Medicare reimbursement, public options and Medicare buy-in

There has been a flurry of liberal health wonk reform proposals this week.

I want to see details just exactly what is meant by the Clinton proposal as it can range from aggressive administrative action small ball (as we talked about in February) to another whack at the legislative pinata. Anything that passes would probably be a net improvement on the status quo. I am curious if any insurer will attempt to hack the exchanges to manipulate quasi-monopolistic offerings to create a large gap between the least expensive and the benchmark determining second least expensive Silver plans. If they do, individuals who receive subsidies in those regions could be worse off, but from the publicly insured side and the public finance side, more competition, on net, is better.

But before I do a long wonk dive, I just want to re-iterate a very simple point. Most liberal health policy goals have a very simple summary: get more people on insurance that pays providers rates that are closer to Medicare rates than commercial large group rates. Large group rates pay providers between 40% and 100% more than Medicare for physical health service. Moving the entire employer sponsored coverage universe to paying Medicare like rates would knock 30% off of the current bill.

We see this in Exchange. There is significant configuration convergence caused by both the subsidy formula and the risk adjustment formula. Plans that are profitable tend to be paying providers Medicare plus a little bit while offering narrow networks. We see this in the proposal to move the Medicare buy-in age to 55. We see this in the proposal to have a public option. The 2009 House public option was pricing out at Medicare plus a bit. All of these efforts are just different ways to achieve an underlying goal of reducing provider compensation by lowering the average payment per service by having more people move from high payment to provider coverage to Medicare based pricing.

Everything else is details. Those details matter a lot but the core policy thrust is fairly simple.

38 replies
  1. 1
    rikyrah says:

    Medicare buy-in for under 55? I don’t really understand that. I think that I understand what lowering the Medicare age to 55 would mean, but not an under 55 buy-in.

  2. 2

    @rikyrah: BAD TWEET ON COHN’S PART

  3. 3
    Reggie Mantle says:

    Clinton formally endorses public option and Medicare for under-55s

    But that’s just the platform, and as we’ve heard over and over here, the platform doesn’t mean anything. She doesn’t really mean it, so Sanders’ supporters really got nothing, just like BJ wants, right? Right?

    And you wonder why younger voters don’t trust Hillary or the Democrats.

  4. 4
    NorthLeft12 says:

    @Reggie Mantle: Reggie, Reggie, Reggie…..I’ll assume you are not snarking and are serious. Perhaps you would be happier if Ms. Clinton pinky swore that she will do everything within her power to implement the public option while she is President?
    Oh, wait, there is that Congress thing right? What was Bernie’s plan for implementing his fantabulist ideas? Ohhh, right.

  5. 5

    @NorthLeft12: There actually is some administrative space where Clinton could significantly push for state level public options in states that give a fuck.

    Look at the rules on the 1332 waiver — relaxing budget neutrality requirements so that budget neutrality is required over the project lifespan instead of annually as well as allowing 1332 and 1115 waivers to mix are major administrative actions that could have pay-offs in 2018 and 2019 benefit years.

  6. 6
    sherparick says:

    This is still an interesting development and show the movement of the Democratic Party to the left and way from he neoliberal ideas that held sway from 1988-2008.

  7. 7
    Yossarian says:

    The “push to the left, thanks Bernie” thing does have some evidence behind it, but on the public option specifically, recall that Hillary had it as part of her health care plan all the way back in 2008. So at least in one sense, she’s not moving to the left so much as coming full circle.

  8. 8
    Jeffro says:

    Wait…why would we cover more people and lower costs through yet more ‘creeping socialism’? I thought the free market solved everything??

    Also while we’re on health-related topics: can someone explain to me why the 2016 GOP platform calls pron a ‘public health epidemic’ (not a single death that I’m aware of) yet toils mightily to KEEP EVEN BASIC RESEARCH FROM BEING DONE ON THE 30K+ GUN DEATHS PER YEAR IN THIS COUNTRY?!?!

  9. 9
    satby says:

    @Jeffro: because the open industry donates to the Dems and the gun industry donates to the Repugs? Just spitballing here.

  10. 10
    Reggie Mantle says:


    The “push to the left, thanks Bernie” thing does have some evidence behind it, but on the public option specifically, recall that Hillary had it as part of her health care plan all the way back in 2008. So at least in one sense, she’s not moving to the left so much as coming full circle.

