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16.1 The Medicaid Program for Low-Income Families
16.2 What Are the Benefits of the Medicaid Program
16.3 The Medicare Program
16.4 What Are the Effects of the Medicare Program
16.5 Long-Term Care
16.6 Health Care Reform in the United States
16.7 Conclusion
Health Insurance II: Medicare, Medicaid, and Health Care Reform
16
Fundamental reform of the U.S. health care system has been a constant source of political debate for much of the past century. In 2010, President Barack Obama signed into law a sweeping overhaul of the U.S. health care system.
Introduction: The Patient Protection and Affordable Care Act
16
The Patient Protection and Affordable Care Act (ACA) makes five fundamental changes to the U.S. health care system.
It bans insurers from denying coverage because of pre-existing conditions.
It bans insurers from charging different prices to different people based on their health.
It mandates all U.S. residents be covered by health insurance.
It requires the federal government extensively subsidize health insurance coverage for the poor.
It takes a variety of actions to lower health care costs.
Introduction: The Patient Protection and Affordable Care Act
16
This legislation was highly controversial and passed through Congress with a very slim margin in a strictly partisan vote (no Republicans voted for it).
The right worried that the law would lead to restricted patient choice and a bloated government bureaucracy.
Those on the left believed that this proposal represented a retreat from the government-run single-payer system that might more efficiently expand coverage and control costs.
Introduction: The Patient Protection and Affordable Care Act
16
This chapter focus on Medicare, Medicaid, and health care reform.
Medicare: Federal program, funded by a payroll tax, that provides health insurance to all elderly over age 65 and disabled persons under age 65.
Medicaid: Federal and state program, funded by general tax revenues, that provides health care for poor families, elderly, and disabled.
Health Insurance, II: Medicare, Medicaid, and Health Care Reform
16.1
Medicaid: Federally mandated, state administered.
Serves low-income families, with different income thresholds in different states.
Children’s Health Insurance Program (CHIP): Program introduced in 1997 to expand eligibility of children for public health insurance beyond the existing limits of the Medicaid program, generally up to 200% of the poverty line.
Generous coverage: Little cost sharing, low premiums.
The Medicaid Program for Low-Income Families
National eligibility rules:
Everyone 18 or younger, up to 100% of the poverty line.
Children under age 6, pregnant women, 133% of the poverty line.
In most states, eligibility extends further for both children and pregnant women: A typical state covers both groups up to 200% of the poverty line.
There was a massive expansion of the Medicaid program put in place by the ACA, which extended eligibility to all families, regardless of family structure, below 138% of the federal poverty line.
Who Is Eligible for Medicaid
16.1
16.1
What Health Services Does Medicaid Cover
Required to cover physician and hospital care.
States also cover dental and prescription drugs.
How Do Providers Get Paid
Payment set by states.
In most states, Medicaid reimbursement is low.
Many physicians refuse to see Medicaid patients.
The Medicaid Program for Low-Income Families
16.2
Medicaid intended to provide insurance coverage to low-income people, thereby improving their health.
How might Medicaid affect health
Medicaid leads to increased insurance coverage…
…Leading to lower prices increases access to care…
…Leading to more utilization of health care…
…Leading to better health…
…At potentially low cost if it increases preventive care.
Does Medicaid Improve Health
16.2
Does Medicaid Improve Health
16.2
Does Medicaid Increase Insurance Take-Up
1982 2000: Huge increase in program eligibility.
Only 10 25% of newly eligible people actually signed up.
Crowd-Out
Many newly eligible people did not sign up because they already had health insurance.
But many may have dropped their private coverage to obtain more generous Medicaid coverage.
Overall, 20 50% crowd out.
How Does Medicaid Affect Health Evidence
16.2
Health Care Utilization and Health
Medicaid still substantially reduces the number of uninsured, so expansions may affect the utilization of health care services.
Medicaid eligibility increases preventive care and reduces infant mortality. Oregon lottery study confirms that Medicaid improves health overall.
How Does Medicaid Affect Health Evidence
16.2
Cost-Effectiveness
It cost Medicaid roughly $1 million per infant life saved through its expansions. This is much lower than the cost of many alternative government interventions designed to save lives, such as food regulation or seat-belt safety.
This finding suggests that investing in low-income health care may be a cost-effective means of improving health in the United States.
How Does Medicaid Affect Health Evidence
16.2
State Medicaid expansions between 1982 and 2000 are a natural experiment for Medicaid’s impact on health.
Medicaid eligibility rose much faster in Missouri than in Michigan.
State-specific trends might bias the comparison between Michigan and Missouri.
Eligibility for 13-year-olds in D.C. rose much faster than for newborns.
