Measuring Coverage for Seniors in Medicare Part A and Estimating the Cost of Making It Universal

By Michael Birnbaum and Elizabeth M. Patchias
Journal of Health Politics, Policy and Law
February 2010
Medicare’s Part A Coverage Gap in the Context of National Health Care Reform
The fact that 1.6 million seniors in the United States — 5 percent of the elderly population — are without full federal Part A coverage is a significant policy issue. While Medicare is widely understood to cover the entire elderly U.S. population, this is at best a substantial exaggeration of Medicare’s reach and perhaps a mischaracterization whose broad acceptance preempts a national debate about Medicare eligibility policy and clouds the existing debate on universal coverage.
Will a national discussion on Medicare eligibility get at least a little traction? At this point it seems unlikely because of a powerful counterargument that Medicare is close enough to universal and that seniors without the full federal Part A benefit have other public programs and sources of government funding to support their health care needs, with some ultimately gaining Medicare Part A through their state Medicaid programs. This argument is valid and empirically strong, but it hangs on a normative question: when we are dealing with Medicare eligibility policy in the context of a national discussion about universal coverage, should we settle for “close enough” and accept that, when people fall through the cracks of Medicare’s eligibility framework, Medicaid and the states will be there as a last resort?
http://jhppl.dukejournals.org/cgi/content/abstract/35/1/49?etoc

And…

Projected Impact of Senate Health Reform Bill; Estimates of Alternative Designs

RAND
February 16, 2010
The (RAND) study finds that health care legislation passed by the Senate in December would cut the number of uninsured Americans to 25 million by 2019 (a 53 percent decrease).
http://www.rand.org/news/press/2010/02/16/

At what level do we say that the rate of coverage under a universal program is “close enough”? For Medicare Part A, we’ve already answered that question. Covering 95 percent of those over age 65 is “close enough,” leaving 1.6 million seniors out of the Part A program (primarily hospital care).
We now hear from our politicians that the Senate reform bill awaiting approval in the House is “close enough” to universal coverage, cutting the number of uninsured in half, leaving only 25 million without coverage, according to this new RAND report.
Many suggest that we abandon the term “single payer” and use “Medicare for All” instead. Universal coverage under single payer means 100 percent – everyone is included automatically, not 95 percent like Medicare Part A.
When we choose to use the Medicare rhetoric because it would resonate better with some audiences, we should refer to it as “improved Medicare for All.” That’s simply code language for replacing Medicare’s numerous flawed policies with a bona fide single payer program – a program that removes financial barriers to health care for absolutely everyone.
During the health reform dialogue, when someone says, “close enough,” you know that person is supporting flawed policies. Jump in immediately, protesting that “close enough” isn’t good enough when we have better policies that will get all of us all the way there.

Measuring Coverage for Seniors in Medicare Part A and Estimating the Cost of Making It Universal

By Michael Birnbaum and Elizabeth M. Patchias
Journal of Health Politics, Policy and Law
February 2010

Medicare’s Part A Coverage Gap in the Context of National Health Care Reform

The fact that 1.6 million seniors in the United States — 5 percent of the elderly population — are without full federal Part A coverage is a significant policy issue. While Medicare is widely understood to cover the entire elderly U.S. population, this is at best a substantial exaggeration of Medicare’s reach and perhaps a mischaracterization whose broad acceptance preempts a national debate about Medicare eligibility policy and clouds the existing debate on universal coverage.

Will a national discussion on Medicare eligibility get at least a little traction? At this point it seems unlikely because of a powerful counterargument that Medicare is close enough to universal and that seniors without the full federal Part A benefit have other public programs and sources of government funding to support their health care needs, with some ultimately gaining Medicare Part A through their state Medicaid programs. This argument is valid and empirically strong, but it hangs on a normative question: when we are dealing with Medicare eligibility policy in the context of a national discussion about universal coverage, should we settle for “close enough” and accept that, when people fall through the cracks of Medicare’s eligibility framework, Medicaid and the states will be there as a last resort?

http://jhppl.dukejournals.org/cgi/content/abstract/35/1/49?etoc

And…

Projected Impact of Senate Health Reform Bill; Estimates of Alternative Designs

RAND
February 16, 2010

The (RAND) study finds that health care legislation passed by the Senate in December would cut the number of uninsured Americans to 25 million by 2019 (a 53 percent decrease).

http://www.rand.org/news/press/2010/02/16/

At what level do we say that the rate of coverage under a universal program is “close enough”? For Medicare Part A, we’ve already answered that question. Covering 95 percent of those over age 65 is “close enough,” leaving 1.6 million seniors out of the Part A program (primarily hospital care).