    Or, perhaps, Clinton, who has always been first and foremost a cautious politician, is realizing that times have changed. When she and Bill were coming up, being tagged as “too liberal” was a quick ticket to Mondale-land. So they ran from the label and tried too hard to please the right. This led to abominations like the 1994 crime bill (can’t be seen as a soft-on-crime liberal!) and the Iraq War (can’t be seen as a soft-on-terror liberal!) Didn’t work, of course–Bill, Hillary and all the other “pragmatic centrist” triangulators were and are still called leftists, socialists, even traitors by the right.

    Now along comes Bernie Sanders, who’s not just liberal, he’s an unapologetic Democratic Socialist–and people go wild for him. Perhaps Hillary is realizing that Republican Lite just isn’t as necessary as it used to be.

  11. 11
    Reggie Mantle says:

    Interesting survey here that the “platforms don’t matter, so Bernie got nothing ha ha ha” crowd might wish to read. Seven out of the eight political scientists consulted said ‘yes they do’ in varying degrees.

  12. 12

    @Reggie Mantle: tell yourself whatever you need to tell yourself, but the record is fairly clear that Clinton has always been to the left of Obama on healthcare (and more thought out as her plan in ’08 had a mandate while his did not — he relied on super generous subsidies to get a decent risk pool)

  13. 13
    Chyron HR says:

    @Reggie Mantle:

    This led to abominations like the 1994 crime bill

    You mean the Bernie Sanders Crime Bill, the one that he proudly voted for and was bragging about over a decade later?

  14. 14
    Mike E says:

    DougJ, ladies and gentlemen!

  15. 15
    Reggie Mantle says:

    @Chyron HR:

    Yes, Admitted Troll Chyron, the one where Bernie Sanders fought against the mandatory minimums that Hillary was so excited about, but finally compromised (something which the Clintonistas claim he’s unable to do) because of the assault weapons ban and the violence against women act.

    Now you can go tell yourself you’ve provoked me into a “screaming fit,” like you say you like to do. Sad that (a) you think that’s actually happened, and (b) you feel it’s something fun. Because, as noted, that’s the definition of trolling.

  16. 16
    chopper says:

    i assume the red ants are still in the mail, waiting to arrive.

  17. 17
    Reggie Mantle says:


    You people and your obsession with the “public option” as some sort of litmus test of who is more progressive.

    So are you for it? Or are you against it because “you people” are for it?

  18. 18
    Paul in KY says:

    @NorthLeft12: Read that in the Cary Grant voice :-)

  19. 19
    FlipYrWhig says:

    @Reggie Mantle: See, when Bernie Sanders supports something ambiguous, it’s only for the best possible reasons, while when Hillary Clinton supports something ambiguous, it’s definitely for all of the worst possible reasons. Because Hillary.

    But I think this part is largely true, except for the “people go wild” part, because people were more wild for Hillary Clinton’s runner-up campaign in ’08 than they were for Bernie Sanders’s runner-up campaign in ’16. Notwithstanding, sure, Hillary Clinton was supposed to be the liberal lodestar in the Bill Clinton administration, which IMHO is why the welfare reform bill needed her imprimatur (to Marian Wright Edelman’s chagrin and disappointment); and I think she has worked hard to demonstrate that she’s capable of kicking ass and getting tough when it comes to foreign affairs, because peacenik squishiness _from a woman_ would get her ruled out from any sort of high-profile political future.

    And I think this was a reasonable deal with the devil to make, as is especially evident this year: Donald Trump desperately wants to run as the law-n-order candidate keeping (white) Americans safe from brown people at home and abroad, but Hillary Clinton can thwart that by having made herself a viable Asskicker In Chief since 1999. Bernie Sanders, whatever his virtues [YMMV], would have a terrible time countering Trump’s saber-rattling a la Nixon.

  20. 20
    FlipYrWhig says:

    @Reggie Mantle: shomi is a troll.

  21. 21
    Miss Bianca says:

    Richard, just out of curiosity, have you been following the Amendment 69 – Colorado Care – ballot initiative? I just went to a presentation on it last night. It sounds promising, but I’m wondering how it compares to what Vermont tried.

    Also, the presenter kept adamantly repeating that this Colorado Care initiative – essentially, single-payer for COlorado – would have nothing to do with the ACA. Is that because as it’s set up, there would be no insurers involved?

