Premium Support: Coming Soon to a Medicare Plan Near You?

Unnoticed by most of the media, the Congressional Budget Office recently released a report that could profoundly change American seniors’ healthcare coverage.

The report updates a 2013 CBO analysis of the potential impact of switching Medicare to a premium support system. Under such a system private plans would compete with the traditional fee-for-service plan much like today, but with a big difference. Whereas now, for most beneficiaries, Part A is free and Part B requires a modest premium, under premium support the government would pay only up to regional benchmark amounts for Parts A and B together. Seniors choosing a plan (or the FFS option) priced above the benchmark would pay the difference.

The concept isn’t new. Over the past twenty years, various versions have been proposed by bipartisan commissions and—more recently—by Republican budgeters in Congress. What is new is the projected magnitude of the federal budget savings.

Both CBO analyses looked at two options for setting the benchmarks, either as the average of all bids (including the projected FFS cost) for a region, or as the lower of the FFS cost and the second lowest private plan bid. The differences between the projections in the two analyses, four years apart—and the numbers themselves—are huge.

The 2013 analysis estimated that (assuming most beneficiaries would be switched to premium support at implementation) the federal savings for 2018-2023 would be $69 billion for the average-bid option, and $275 billion for the second-lowest-bid option. In startling contrast, the 2017 report estimates savings for 2022-2026 of $184 billion for the average-bid option and $419 billion for the second-lowest-bid option. In fact, these numbers underestimate the increase in potential savings. If the 2017 analysis had covered six years, like the 2013 report, savings for the average-bid estimate would have been close to $240 billion, and for the second-lowest-bid option would have been more than a half trillion dollars. (Estimated savings would have been greater still if the CBO had included dual eligibles in their analyses.)

Both the 2013 and 2017 analyses also considered the effect on savings that would result from “grandfathering,” allowing beneficiaries at the date of implementation to keep their coverage with no additional premium required. The estimates for this option assumed that most seniors would prefer to stay in their current plans and so are much lower, all in the $10 billion to $50 billion range.

What are the implications for seniors of a switch to premium support?

According to the new CBO analysis, under the average-bid option, without grandfathering, the average beneficiary’s premium would be about 5 percent lower than under current law. Under the second-lowest-bid option, it would be 18 percent higher.  The premium for choosing the FFS alternative under the average-bid option would be 57 percent more, on average, than the projected current-law premium, while under the second-lowest-bid option it would be twice the projected current-law premium. These are overall averages; individual seniors could face very different situations. Most seniors choosing plans below the benchmarks would see reductions in their premiums, but those choosing traditional FFS under the second-lowest-bid option in a region in which FFS costs are high could face premiums three times those under current law.

Why are the estimated savings in the 2017 report so much greater than four years earlier? The main reason is that private plan bids are now much lower relative to FFS costs than expected in 2013. In the earlier analysis, CBO expected that the ratio of private plan bids to FFS costs would increase from the then 92 percent. In fact, it decreased, primarily due to legislation increasing physician payments (and thus FFS costs), and to private plans gaining greater risk payments than expected (allowing them to lower their base bids). (In the new CBO analysis it is assumed that Congress will limit such risk “bonuses.”) In addition to these factors is the obvious one: Medicare has grown and costs have inflated over the past four years.

So, is Medicare premium support a good idea?

It would be much more equitable than Medicare today. There is inherent unfairness in a system that pays far more for some coverage options than others. From a taxpayer viewpoint, savings in the hundreds of billions of dollars provide a persuasive argument for change. Even if savings are maximized, the design of the various options means that beneficiaries will always be able to select coverage with no added premium. Many seniors, however, would be faced with a painful choice: pay an additional (possibly unaffordable) premium or be forced to switch physicians and other providers, something that could be especially difficult for the oldest and sickest beneficiaries—and something that could lead to considerable resistance from seniors’ groups.

Is it likely to happen? There are some recent clues.

First, CMS administrator Seema Verma recently declared that Medicare was facing a fiscal crisis and that it was necessary to give consumers “incentives to be cost-conscious.” Second, the probability grew of tax bill enactment that will substantially increase the federal deficit—and potentially lead to efforts to find compensating savings. Third, as in some prior years, the House of Representatives 2018 budget resolution assumed a move to premium support by 2024.