EVIDENCE: Using State Medicaid Expansions to Estimate Program Effects
16.2
EVIDENCE: Using State Medicaid Expansions to Estimate Program Effects
Eligibility for All Children, by State Year Missouri Eligibility Michigan Eligibility
1982 12% 20%
2000 76% 34%
Eligibility for Children by Age in Washington, D.C. Year Age 13 Age 0
1982 18% 48%
2000 59% 56%
16.3
Medicare:
Largest public health insurance program in the United States.
Administered at the federal level.
All U.S. citizens who have worked and paid payroll taxes for ten years, and their spouses, are eligible.
Ineligible citizens can purchase Medicare coverage at its full cost.
How Medicare Works
16.3
Medicare Part A: Part of the Medicare program that covers inpatient hospital costs and some costs of long-term care; financed from a payroll tax.
Medicare Part B: Part of the Medicare program that covers physician expenditures, outpatient hospital expenditures, and other services; financed from enrollee premiums and general revenues.
Medicare Part D: Part of the Medicare program that covers prescription drug expenditures.
(There is no Part C to consider in this discussion.)
Medicare Is Really Three Different Programs
16.3
Relative to private health insurance, the Medicare program has fairly high copayments and deductibles and a relatively lean benefits package.
This greatly lowers the consumption-smoothing value of Medicare since there is still some risk of very high medical expenditures if you are ill.
This is not as big a concern relative to Medicaid, as the Medicare program assists all elderly, both rich and poor.
Medicare Has High Patient Costs
16.3
Comparing Medicaid and Medicare
Eligibility:
Medicaid: Families on welfare, low-income children, pregnant women, elderly, disabled.
Medicare: Retirees and spouses 65+, certain disabled people, people with kidney failure.
Premiums:
Medicaid: None.
Medicare: Physician coverage $100/month, variable premiums for prescription drug coverage.
16.3
Comparing Medicaid and Medicare
Deductibles/copayments:
Medicaid: None (or very small).
Medicare: Hospitals: $1,260 deductible, physicians $147 deductible and 20% copay, and cost-sharing for drugs.
Services excluded:
Medicaid: None (or very minor).
Medicare: Prescription drugs (until 2006), routine checkups (until 2010), dental care, nursing home care, eyeglasses, hearing aids, immunization shots.
16.3
In 1965, Medicare covered hospital and doctor costs, but it excluded coverage for prescription drugs.
Drugs not very important in 1965.
Today they are used to treat many common conditions.
Democrats wanted government-provided drug insurance to negotiate prices with drug companies.
Republicans wanted to subsidize private drug insurance, to avoid adverse selection. President Bush signed into law a bill that followed this approach.
APPLICATION: The Medicare Prescription Drug Debate
16.3
APPLICATION: The Medicare Prescription Drug Debate
For basic Part D plans, individuals receive coverage for:
None of the first $250 in drug costs each year.
75% of costs for the next $2,250 of drug spending (up to $2,500 total).
0% of costs for the next $3,600 of drug spending (up to $5,100 total).
95% of costs above $5,100 of drug spending.
Poor insurance design intended to garner political support. May have adverse effects on utilization.
16.4
Despite broad support, there is surprisingly little evidence that the Medicare program actually improves the health of the elderly.
Medicare provides valuable risk protection: Consumption-smoothing alone worth half the cost.
Prospective Payment System (PPS): Medicare’s system for reimbursing hospitals based on nationally standardized payments for specific diagnoses.
What Are the Effects of the Medicare Program
16.4
In 1983, Medicare switched from retrospective to prospective payment system.
Prospective Payment System (PPS): Medicare’s system for reimbursing hospitals based on nationally standardized payments for specific diagnoses.
Diagnoses for hospital admissions grouped into 467 “Diagnosis Related Groups,” or DRGs.
Each DRG receives a fixed payment, depending on cost of national cost of treatment and local expenses.
What Are the Effects of the Medicare Program
16.4
Prospective payment reduced utilization:
Average length of a hospital stay for elderly patients fell from 9.7 days to 8.4 days in just one year.
Hospital costs under Medicare grew at only 3.0% per year from 1983 to 1988, after growing at 9.6% per year from 1967 to 1982.
Health did not suffer.
But health care costs soon resumed their rapid rise.
Empirical Evidence on the Move to the PPS
16.4
Why didn’t the PPS solve the long-run cost growth problems of the Medicare program
Medicare was paying a fixed price per diagnosis, but the choice of a diagnosis is something the hospital has some control over when patients are admitted.
There was a large increase in reported severity of admission diagnoses for the elderly around the time of PPS!
Almost half of the DRG designations are based not purely on diagnosis but also on the actual treatment used for the patient.
It reimburses hospitals per admission, providing incentive to raise hospital admissions.
Problems with PPS
16.4
An unintended effect of moving to PPS for hospitals was a shift toward more use of other types of facilities that were exempt from this system.
