PNHP

Means-testing Medicare benefits?

Means Testing, for Medicare

By Tyler Cowen
The New York Times
July 20, 2008
As Mark V. Pauly, professor of health care systems at the University of Pennsylvania, has said, “Medicare as we know it today cannot be sustained over the next 50 years and probably will run into financial difficulties within the next 15.”
There’s one important idea lurking in the shadows that neither campaign is keen to talk about: paying out government benefits more efficiently. To put it bluntly, it means paying out full benefits only to those who really need them, and cutting back on payments to everybody else.
“Means testing” — cutting back on payments to the relatively wealthy — is one way to better allocate benefits. For health care costs, this could be done by expanding Medicaid, which is focused on the needs of the poor… At the same time, the government would need to limit the growth of Medicare… With limited resources, it would be better to reallocate health care subsidies toward the poor…
An alternative path is to put in place more means testing throughout Medicare.
The best option is probably to tie the size of Medicare benefits to a person’s lifetime income, which is relatively easily measured and hard to game, rather than to one’s income or assets in any current year. In essence, higher earners would receive lower benefits instead of facing the prospect of higher taxes, as current trends predict. This policy reflects an ethic of individual responsibility — namely, that people who have earned well throughout their lives should be expected to take care of themselves, precisely so that the truly unfortunate can be helped.
Tyler Cowen is a professor of economics at George Mason University.
http://www.nytimes.com/2008/07/20/business/economy/20view.html?ref=economy

Everyone agrees that health care is now so expensive that those of modest means cannot be expected to contribute as much to the financing of health care as those who are more affluent. Traditionally, the Medicare program has been financed primarily through a common risk pool with contributions paid based on income levels. Now, instead of establishing equity through the revenue side of the balance sheet, efforts are being made to shift equity, or the appearance of equity, over to the benefit/expenditure side.
(For this discussion, revenues are considered to be Part A payroll taxes, and Part B general revenue taxes plus Part B premiums; supplemental premiums, deductibles and coinsurance are considered to be adjustments to the benefits.)
The Medicare Modernization Act, which established the Party D drug benefit, was an effort not only to privatize Medicare but to shift more of the responsibility of paying for care to the individual beneficiaries. The first step towards shifting the funding to the benefit side was the establishment of a means-tested premium for the Part D program. Those with higher incomes pay larger premiums. What could be wrong with that?
Professor Cowen doesn’t really hide the potential impact of means-tested benefits, including means-tested premiums and cost sharing. He suggests that those of limited means (now the majority) should be placed in a Medicaid-like welfare program, while the wealthy pay for more of their care with private funds. This is an explicit endorsement of two-tiered health care: the finest care money can buy for the wealthy, and under-funded mediocre care for the rest of us.
Professor Cowen states, “This policy reflects an ethic of individual responsibility.” That is precisely the problem. It rejects the concept of social solidarity: the glue that holds together the people of all other societies that have universal, comprehensive health care systems.
Financing health care through revenues paid into a single, universal risk pool establishes equity by using progressive tax policies, while providing broad political support for a program from which we would all benefit equally. Providing benefit levels inversely related to life-time income might create the appearance of equity, but, in fact, it destroys equity by forcing many of us into a welfare program, impairing access to the health care that we need.
Instead of means-testing our people, maybe we need to start mean-testing the economists and reject those who really are mean.

Means-testing Medicare benefits?

Means Testing, for Medicare

By Tyler Cowen
The New York Times
July 20, 2008

As Mark V. Pauly, professor of health care systems at the University of Pennsylvania, has said, “Medicare as we know it today cannot be sustained over the next 50 years and probably will run into financial difficulties within the next 15.”

There’s one important idea lurking in the shadows that neither campaign is keen to talk about: paying out government benefits more efficiently. To put it bluntly, it means paying out full benefits only to those who really need them, and cutting back on payments to everybody else.

“Means testing” — cutting back on payments to the relatively wealthy — is one way to better allocate benefits. For health care costs, this could be done by expanding Medicaid, which is focused on the needs of the poor… At the same time, the government would need to limit the growth of Medicare… With limited resources, it would be better to reallocate health care subsidies toward the poor…

An alternative path is to put in place more means testing throughout Medicare.

The best option is probably to tie the size of Medicare benefits to a person’s lifetime income, which is relatively easily measured and hard to game, rather than to one’s income or assets in any current year. In essence, higher earners would receive lower benefits instead of facing the prospect of higher taxes, as current trends predict. This policy reflects an ethic of individual responsibility — namely, that people who have earned well throughout their lives should be expected to take care of themselves, precisely so that the truly unfortunate can be helped.

Tyler Cowen is a professor of economics at George Mason University.

http://www.nytimes.com/2008/07/20/business/economy/20view.html?ref=economy

Comment:

By Don McCanne, MD

Everyone agrees that health care is now so expensive that those of modest means cannot be expected to contribute as much to the financing of health care as those who are more affluent. Traditionally, the Medicare program has been financed primarily through a common risk pool with contributions paid based on income levels. Now, instead of establishing equity through the revenue side of the balance sheet, efforts are being made to shift equity, or the appearance of equity, over to the benefit/expenditure side.

(For this discussion, revenues are considered to be Part A payroll taxes, and Part B general revenue taxes plus Part B premiums; supplemental premiums, deductibles and coinsurance are considered to be adjustments to the benefits.)

The Medicare Modernization Act, which established the Party D drug benefit, was an effort not only to privatize Medicare but to shift more of the responsibility of paying for care to the individual beneficiaries. The first step towards shifting the funding to the benefit side was the establishment of a means-tested premium for the Part D program. Those with higher incomes pay larger premiums. What could be wrong with that?

Professor Cowen doesn’t really hide the potential impact of means-tested benefits, including means-tested premiums and cost sharing. He suggests that those of limited means (now the majority) should be placed in a Medicaid-like welfare program, while the wealthy pay for more of their care with private funds. This is an explicit endorsement of two-tiered health care: the finest care money can buy for the wealthy, and under-funded mediocre care for the rest of us.

Professor Cowen states, “This policy reflects an ethic of individual responsibility.” That is precisely the problem. It rejects the concept of social solidarity: the glue that holds together the people of all other societies that have universal, comprehensive health care systems.

Financing health care through revenues paid into a single, universal risk pool establishes equity by using progressive tax policies, while providing broad political support for a program from which we would all benefit equally. Providing benefit levels inversely related to life-time income might create the appearance of equity, but, in fact, it destroys equity by forcing many of us into a welfare program, impairing access to the health care that we need.

Instead of means-testing our people, maybe we need to start mean-testing the economists and reject those who really are mean.