We now hear from our politicians that the Senate reform bill awaiting approval in the House is “close enough” to universal coverage, cutting the number of uninsured in half, leaving only 25 million without coverage, according to this new RAND report.

Many suggest that we abandon the term “single payer” and use “Medicare for All” instead. Universal coverage under single payer means 100 percent – everyone is included automatically, not 95 percent like Medicare Part A.

When we choose to use the Medicare rhetoric because it would resonate better with some audiences, we should refer to it as “improved Medicare for All.” That’s simply code language for replacing Medicare’s numerous flawed policies with a bona fide single payer program – a program that removes financial barriers to health care for absolutely everyone.

During the health reform dialogue, when someone says, “close enough,” you know that person is supporting flawed policies. Jump in immediately, protesting that “close enough” isn’t good enough when we have better policies that will get all of us all the way there.

Republicans Spurn Once-Favored Health Mandate

By Julie Rovner
NPR
February 15, 2010

For Republicans, the idea of requiring every American to have health insurance is one of the most abhorrent provisions of the Democrats’ health overhaul bills.

“Congress has never crossed the line between regulating what people choose to do and ordering them to do it,” said Sen. Orrin Hatch (R-UT). “The difference between regulating and requiring is liberty.”

But Hatch’s opposition is ironic, or some would say, politically motivated. The last time Congress debated a health overhaul, when Bill Clinton was president, Hatch and several other senators who now oppose the so-called individual mandate actually supported a bill that would have required it.

In fact, says Len Nichols of the New America Foundation, the individual mandate was originally a Republican idea. “It was invented by Mark Pauly to give to George Bush Sr. back in the day, as a competition to the employer mandate focus of the Democrats at the time.”

Pauly, a conservative health economist at the University of Pennsylvania’s Wharton School, says it wasn’t just his idea. Back in the late 1980s — when Democrats were pushing not just a requirement for employers to provide insurance, but also the possibility of a government-sponsored single-payer system — “a group of economists and health policy people, market-oriented, sat down and said, ‘Let’s see if we can come up with a health reform proposal that would preserve a role for markets but would also achieve universal coverage.’ “

The idea of the individual mandate was about the only logical way to get there, Pauly says. That’s because even with the most generous subsidies or enticements, “there would always be some Evel Knievels of health insurance, who would decline coverage even if the subsidies were very generous, and even if they could afford it, quote unquote, so if you really wanted to close the gap, that’s the step you’d have to take.”

One reason the individual mandate appealed to conservatives is because it called for individual responsibility to address what economists call the “free-rider effect.” That’s the fact that if a person is in an accident or comes down with a dread disease, that person is going to get medical care, and someone is going to pay for it.

“We called this responsible national health insurance,” says Pauly. “There was a kind of an ethical and moral support for the notion that people shouldn’t be allowed to free-ride on the charity of fellow citizens.”

So while President Clinton was pushing for employers to cover their workers in his 1993 bill, John Chafee of Rhode Island, along with 20 other GOP senators and Rep. Bill Thomas of California, introduced legislation that instead featured an individual mandate. Four of those Republican co-sponsors — Hatch, Charles Grassley of Iowa, Robert Bennett of Utah and Christopher Bond of Missouri — remain in the Senate today.

But the summary of the Republican bill from the Clinton era and the Democratic bills that passed the House and Senate over the past few months are startlingly alike.

Beyond the requirement that everyone have insurance, both call for purchasing pools and standardized insurance plans. Both call for a ban on insurers denying coverage or raising premiums because a person has been sick in the past. Both even call for increased federal research into the effectiveness of medical treatments — something else that used to have strong bipartisan support, but that Republicans have been backing away from recently.

