|Covering the Uninsured|
|Mandates for Health Insurance|
|Implemented in this survey?|
There is currently a strong push within the US Congress to create major healthcare reform this year. Specific legislation has not yet been proposed, but one option potentially under consideration is the expansion of the Federal Employees Health Benefit program, which may or may not include an expansion of Medicare. Though this has been the intention of Medicare since its inception in 1965, there is broad controversy on how such an expansion would affect the uninsured, providers and providers.
The recent change in administration in the United States has created an atmosphere ready for healthcare policy change. President Obama campaigned on healthcare reform, calling for universal insurance coverage. Currently 45 million Americans lack health insurance coverage. One option is to expand the existing Federal Employees Health Benefit (FEHB) program, which is the plan offered to all Federal employees, to include the uninsured.
The Congressional Budget Office issued a report on options for expanding coverage in December 2008 which included a discussion of the impact of expanding the FEHB or other federal programs as a means of providing coverage to the uninsured. Two potential forms of expansion were addressed: FEHB with and without a Medicare expansion. This has become the major issue in the health reform debate with some advocating for a public option while others want the system to remain in private hands.
The theory behind expanding a Federal program to cover the uninsured is that such a program may be able to be offered at a lower price, thus making increasing coverage of the uninsured more affordable for the government as well as for the individuals being asked to gain coverage (CBO 2008). Efficiency is also a concern, and expanding an existing system is both a way to quickly expand coverage as well as a way to keep the system relatively efficient and possibly less costly since administrative costs are lower.
The main argument against the public option is that the government has an unfair advantage competing agianst the private sector since it can use regulation to set prices. The concern is that the government will "crowd out " the private sector and lower rates that are unsustainable for providers.
The idea of expanding coverage through a Federal program is not new (RWJF 2009), but it has struggled to find traction in the past, with considerable opposition coming from conservatives and supporters of market-based healthcare. There are also advocates for a single payer that do not want the private sector involved at all. Now, with the change in administration and the push to achieve meaninful healthcare reform within the year, there may be political will behind an option to increase coverage through a FEHB expansion for the uninsured (NY Times 2009).
The CBO report identifies and evaluates a number of different options for expanding coverage to the uninsured: regulating insurance premiums and sales, reducing or eliminating the current tax subsidy for employer-sponsored health insurance, establishing managed competition, where the government or employers cover a fixed amount of the premium with individuals covering the remainder, expanding access to the Federal Employees Health Benefit, or expanding access to Medicare. (CBO 2008)
Expanding access to Federal plans is likely to be a proposal that comes before Congress as part of a larger healthcare reform plan. A Medicare expansion in particular is likely to be a highly contentious issue. The main reasons for a Medicare expansion are the ease of immediately enrolling a large number of people to the plan; and the existing administrative infrastructure, which is less costly than its private sector counterparts. Some concerns must be addressed, though, in establishing any plan, but particularly in expanding Medicare, including the benefit package offered to everyone, whether supplemental insurance would be available as it is now, whether traditional fee-for-service plans would be available or if private HMOs would be used to increase cost-reductions. Cost-saving proposals often depend on limiting reimbursement to physicians and hospitals, so these groups may be concerned with and resistant to any such proposal.
Specific financial and non-financial incentives have not yet been laid out as no specific legislative plans for expanding Medicare have been proposed and seriously considered. However, a Medicare-expansion to cover the uninsured would probably include subsidies for the poor, to help them to afford the costs of coverage. There may also be a mandate to obtain coverage associated with the plan, which could be determined through the tax system, though this is an area of considerable disagreement.
Private insurers may be incentivized to provide managed care through Medicare in a way that is similar to the existing Medicare Advantage payment scheme, which reimburses HMOs 13% more on average than traditional fee-for-service reimbursements (Kaiser 2008) (also see report Payments to Medicare Advantage Plans (13) 2009).
Government, Employers, Patients, Insurance Companies, Providers
|Medienpräsenz||sehr gering||sehr hoch|
Medicare is an existing program, with existing infrastructure and administration, so the program itself is not particularly innovative. However, there is a lot of controversy around expanding the program to the non-elderly due to concerns about costs and fears that a government sponsored plan will crowd out private insurers, effectively creating a single-payer system. A plan that incorporates a Medicare expansion will face considerable opposition in Congress from fiscal conservatives and those who believe that health insurance should be a market-based system.
The election of President Obama, as well as the Democratic majority in Congress has been a strong motivator for healthcare reform. Expansion of a public system in particular was a campaign promise made by President Obama. Medicare expansion was not the specific promise made by President Obama, but it follows from discussions that have occurred in the academic literature as well as in Congress.