Long-term care hospitals have become the fastest growing and highest-paid providers of post-acute care [care delivered after hospitalization] in the Medicare program.
Part of this growth was fueled by the implementation of PPS, which exempted these types of providers, creating incentives for acute-care hospitals to discharge patients quickly to these fee-for-service hospitals.
Evidence: Short Stays in Long-Term Care Hospitals
16.4
To remedy this situation, in October 2002 the government introduced a PPS system for long-term care hospitals that was to be phased in over several years.
To discourage the transfer of short-stay patients to these facilities, the system included a reduction in payments for patients discharged before a threshold length of stay (that varied by condition). This reduction was sizeable.
Evidence: Short Stays in Long-Term Care Hospitals
16.4
The question addressed by a 2015 study by Kim et al, is whether long-term care facilities responded to this incentive by keeping patients beyond the 29 day threshold.
In particular, if hospitals are responding to this financial incentive, we should expect to see increased discharges right after the threshold, when patients qualify for the higher payments.
Evidence: Short Stays in Long-Term Care Hospitals
16.4
Before the policy change, 2% of patients were discharged at 29 days. After the policy change, the share almost tripled. Clearly, this change in reimbursement policy influenced hospital behavior.
Evidence: Short Stays in Long-Term Care Hospitals
16.4
Just as with designing optimal insurance systems for workers, designing optimal reimbursement systems for providers reflects a trade-off.
Retrospective reimbursement systems do not provide sufficient incentives to control medical costs.
A purely prospective system, which we have not yet achieved, might lead providers to cut care too much in order to make money.
Lesson: The Difficulty of Partial Reform
16.4
Starting in 1985, the federal government allowed Medicare enrollees a choice of Medicare HMOs as well.
Managed care gives providers an incentive to reduce costs and are reimbursed at 95% of Medicare average.
HMO enrollees avoid Medicare’s cost sharing.
But HMOs restrict the choice of provider and potentially engage in other rationing to keep down costs.
Medicare Managed Care
16.4
Medicare Managed Care
Enrollment in Medicare HMOs rose steadily to 16% of all enrollees in 1999, dipped somewhat, and then rose again after 2003 due to an increase in reimbursement rates to the managed care providers; enrollment growth has been particularly rapid in recent years.
16.4
Medicare Managed Care
Do Medicare HMOs save money
Medicare reimburses at 95% of average cost…
…But low-cost individuals may be drawn to HMOs…
…In which case the government ends up overpaying for their coverage.
Consider example with 100 people in each of three groups. Costs per group are $1,000, $2,000, or $3,000.
30% of the low-cost, 15% of the middle-cost, and none of the high-cost people use HMOs.
16.4
Medicare Managed Care
Cost: Without HMO With HMO # in Medicare # in Medicare # In HMO
1,000 100 70 30
2,000 100 85 15
3,000 100 100 0
Avg. Medicare cost: $2000 Average Medicare cost: $2,118 Average HMO cost: $1,333 Average reimbursement: 2,012 Cost to government: 600,000 Cost to government: 630,530 16.4
The problem with managed care reimbursement is determining how much to pay insurers.
Premium support is an alternative.
Premium support: A system of full choice among health care plans for Medicare enrollees, whereby they receive a voucher for a certain amount that they can apply to a range of health insurance options (either paying or receiving the difference between plan premiums and the voucher amount).
Should Medicare Move to a Full Choice Plan
Premium Support
16.4
APPLICATION: A Premium Support System for Medicare
The advantages of a premium support system mirror the advantages of voucher systems for education.
Respects consumer sovereignty by allowing individuals to choose the health plan that best matches their taste rather than forcing them into one government-provided option.
Promotes efficiency in medical care delivery by allowing individuals to shop across plans.
Solves the problem of “appropriate” reimbursement levels for managed care plans by simply letting the market work.
16.4
APPLICATION: A Premium Support System for Medicare
The disadvantages of a premium support system include:
Adverse selection: Healthy individuals choose the less expensive plans, raising costs even further for sicker individuals, who prefer the more generous plans.
Poor decision-making by seniors: Studies in a wide variety of contexts show that more choices lead to less participation in a market and to less satisfaction with the choices that are made.
16.4
APPLICATION: A Premium Support System for Medicare
Plan Cost Voucher Price
Full-choice Medicare (before adverse selection) A $1,800 $2,000 $200
B $2,000 $2,000 0
C $2,500 $2,000 $500
Full-choice Medicare (after adverse selection) A $1,600 $2,100 $500
B $2,100 $2,100 0
C $3,000 $2,100 $900
16.4
Individuals fill these coverage gaps in Medicare in one of three ways:
Low-income individuals have Medicaid.