And how does economist Pauly feel about the GOP’s retreat from the individual mandate they used to promote? “That’s not something that makes me particularly happy,” he says.

http://www.npr.org/templates/story/story.php?storyId=123670612

And…

Chafee’s political prescriptions – Republican Senator John Chaffee has his own proposals for health care reform

By Rich Lowry
National Review
January 24, 1994

Senate Minority Leader Robert Dole tapped (Sen. John) Chafee, a long-time student of health care, to craft the principles that 23 Republicans signed last fall as a buffer against the Clinton onslaught.

Chafee’s plan then looked, as critics said, like “Clinton Lite”: no price controls or employer mandates, but, universal coverage, a comprehensive benefits package, a National Health Board, and purchasing alliances. Before long Hillary Clinton, eager for Republican cooperation, was calling him her “counselor and advisor.”

In October Chafee’s bill was redrafted under pressure from conservatives and Dole. It went from having mandatory purchasing alliances–the linch-pin of the Clinton plan–to voluntary ones. “This is night and day,” says Don Devine, head of Citizens against Rationing Health, a group supported by the American Conservative Union. The plan now includes medical savings accounts–an essential feature of the conservative John Goodman plan. And Chafee puts off universal coverage to 2005, promising to extend coverage only as savings are realized.

Newt Gingrich delivered perhaps his sharpest attack on the Clinton proposal yet in a speech to Empower America December 14. And, significantly, in a December 16 news conference Dole said, “I don’t think there’s a [health-care] crisis.” He went on to endorse incremental reforms: “When we’ve got some areas we agree on, why not just go ahead and pass those early next year?” Administrative simplification, coverage for people with pre-existing conditions, malpractice reform, insurance portability–the list goes on–would improve the system without scrapping it.

http://findarticles.com/p/articles/mi_m1282/is_n1_v46/ai_14809418/

Comment: 

By Don McCanne, MD

In perhaps the greatest irony of the reform process, President Obama has scheduled a bipartisan health care summit in which the Democrats will submit a right-wing proposal similar to that crafted by conservative economist Mark Pauly and his market-oriented colleagues. The Republicans will offer nominal proposals that would provide no significant benefit in correcting the problems that we face with our health care system.

When President and Mrs. Clinton began their reform efforts, they understood the superiority of the single payer model, but they anticipated that it would be rejected as being a left-wing government program. They decided to stake out a position that they perceived to be in the middle, when in fact it was a market-oriented proposal that would have appeal more to those on the right except for the level of regulatory oversight.

Although with the Clintons already negotiating to the right of center, the conservatives moved the fulcrum of the negotiations further to the right by offering a counter-proposal for mandatory purchasing alliances – “a health reform proposal that would preserve a role for markets but would also achieve universal coverage.” The conservatives then again pulled up stakes and moved even further to the right by making them voluntary. The process ended with Sen. Robert Dole saying that all we needed was some incremental reforms. We all know what’s happened to our health care system since then.

President Obama clearly understands the superiority of the single payer model and has stated so on several occasions, going so far as to say that we would adopt single payer if we were starting from scratch. But the position he eventually staked out was far to the right, even further to the right than the initial Republican counter-proposal offered in 1993. He campaigned against an individual mandate to purchase private plans since they were not affordable to middle-income individuals and families. Although a pseudo-mandate has been included in the Democrat’s proposal, it would still leave tens of millions without coverage, falling short of the goal that conservative economist Mark Pauly likely envisioned.

This bipartisan process began on the right. Over the past couple of decades it has been pulled further and further to the right until it has deteriorated into a process in which we are looking for those reforms, all in right-wing territory, that we can agree on. We’re only one step away from returning to Bob Dole’s incrementalism – a path that leads ever downward into despair.

It’s not too late. We can start over with single payer – an improved Medicare that covers everyone. That would end our despair.