The push to reform healthcare has come largely from the change of administration.
The expansion of a Federal program, either Medicare or the FEHB, responds to the promises made by President Obama during his Presidential campaign, in which he made universal health insurance coverage a priority.
|Implemented in this survey?|
The idea to expand Medicare as a means of covering the uninsured is not a new idea having been around for over 40 years since the Medicare program was enacted. It was recently voiced by Anderson and Waters in 2007 and Hacker in 2003, has been presented in legislation in Congress, and has been under discussion in broader social contexts for a number of years. The theory behind such an expansion is that the Medicare system is established, takes relatively good care of the high-needs population of elderly in the US, has lower administrative costs than private insurers (CBO 2008), and can be expanded quickly to cover the many uninsured in the US.
Consideration of such a proposal now has been increased by the support of Democrats in Congress and the Obama administration. It is further bolstered by the calls for action coming from the public to engage in healthcare reform (KFF 2009). Public support is not clearly on the side of expanding Medicare, so if this type of proposal is considered, there will be considerable disagreement at the national level. Significant support from the public and stakeholder groups, such as physicians, hospitals, patient groups and others will be essential to the success of the program.
The approach of the idea is described as:
renewed: Expansions of Medicare to the non-elderly population have been proposed in the past as a means to expand coverage to the uninsured (Anderson and Waters 2007; Hacker 2003). They have also been voiced in Congress, but have not been successful.
Physician groups, hospitals and insurance companies are all likely to be concerned with the ways in which a Medicare-expansion proposal is designed. All have a financial stake in the status quo, and if the Medicare-expansion significantly draws from one of them, we are liable to see them actively opposing the bill.
Particular among these are physicians and insurance companies. Hospitals, physicians, and other healthcare providers may bear the burden of cost for an expansion plan if the methods for cost-reduction include reducing the reimbursement rates to providers (CBO 2008). Insurance companies are also concerned, since the availability of a government plan may result in crowd-out, where employers and individuals shift coverage to the public sector plan, which can operate at a loss, unlike private insurers, and may be able to provide reduced premiums. This is not a guaranteed outcome of a Medicare expansion, and may actually be the opposite of the result (CBO 2008), but it is a legitimate concern among insurers and may cause them to strongly oppose the bill.
The policy paper put forth by Anderson and Waters in 2007 as part of the Hamilton Project, supported by the Brookings Institute, proposed a Medicare expansion entitled Medicare Part E(veryone). In their proposal, they acknowledge the many benefits of expanding Medicare to cover the uninsured, including those also mentioned by the CBO: cost-savings on administration and existing infrastructure. They also note that low-income subsidies and mandates for coverage would have to be part of the proposal. Long-term impacts of such a proposal expect enrollment of at least half the population under the Medicare expansion, which would significantly change the structure of insurance in the US.
|Democrats||sehr unterstützend||stark dagegen|
|President Obama||sehr unterstützend||stark dagegen|
|Republicans||sehr unterstützend||stark dagegen|
|American Medical Association||sehr unterstützend||stark dagegen|
|National Nurses Organizing Committee||sehr unterstützend||stark dagegen|
|Employers||sehr unterstützend||stark dagegen|
|Public opinion (KFF 2009)||sehr unterstützend||stark dagegen|
|Privatwirtschaft, privater Sektor|
|AHIP||sehr unterstützend||stark dagegen|
Proposals for expanding Medicare to cover the uninsured have been put forth by researchers and politicians alike over the years (Anderson and Waters 2007). None of the legislative proposals has made any headway in Congress. However, there is now a strong push from the Democrats to achieve healthcare reform this year.
President Obama established healthcare reform as one of his primary goals this year, and has been supported in that committment by Senators Max Baucus (D-MT) and Edward Kennedy (D-MA), who chair the Finance and Health, Education, Labor and Pensions Committees, respectively. These Senate committees have jurisdiction over tax reforms, Medicare/Medicaid, insurance coverage and labor laws, all of which may be considerably affected by any proposal extending Medicare.
On the House side, Representatives Charles Miller (D-CA), Harry Waxman (D-CA) and Charles Rangel (D-NY) have made a similar committment to support healthcare reform this year (NYTimes 2009), and have promised to work together to ensure a single bill is reviewed by each of their committees.
Strong support for the healthcare bill will be needed to make such a major overhaul of healthcare a possibility. The strong Democratic majority in Congress and the support from President Obama have been essential in creating the atmosphere for change that is now evident in the ongoing negotiations in Congress. Further movement will likely require considerable bipartisan support, though, because the Democrats do not have sufficient numbers in the Senate to prevent a filibuster.