About 16% of all Medicare-eligible retirees over 65 have health insurance from their former employers.
Many retirees buy individual “Medi-gap” policies from insurance companies.
These three means of filling the gaps in Medicare coverage exert a negative financial externality on the Medicare program.
Gaps in Medicare Coverage
16.5
Long-term care is not covered by Medicare and represents 8% of all health care costs.
Long-term care: Health care delivered to the disabled and elderly for their long-term rather than acute needs either in an institutional setting (a nursing home) or in their homes.
Delivered mainly in institutional care (nursing homes) and by nurses and other aids in home health care.
Medicaid covers long-term care, but to become eligible, individuals must first spend all their assets.
Long-Term Care
16.5
Individuals initially pay for long-term care by drawing down their savings.
But long-term care costs $80,300/year.
After savings are depleted, Medicaid covers long-term care.
Implicitly taxes savings.
Long-term care insurance would be a better solution, but market is hampered by adverse selection.
Financing Long-Term Care
16.6
There has been an historical impasse over national health insurance.
Some argue for a single-payer system.
Government-provided health insurance for all.
Guarantees full coverage.
Low administrative costs.
Eliminates inequality in care.
Straightforward to control costs by budgeting.
Health Care Reform in the United States
16.6
Public system also has disadvantages:
Dramatically increase government expenditure.
Budgeting a blunt instrument.
Severe political hurdles from health insurance companies.
Others push for a private sector solution, possibly with subsidies.
Adverse selection, other market failures remain.
No evidence private sector can contain costs.
Health Care Reform in the United States
16.6
In 2006, Massachusetts pushed to cover remaining 9% without insurance.
“Three-legged stool” approach:
Ban pre-existing conditions exclusion, health-based pricing.
Individual mandate, avoiding adverse selection.
Mandate: A legal requirement for employers to offer insurance or for individuals to obtain some type of insurance coverage.
Subsidized/free insurance for low-income families.
The Massachusetts Experiment with Incremental Universalism
16.6
Striking results:
MA uninsurance rate 3%, compared to 18% nationally.
Half of the increase in coverage from Medicaid or government subsidized plans.
Premiums in the non-group market have fallen by half relative to national trends.
Costs of the reform roughly consistent with projections.
Some studies have found the policy has improved health of population.
The Massachusetts Experiment with Incremental Universalism
16.6
In 2010, President Obama signed into law the Affordable Care Act, based on the MA health reform.
Adopts “Three-legged stool” of MA:
Prices are community-rated, not health-specific.
Individuals are mandated to buy insurance.
Medicaid expanded, with subsidies for lower-income people.
Expected to cost $1 trillion over the next decade.
Includes substantial efforts to control costs.
The Affordable Care Act
16.6
Since 1950, the price index for medical care has risen by 2.1 percentage points more per year than inflation, but much of the rapid rise in spending has been quality-improving technological change.
Between 1984 and 1991, average cost of treating heart attacks rose by 4% annually in real terms, but cost of intensive treatment fell.
Cost increase reflects growing use of intensive treatment.
Heart attack treatment represents an efficient use of medical spending.
APPLICATION: Rising Health Care Costs and Cost Control Efforts in the ACA
16.6
Limiting spending to efficient uses would reduce costs but is hard to do. The ACA has five approaches.
Cap tax break of employer-provided insurance.
Increase competition for health insurance.
“Depoliticize” rate-setting for providers.
Sponsor “comparative effectiveness” research.
Promote pilot programs of alternative structure for organizing and reimbursing providers.
APPLICATION: Rising Health Care Costs and Cost Control Efforts in the ACA
16.6
Projecting the impacts of a reform as large as the ACA is difficult, but the CBO has attempted to do so, most recently in CBO (2014).
They project that these reforms will lead to 2,632 million newly-insured residents by 2019.
The CBO also projects that the spending cuts and revenue increases in the ACA will more than offset the new spending under the ACA, so that the law will reduce the deficit by more than $100 billion over the first decade, and more than $1 trillion over the next.
Projected Impacts of the ACA and Early Evidence on its Effects
16.6
Early evidence on the effects of the ACA appears to support the contentions of the CBO analysis.
The number of uninsured in the United States has fallen by at least 15 million, with the uninsurance rate declining by more than one-third.
Other studies suggest that this coverage has also improved access to care and self-reported health, decreased emergency room use, and increased use of preventive care.
Cost growth since the passage of the ACA has been historically low, at a rate of 1.4% since 2010.
Projected Impacts of the ACA and Early Evidence on its Effects
16.7
The ACA holds the potential to address many shortcomings in our health insurance system, greatly reducing the ranks of the uninsured.
Evidence from past insurance expansions suggests that this will provide a cost-effective means of improving health.
Further reform is needed to control costs.
Conclusion

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