Republicans Spurn Once-Favored Health Mandate

By Julie Rovner
NPR
February 15, 2010
For Republicans, the idea of requiring every American to have health insurance is one of the most abhorrent provisions of the Democrats’ health overhaul bills.
“Congress has never crossed the line between regulating what people choose to do and ordering them to do it,” said Sen. Orrin Hatch (R-UT). “The difference between regulating and requiring is liberty.”
But Hatch’s opposition is ironic, or some would say, politically motivated. The last time Congress debated a health overhaul, when Bill Clinton was president, Hatch and several other senators who now oppose the so-called individual mandate actually supported a bill that would have required it.
In fact, says Len Nichols of the New America Foundation, the individual mandate was originally a Republican idea. “It was invented by Mark Pauly to give to George Bush Sr. back in the day, as a competition to the employer mandate focus of the Democrats at the time.”
Pauly, a conservative health economist at the University of Pennsylvania’s Wharton School, says it wasn’t just his idea. Back in the late 1980s — when Democrats were pushing not just a requirement for employers to provide insurance, but also the possibility of a government-sponsored single-payer system — “a group of economists and health policy people, market-oriented, sat down and said, ‘Let’s see if we can come up with a health reform proposal that would preserve a role for markets but would also achieve universal coverage.’ ”
The idea of the individual mandate was about the only logical way to get there, Pauly says. That’s because even with the most generous subsidies or enticements, “there would always be some Evel Knievels of health insurance, who would decline coverage even if the subsidies were very generous, and even if they could afford it, quote unquote, so if you really wanted to close the gap, that’s the step you’d have to take.”
One reason the individual mandate appealed to conservatives is because it called for individual responsibility to address what economists call the “free-rider effect.” That’s the fact that if a person is in an accident or comes down with a dread disease, that person is going to get medical care, and someone is going to pay for it.
“We called this responsible national health insurance,” says Pauly. “There was a kind of an ethical and moral support for the notion that people shouldn’t be allowed to free-ride on the charity of fellow citizens.”
So while President Clinton was pushing for employers to cover their workers in his 1993 bill, John Chafee of Rhode Island, along with 20 other GOP senators and Rep. Bill Thomas of California, introduced legislation that instead featured an individual mandate. Four of those Republican co-sponsors — Hatch, Charles Grassley of Iowa, Robert Bennett of Utah and Christopher Bond of Missouri — remain in the Senate today.
But the summary of the Republican bill from the Clinton era and the Democratic bills that passed the House and Senate over the past few months are startlingly alike.
Beyond the requirement that everyone have insurance, both call for purchasing pools and standardized insurance plans. Both call for a ban on insurers denying coverage or raising premiums because a person has been sick in the past. Both even call for increased federal research into the effectiveness of medical treatments — something else that used to have strong bipartisan support, but that Republicans have been backing away from recently.
And how does economist Pauly feel about the GOP’s retreat from the individual mandate they used to promote? “That’s not something that makes me particularly happy,” he says.
http://www.npr.org/templates/story/story.php?storyId=123670612

And…

Chafee’s political prescriptions – Republican Senator John Chaffee has his own proposals for health care reform

By Rich Lowry
National Review
January 24, 1994
Senate Minority Leader Robert Dole tapped (Sen. John) Chafee, a long-time student of health care, to craft the principles that 23 Republicans signed last fall as a buffer against the Clinton onslaught.
Chafee’s plan then looked, as critics said, like “Clinton Lite”: no price controls or employer mandates, but, universal coverage, a comprehensive benefits package, a National Health Board, and purchasing alliances. Before long Hillary Clinton, eager for Republican cooperation, was calling him her “counselor and advisor.”
In October Chafee’s bill was redrafted under pressure from conservatives and Dole. It went from having mandatory purchasing alliances–the linch-pin of the Clinton plan–to voluntary ones. “This is night and day,” says Don Devine, head of Citizens against Rationing Health, a group supported by the American Conservative Union. The plan now includes medical savings accounts–an essential feature of the conservative John Goodman plan. And Chafee puts off universal coverage to 2005, promising to extend coverage only as savings are realized.
Newt Gingrich delivered perhaps his sharpest attack on the Clinton proposal yet in a speech to Empower America December 14. And, significantly, in a December 16 news conference Dole said, “I don’t think there’s a [health-care] crisis.” He went on to endorse incremental reforms: “When we’ve got some areas we agree on, why not just go ahead and pass those early next year?” Administrative simplification, coverage for people with pre-existing conditions, malpractice reform, insurance portability–the list goes on–would improve the system without scrapping it.
http://findarticles.com/p/articles/mi_m1282/is_n1_v46/ai_14809418/

