By Lane Koenig, PhD, Asha Saavoss, Samuel Soltoff, Berna Demiralp, PhD, Jing Xu, PhD
KNG Health Consulting, LLC, March 12, 2019
In this study, we model the effects of the Medicare-X Choice Act on coverage and healthcare spending. Although not as expansive as Medicare-for-All, Medicare-X Choice would allow any individual to voluntarily enroll in a public plan offered on each health exchange.
We find that national enrollment in the public plan would be 40.7 million in 2024 and would increase slightly to 42.3 million by 2033 (Table ES1). Under Medicare-X Choice, the number of uninsured and the commercially insured on the non-group market would fall by 5.5 and 12.6 million in 2024, respectively, while enrollment in employer-sponsored insurance (ESI) would fall by 22.6 million. About ninety percent of the enrollment in the public plans would comprise individuals who were either covered under ESI or on a commercial non-group plan in the baseline. While most of the enrollment in the public plan comes from those previously with ESI, the public plan take-up rate is highest (67%) among those with commercial non-group insurance.
We estimate considerable reductions in healthcare spending of 7 percent under Medicare-X Choice over the 10-year period from 2024 to 2033 (Table ES2). Spending on individuals who are uninsured in the baseline is projected to increase by 9 percent in 2024, however, increased spending on the uninsured would be more than offset by spending reductions among those who are enrolling in the public plan but previously insured through private insurance. While hospital- based services represent 47 percent of total baseline healthcare spending, these services would account for roughly 67 percent of the reduction in total spending. Overall, we estimate that hospitals would experience a 10-percent reduction in payments among the relevant population.
Medicare-X Choice would result in significant changes in the health insurance landscape, with 36.5 million people leaving private coverage for the new government-run public option, and 5.5 million individuals without insurance gaining coverage. While we estimate material reductions in the number of uninsured, most of those choosing coverage under a public plan would come from those currently covered under a commercial non-group plan or ESI. We estimate reductions in total healthcare spending due to reduced payments to providers, given the large differences in prices between Medicare and commercial insurers. For hospitals and other providers, the introduction of Medicare-X Choice would reduce revenue without commensurate reductions in costs. Although the increase in the number of insured individuals would increase revenue from the formerly uninsured, higher spending from this group would not be enough to offset the lost revenue from shifts between private and public insurance coverage.
For hospitals, the introduction of a public plan that reimburses providers using Medicare rates would compound financial stresses already faced by the sector, potentially impacting access to care and provider quality. CBO projects that between 40 and 50 percent of hospitals could have negative margins by 2025 under current law. Given that Medicare pays hospitals below their costs (e.g., the Medicare Payment Advisory Commission estimates that Medicare inpatient margins will be -11 percent in 2018), Medicare-X Choice would be expected to increase the number of hospitals with negative margins. While hospitals may attempt to shift some costs to commercial insurers, the ability to do this under a public plan may be limited because of the study’s projected significant take-up by those in the non-group market. Policymakers should have a clear understanding of potential effects on patient access, provider payment, the commercial insurance market, and ESI (desired as well as unintended) when considering proposals to expand Medicare coverage.
By Don McCanne, M.D.
This study was prepared for the American Hospital Association and the Federation of American Hospitals. They wanted to see the potential impact of a Medicare-for-some model of reform, choosing as an example the Medicare-X Choice Act of Sen. Michael Bennet and Sen. Tim Kaine. They show that the shift of enrollees from employer-sponsored plans and commercial non-group plans into the public option Medicare-X plan, which would have payment rates set at Medicare levels, would reduce hospital net revenues without commensurate reductions in costs, even though the impact is partially offset by the newly insured.
Although the report is mostly about hospitals (understandably so considering the sponsors of the study), the report does show that not only would payments to hospitals decline by 10 percent, continuing over a decade, but payments to physicians also would decline by 8 percent (page 10, Table 4).
More importantly, and not mentioned in this study, is that the Medicare-X Act and all other Medicare-for-some Acts would leave in place most of the critical flaws in our health care financing system – flaws that would be corrected by enacting and implementing a well designed, Single Payer Medicare for All program. The authors suggest that instead we should strengthen existing components of the Affordable Care Act, but that won’t do it. We really desperately need to enact Single Payer Medicare for All.
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