  22. 22
    Reggie Mantle says:


    Your evasion is duly noted.

  23. 23
    gene108 says:

    @Reggie Mantle:

    When she and Bill were coming up, being tagged as “too liberal” was a quick ticket to Mondale-land. So they ran from the label and tried too hard to please the right.

    1. Getting gays to serve openly in the military was not trying to please the Right.
    2. Passing Family Medical Leave, which Bush, Sr. vetoed was not trying to please the Right.
    3. Setting up a “safe space” around abortion clinics, so protesters could not demonstrate right up to the clinics doors was not done to please the Right.
    4. Trying to get us towards universal healthcare, but failing, was not trying to please the Right.*
    5. Passing two gun control bills was not trying to please the Right.

    There’s probably more liberal stuff from Bill’s first two years that was done, but those just jump out. Bill was well to the Left of where the Democrats were in 1993, let alone where Republicans were. It’s just a lot of his more liberal agenda did not fully materialize or materialize at all.

    * You know, who crafted Bill’s healthcare reform law? Hillary! Clearly she had no interest in universal healthcare for everyone until Bernie dragged her Left.

  24. 24
    FlipYrWhig says:

    @gene108: I think there was a window in the 1990s where Democrats could co-opt Republican issues and address them with center-left approaches (like welfare and children’s health insurance, or crime and gun control). It worked pretty well. It worked so well in fact that Bill Clinton reaped all of the benefits from it, which led Mitch McConnell to declare that sort of cooperation anathema under Obama, because doing bipartisan things would make the president look too good, and he had to lose at all costs.

  25. 25
    Yossarian says:

    Hillary’s health care push in ’93 was far more radical than the ACA, and she nearly destroyed her career trying to do it when the entire insurance industry and medical care establishment rose up against it. She then came back in 2008 with a more progressive health care plan than Obama’s (and I worked on the Obama campaign, so I know whereof I speak), and Obama hit her from the right.

    But sure, her announcement of support for the public option is sheer calculation from a dyed-in-the-wool corporatist. That makes a lot of sense.

  26. 26

    @Miss Bianca: Let me get back to you when I have time to read up more on Colorado Care as I don’t know enough to have a reasonably informed opinion yet.

  27. 27

    @Yossarian: You know not to bring facts into a comments thread with ‘Busters

    Time out for you


  28. 28

    Richard, do you think there’s enough slop in the system that moving to Medicare level reimbursement will still allow doctors to be compensated at the level they are?

  29. 29
    Miss Bianca says:

    @Richard Mayhew: much appreciated, sir. As are all your efforts to educate us on the intricacies of the insurance and health care industries. It was because of those efforts that I asked the question I *did* think to ask: “how many people work in the insurance industry in CO, and how will they be affected by this?” (Answer: inconclusive)

  30. 30
    Richard Mayhew says:

    @Iowa Old Lady: no. Long run compensation will come down in real terms even if up in nominal terms… need to think of the stickiness of wages at 0% inflation note to self

  31. 31
    gene108 says:


    2008 was a huge Democratic wave election, much more so than 1992 ever was.

    Republicans really faced the risk of becoming a regional rump party, especially if Obama got any credit at all.

    Probably another reason for the scorched Earth tactics by McConnell, et. al. They were desperate.

  32. 32

    @Miss Bianca: I would not really worry about job losses in healthcare if we are not in a recession for a couple of reasons.

    a) Some proportion of jobs will be needed to run a state wide single payer system

    b) Winding down in-state private insurance will take time.

    c) Most people who will lose jobs have reasonably transferable skills with a six to eighteen month lead time to look for new jobs.

    It is an issue, the optics suck, but if the economy is adding jobs, it is not that big of a deal. Now doing that in the winter of 2009 would be an economic clusterfuck.

  33. 33
    Miss Bianca says:

    @Richard Mayhew: excellent, good points to ponder! thanks again!