In perhaps the greatest irony of the reform process, President Obama has scheduled a bipartisan health care summit in which the Democrats will submit a right-wing proposal similar to that crafted by conservative economist Mark Pauly and his market-oriented colleagues. The Republicans will offer nominal proposals that would provide no significant benefit in correcting the problems that we face with our health care system.
When President and Mrs. Clinton began their reform efforts, they understood the superiority of the single payer model, but they anticipated that it would be rejected as being a left-wing government program. They decided to stake out a position that they perceived to be in the middle, when in fact it was a market-oriented proposal that would have appeal more to those on the right except for the level of regulatory oversight.
Although with the Clintons already negotiating to the right of center, the conservatives moved the fulcrum of the negotiations further to the right by offering a counter-proposal for mandatory purchasing alliances – “a health reform proposal that would preserve a role for markets but would also achieve universal coverage.” The conservatives then again pulled up stakes and moved even further to the right by making them voluntary. The process ended with Sen. Robert Dole saying that all we needed was some incremental reforms. We all know what’s happened to our health care system since then.
President Obama clearly understands the superiority of the single payer model and has stated so on several occasions, going so far as to say that we would adopt single payer if we were starting from scratch. But the position he eventually staked out was far to the right, even further to the right than the initial Republican counter-proposal offered in 1993. He campaigned against an individual mandate to purchase private plans since they were not affordable to middle-income individuals and families. Although a pseudo-mandate has been included in the Democrat’s proposal, it would still leave tens of millions without coverage, falling short of the goal that conservative economist Mark Pauly likely envisioned.
This bipartisan process began on the right. Over the past couple of decades it has been pulled further and further to the right until it has deteriorated into a process in which we are looking for those reforms, all in right-wing territory, that we can agree on. We’re only one step away from returning to Bob Dole’s incrementalism – a path that leads ever downward into despair.
It’s not too late. We can start over with single payer – an improved Medicare that covers everyone. That would end our despair.

Republicans Spurn Once-Favored Health Mandate

By Julie Rovner
NPR
February 15, 2010

For Republicans, the idea of requiring every American to have health insurance is one of the most abhorrent provisions of the Democrats’ health overhaul bills.

“Congress has never crossed the line between regulating what people choose to do and ordering them to do it,” said Sen. Orrin Hatch (R-UT). “The difference between regulating and requiring is liberty.”

But Hatch’s opposition is ironic, or some would say, politically motivated. The last time Congress debated a health overhaul, when Bill Clinton was president, Hatch and several other senators who now oppose the so-called individual mandate actually supported a bill that would have required it.

In fact, says Len Nichols of the New America Foundation, the individual mandate was originally a Republican idea. “It was invented by Mark Pauly to give to George Bush Sr. back in the day, as a competition to the employer mandate focus of the Democrats at the time.”

Pauly, a conservative health economist at the University of Pennsylvania’s Wharton School, says it wasn’t just his idea. Back in the late 1980s — when Democrats were pushing not just a requirement for employers to provide insurance, but also the possibility of a government-sponsored single-payer system — “a group of economists and health policy people, market-oriented, sat down and said, ‘Let’s see if we can come up with a health reform proposal that would preserve a role for markets but would also achieve universal coverage.’ ”

The idea of the individual mandate was about the only logical way to get there, Pauly says. That’s because even with the most generous subsidies or enticements, “there would always be some Evel Knievels of health insurance, who would decline coverage even if the subsidies were very generous, and even if they could afford it, quote unquote, so if you really wanted to close the gap, that’s the step you’d have to take.”

One reason the individual mandate appealed to conservatives is because it called for individual responsibility to address what economists call the “free-rider effect.” That’s the fact that if a person is in an accident or comes down with a dread disease, that person is going to get medical care, and someone is going to pay for it.

“We called this responsible national health insurance,” says Pauly. “There was a kind of an ethical and moral support for the notion that people shouldn’t be allowed to free-ride on the charity of fellow citizens.”

So while President Clinton was pushing for employers to cover their workers in his 1993 bill, John Chafee of Rhode Island, along with 20 other GOP senators and Rep. Bill Thomas of California, introduced legislation that instead featured an individual mandate. Four of those Republican co-sponsors — Hatch, Charles Grassley of Iowa, Robert Bennett of Utah and Christopher Bond of Missouri — remain in the Senate today.

