should we treat people whose current insurance has an actuarial value (AV) in the high 80s or better (Medicaid, CHIP, Cost sharing Silver 1st and 2nd Tier, Platinum, good union deals etc)? Do we transition everyone to Medicare’s 81/82% acturial value and tell people with good, high AV insurance to suck it? Do we keep high AV plans? If we keep high AV plans, how do we prevent massive cost dumping of sick people from private pools into public pools.
- How do we treat Medicare Supplemental policies to increase AV?
- As we’ve talked about in the rest of the series, Medicare is a good insurance program but it is not a perfect insurance program. The biggest problem with Medicare from a beneficiary point of view is that it does not limit maximum annual exposure to costs nor does it do well with extreme outliers of care. As we’ve seen, Medicare Part B has a 20% co-insurance rate with no out of limit cap. Medicare Part D has a 5% co-insurance rate with no annual cap. Medicare Part A limits annual and lifetime hospital days covered. An individual with Hep-C and cancer is far better off on a PPACA compliant Bronze exchange policy than they would be in Medicare.
- What benefits are covered (most private insurance will cover elective abortions, Medicare via Hyde is prevented from doing that)
- Is private pay for services allowed or is private pay outlawed?
- What do we do with Medicare Part C?Do we place limits on lifetime and annual individual exposure? If so, how do we pay for the increased AV?
- How much do individuals pay?
- Does everyone pay the same amount, or are individual contributions keyed to income/assets? If they are keyed, how?
- Does everyone pay the same deductible or does that vary based on ability to pay? (Same deductible for Bill Gates and the 31 year old with 3 kids working at an $11.00/hour job? Or do they face different cost sharing?)
- Do we use a single national risk pool and contracting model, or regional models (the New York versus North Dakota problem)
- What do we pay providers?
- Is Medicare-E allowed to negoatiate for drugs?
- HOW DO WE GET 218-51-1-5?
I have a much harder time seeing how that end is achieved if Medicare-E advocates don’t start answering the hundreds of policy implementation and management questions that Medicare-E would entail. The biggest problem with Medicare-E is how to finance it from people who will be made significantly worse off. People with high incomes are highly likely to already have better than Medicare insurance through either work or the Exchange. Not pissing this group of people off is critical to building a winning political/legislature coalition. Not pissing this group of people off will either involve unicorns shitting bricks of gold out of their ass, or some seriously odd plumbing. A simple slogan does not address this critical blocking problem.
What is the solution?