Until legislation is hammered out, it is difficult to know how implementation will be accomplished. It is safe to say it will require the involvement of a broad array of stakeholders, especially physicians, patients and insurers.
|President Obama||sehr groß||kein|
|American Medical Association||sehr groß||kein|
|National Nurses Organizing Committee||sehr groß||kein|
|Public opinion (KFF 2009)||sehr groß||kein|
|Privatwirtschaft, privater Sektor|
Successful implementation of a Medicare expansion will take many steps and involve many stakeholders who may or may not be willing to move forward. There seems to be a general feeling in Congress that while healthcare reform may happen this year, a single-payer plan is unlikely to be the means by which this change is achieved. While a Medicare expansion is NOT equivalent to a single-payer option, many critics of a single-payer option see the Medicare expansion as the first step down the slippery slope of government control (Sparer 2009) and will fight to prevent any such move. Successfully proposing legislation in Congress, and ensuring that it is given full attention from both the House and Senate, will require considerable support from Democrats within Congress and from the Obama Adminstration. Further support will be needed from advocacy organizations, especially physician and patient groups, to maintain the momentum on the legislation.
If a piece of legislation is proposed and given the full attention of the Congress, many decisions will still have to be made regarding coverage levels, reimbursement rates, cost-sharing mechanisms, private-sector protections and more that could easily derail the entire bill. These negotiations will have to occur in any plan for health reform, but expanding a government program is particularly contentious in light of the fears over a single-payer model (KFF 2009).
No specific policy has yet been suggested and seriously considered by Congress that details a plan for how a Medicare expansion to cover the uninsured would go. Any plan that is proposed will be closely watched for cost-containment strategies, and will be monitored for success enrolling beneficiaries. While the specific plans for monitoring and evaluation willl be determined by the structure of the proposed change, it is certain that there will be considerable governmental and societal attention paid to the successes and failures of the policy.
At the present time it is difficult to assess what will happpen with health reform generally and with the public option specificially. The budget issues the US confronts make the issue much more complicated. The expectation is that there will be debate in September and October and something will or will not pass this year. Next year is an election year and so it is unlikely to pass in an election year.
|Qualität||kaum Einfluss||starker Einfluss|
|Gerechtigkeit||System weniger gerecht||System gerechter|
|Kosteneffizienz||sehr gering||sehr hoch|
An expansion of Medicare to the broader population would represent a considerable shift in the insurance coverage structure in the US. If the plan is able to cover a majority of the currently uninsured, it promises to make the system more equitable. However, many questions are yet to be answered on the true costs of the program, and it is not clear that a cost savings will be evident in the early years of the program, and may in fact never come to pass.
Robert Wood Johnson Foundation. Covering America. www.rwjf.org/files/research/chart1.pdf 2009.
Congressional Budget Office (CBO). Key Issues in Analyzing Major Health Insurance Proposals. 2008.
A Public Plan for Health Insurance? New York Times. 4/7/09. A28. www.nytimes.com/2009/04/07/opinion/07tue1.html?ref=opinion.
Kaiser Family Foundation. Medicare Advantage Factsheet. September 2008. www.kff.org/medicare/upload/2052-11.pdf.
Anderson, Gerard and Waters, Hugh. Achieving Universal Coverage Through Medicare Part E(veryone). The Hamilton Project. 2007. www.brookings.edu/papers/2007/~/media/Files/rc/papers/2007/07useconomics_anderson/07useconomics_anderson.pdf.
Hacker, Jacob. Medicare Plus: Increasing Health Coverage by Expanding Medicare. Robert Wood Johnson Foundation. 10/31/09. www.rwjf.org/pr/product.jsp?id=39853.
Kaiser Family Foundation. The Public and Healthcare Reform. 2009. www.kaiseredu.org/tutorials/reform/player.html.
Team Effort in the House to Overhaul Health Care. New York Times. 3/18/09. A12.www.nytimes.com/2009/03/18/us/politics/18health.html?partner=rss&emc=rss.
Ameirca's Health Insurance Plans (AHIP). We Believe Every American Should Have Access to Affordable healthcare Coverage: A Vision for Reform. 2009. www.ahip.org/redirect/FederalAccess.pdf.
Sparer, Michael. Medicaid and the U.S. Path to National Health Insurance. The New England Journal of Medicine (360)4: 323-325, 2009.
|Covering the Uninsured|
Process Stages: Idee
|Mandates for Health Insurance|
Process Stages: Idee
Holzer, Jessica and Gerard Anderson