But the summary of the Republican bill from the Clinton era and the Democratic bills that passed the House and Senate over the past few months are startlingly alike.

Beyond the requirement that everyone have insurance, both call for purchasing pools and standardized insurance plans. Both call for a ban on insurers denying coverage or raising premiums because a person has been sick in the past. Both even call for increased federal research into the effectiveness of medical treatments — something else that used to have strong bipartisan support, but that Republicans have been backing away from recently.

And how does economist Pauly feel about the GOP’s retreat from the individual mandate they used to promote? “That’s not something that makes me particularly happy,” he says.

http://www.npr.org/templates/story/story.php?storyId=123670612

And…

Chafee’s political prescriptions – Republican Senator John Chaffee has his own proposals for health care reform

By Rich Lowry
National Review
January 24, 1994

Senate Minority Leader Robert Dole tapped (Sen. John) Chafee, a long-time student of health care, to craft the principles that 23 Republicans signed last fall as a buffer against the Clinton onslaught.

Chafee’s plan then looked, as critics said, like “Clinton Lite”: no price controls or employer mandates, but, universal coverage, a comprehensive benefits package, a National Health Board, and purchasing alliances. Before long Hillary Clinton, eager for Republican cooperation, was calling him her “counselor and advisor.”

In October Chafee’s bill was redrafted under pressure from conservatives and Dole. It went from having mandatory purchasing alliances–the linch-pin of the Clinton plan–to voluntary ones. “This is night and day,” says Don Devine, head of Citizens against Rationing Health, a group supported by the American Conservative Union. The plan now includes medical savings accounts–an essential feature of the conservative John Goodman plan. And Chafee puts off universal coverage to 2005, promising to extend coverage only as savings are realized.

Newt Gingrich delivered perhaps his sharpest attack on the Clinton proposal yet in a speech to Empower America December 14. And, significantly, in a December 16 news conference Dole said, “I don’t think there’s a [health-care] crisis.” He went on to endorse incremental reforms: “When we’ve got some areas we agree on, why not just go ahead and pass those early next year?” Administrative simplification, coverage for people with pre-existing conditions, malpractice reform, insurance portability–the list goes on–would improve the system without scrapping it.

http://findarticles.com/p/articles/mi_m1282/is_n1_v46/ai_14809418/

In perhaps the greatest irony of the reform process, President Obama has scheduled a bipartisan health care summit in which the Democrats will submit a right-wing proposal similar to that crafted by conservative economist Mark Pauly and his market-oriented colleagues. The Republicans will offer nominal proposals that would provide no significant benefit in correcting the problems that we face with our health care system.

When President and Mrs. Clinton began their reform efforts, they understood the superiority of the single payer model, but they anticipated that it would be rejected as being a left-wing government program. They decided to stake out a position that they perceived to be in the middle, when in fact it was a market-oriented proposal that would have appeal more to those on the right except for the level of regulatory oversight.

Although with the Clintons already negotiating to the right of center, the conservatives moved the fulcrum of the negotiations further to the right by offering a counter-proposal for mandatory purchasing alliances – “a health reform proposal that would preserve a role for markets but would also achieve universal coverage.” The conservatives then again pulled up stakes and moved even further to the right by making them voluntary. The process ended with Sen. Robert Dole saying that all we needed was some incremental reforms. We all know what’s happened to our health care system since then.

President Obama clearly understands the superiority of the single payer model and has stated so on several occasions, going so far as to say that we would adopt single payer if we were starting from scratch. But the position he eventually staked out was far to the right, even further to the right than the initial Republican counter-proposal offered in 1993. He campaigned against an individual mandate to purchase private plans since they were not affordable to middle-income individuals and families. Although a pseudo-mandate has been included in the Democrat’s proposal, it would still leave tens of millions without coverage, falling short of the goal that conservative economist Mark Pauly likely envisioned.

This bipartisan process began on the right. Over the past couple of decades it has been pulled further and further to the right until it has deteriorated into a process in which we are looking for those reforms, all in right-wing territory, that we can agree on. We’re only one step away from returning to Bob Dole’s incrementalism – a path that leads ever downward into despair.

It’s not too late. We can start over with single payer – an improved Medicare that covers everyone. That would end our despair.