  34. 34
    cmorenc says:

    @Richard Mayhew:

    Legitimate question here, Richard: at what point in provider reimbursement rate reduction do we reach a crossover point where it becomes substantially less worthwhile for people to become orthopedic surgeons, anesthesiologists, or other physician specialties which require especially long, difficult, and arduous education and apprenticeships (and for many, at least an additional four-year accumulation of student loans?) Specialties like these require not only doing extremely well during college (including some requisite very demanding premed coursework) but four years of extremely intense medical school study (again, unpaid) and another four years of internship/residency which ARE also paid jobs, but the typical salary is about equal to what a registered nurse makes the first year or two out of school working at a hospital. I mean no disrespect to registered nurses in saying this – my younger adult daughter is a registered nurse, and my older adult daughter is a freshly board-certified anesthesiologist, both in their first year or two working after completing their respective training. Let’s concede that there’s some room for reduction of physician pay rates without undermining the incentives for someone to endure the requisite gauntlet to get there, but at what point in reduction do medicare reimbursement rates simply become counterproductively stingy?

    I had a knee joint replacement at age 66 a week after undergoing a routine colonoscopy, and I was frankly surprised at how modest the Medicare reimbursement rates were for both my orthopedic surgeon and my gastroenterologist. Orthopedic knee replacement surgeons are decidedly NOT fungible quantities – the prospects for a successful outcome are heavily dependent on BOTH the skill of the surgeon and the diligence of the patient in doing the requisite physical rehab. During my rehab visits at my physical therapy provider, I encountered several patients who were struggling in part because something wasn’t done quite right during the surgery (some of whom were rehabbing from hopefully more successful revisions because the initial replacement simply didn’t work out). Given what I know now, I would NOT gladly accept whichever surgeon my insurance company tried to force me to use, without my research confirming that they have a solid reputation for producing good outcomes – I’ve heard too many stories of regret from other patients. Fortunately, my surgeon was excellent, and I’m getting a good result 5+ months out.

  35. 35
    Richard Mayhew says:

    @cmorenc: excellent question and I simply do not have the data to answer it. However the convergence/conversion of high ESI to Medicare plus a bit payment slices is a long slow, gradual project. We should see warning signs in the med school application pool composition early enough to change policy if we are scaring away too many great potential surgeons

  36. 36
    Uncle Cosmo says:

    I propose a cage match between Drudgie Mumble & blomi. To the death. One less fuckhead on the planet guaranteed, & with any luck the winner will bleed out right afterward.

    I’ll bring popcorn.

  37. 37
    ezra abrams says:

    Novartis has built or renovated several large buildings in Cambridge MA; the newest one looks like they spent way more money on a fancy building then they needed to for something nice that would do the job

    so, yeah, some cost squeezing could definitely occur

    I might add, if you wish to see American Biomedical Research in its moneyed majesty, stand on the corner of Main and Vassar in Cambridge
    One corner is the Whitehead Institute; another is the Koch Cancer Center; another is the McGovern Brain Institute, and the 3rd is a biotech company – Amgen, iirc.
    All are large buildings, and they are certainly not utilitarian academic buildings; they are , like the new chemistry at Princeton, almost embarrassingly luxurious.
    In the old days, the Nobel Prize winners of MIT managed to make due with building 56, a spartan academic structure.

    And Next to the four buildings on the corner are the MIT biology building, the Broad, and several buildings in Kendall Square; down the street is the Novartis Institute; a half mile over the Charles is the massive MGH/MEEI complex
    And this doesn’t include, remember the Boston metro area isn’t that big, Harvard, the Longwood Medical area (maybe a dozen large buildings) Brandeis, Northeastern, Tufts, etc
    When I first moved to Boston, I remarked to a friend that even tho the longwood area seemed stuffed with huge buildings, they were building more.
    And he said, yeah, every year they tear down the smallest building and put up a new building that is much larger.
    And the funny thing is, the main street for this complex, full of hospitals that get dozens of ambulances with critically ill people everyday, the main street is Longwood, a narrow two lane road, totally congested, and all the superbrains at Harvard put the parking lot entrances at the *middle* of the road, rather then at the ends…..

  38. 38
    ezra abrams says:

    @cmorenc: Last time I looked, MD salaries are ~ 15% of the healthcare cost in the US, so MD salaries are not a large part of the cost problem.

    (I was a little surprised by this stat – I found it via google and am not really sure how accurate it is)

    and, of that 15%, I suspect no more then 5-10% is for specialized people like a knee surgeon
    WE (the taxpayers) already pay a lot of the training (via payments to teaching hospitals and medical schools) so I think incentivizing surgeons is not a problem.
    So, If we spend a little on training , I think we are ok here.

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