If these clues indicate serious administration intent, we may see attempts in the next few months—prior to the November 2018 elections—to introduce some version, probably with grandfathering (to minimize seniors’ protests), and possibly taking a middle course between the average-bid and second-lowest-bid options (to achieve spending neutrality for the average beneficiary). Stay tuned!

Roger Collier was previously CEO of a national healthcare consulting firm.

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3 replies »

  1. Paul Ryan stated recently that in 2018 the repugs will be addressing Medicare, Medicaid and SS. In his interview he said people need “options”. Once these tax cuts are in place the Repugs will have set the scenario of a huge budget deficit which of course will need to be paid for – but not by the “rich” or corporations with a permanent cut. The term “options” is code for cuts to government programs as we certainly can’t have a tax increase. Repugs will say they’re backed into a corner.

    Here in NC income taxes were cut (the carrot) but other more regressive taxes were applied, such as a sales tax on labor (the carrot placed on a longer stick). As well programs were cut.

    Not sure how long it will take Trump supporters to realize that he’s not their friend.

  2. The non-neutralizing antibodies are doing something to the virus that aids either its entry into the cell or its multiplication after entry. This is the key mystery. I think this has been seen in-vitro also–in the lab.

    It must have to do with improving receptor function or RNA polymerase or decreasing natural immunity. Great keys for new discoveries!

  3. Ultimately, we cannot depend on “behavioral economics” as a basis to solve the cost dilemma of our nation’s healthcare. Health spending for our nation’s healthcare represented 18.2% of nation’s economy last year. For the other 34 OECD nations of the world, the portion of their economies devoted to health spending mostly clustered around 12%. For 2016, the realistic excess in health spending between 18% and 13% for our GDP represented $1 Trillion. Since our Federal government pays cash for 40% or our nation’s health spending, the excess health spending represented $400 Billion of our nation’s Federal deficit in 2016 (~80% of the Federal deficit that year).
    We will need to fix the fundamental problems underlying our nation’s healthcare. The path to evolving bureaucratic rationing has no justly equitable constituency other than for a single payer solution. So far, the single-payer concept has many unspoken opponents, chiefly represented by our nation’s States’ Rights tradition. Unlike the other 34 OECD nations, we do not have a nationally sanctioned and locally driven reform strategy to assure that equitably available, enhanced Primary Healthcare is offered to each citizen, community by community. With this focus, it is likely that the egregious gaps in quality for our nation’s healthcare would be resolved with its improved ecological accessibility, just efficiency and reliable effectiveness achieved by enhanced Primary Healthcare.
    For one concept, see https://nationalhealthusa.net/summary/
    For an annual Federal expense limited to $1.00 dollar per citizen, the concept describes a new strategy for healthcare reform that honors the Design Principles for Managing a Common Pool Resource as in the portion of our GDP devoted to health spending. It is based on a new, semi-autonomous institution chartered by Congress and named NATIONAL HEALTH. This new institution could be “up and running” 6 months after authorized.
    NATIONAL HEALTH would mobilize the legitimate stakeholders of each community to invigorate the traditions of their local COMMON GOOD *) to achieve equitably available Primary Healthcare for each citizen, *) to coordinate local collective impact strategies to ameliorate their social adversities, and *) to annually assess the community’s Disaster Mitigation Plan, especially its connection with regional and national Plans. Each community of @400,000 citizens, nearly 800 Nation-wide would be locally funded, supported with technical training, and energized by three national projects to improve the resiliency of Primary Healthcare. The unified recognition by all payer sources of a unified reimbursement system would be applied.
    At set of collaboratively maintained definitions for a CARING RELATIONSHIP, SOCIAL CAPITAL, COMMON GOOD, HEALTH and INSTITUTION will be offered as a basis to lower the cognitive dissonance amidst the “idle talk” necessary for meaningful ‘health care’ reform. NATIONAL HEALTH could begin with a proposed set of these definitions.
    See https://nationalhealthusa.net/home/rationale/