Retiring Baby Boomers: Meeting the Challenges
Special Committee on Aging
Gail R. Wilensky, Ph.D.
John M. Olin Senior Fellow
March 6, 1997
Mr. Chairman and members of the committee, thank you for inviting me to appear before you. My name is Gail Wilensky. I am a John M. Olin Senior Fellow at Project HOPE, an international health education foundation, and Chair of the Physician Payment Review Commission (PPRC). I am also a former Administrator of the Health Care Financing Administration. However, I am here today to present only my own views on Medicare, and my testimony should not be regarded as representing the position of Project HOPE or PPRC.
In my comments, I will discuss some of the implications of the financial crisis facing Medicare. My concern is that most of the reforms considered in the last session of Congress and those already being raised in this session do not resolve the long term problems of Medicare and in many cases, not even the intermediate financing needs of Medicare. The public needs to be more aware of the magnitude of the changes needed to keep the Hospital Insurance Trust Fund afloat until the baby boomers begin to retire, in addition to the changes that will be needed to accommodate the baby boomers.
The Need for Reform
Medicare, one of the country’s most popular social programs, is in serious need of reform. The most immediate problem facing Medicare concerns its future financing. Without substantial changes in Medicare’s financing mechanisms, its benefits package, its payment policies or in the basic design of Medicare itself, it will be impossible to provide the medical security that Medicare has promised to present and future generations of seniors.
Medicare’s current financing problems pose short term, intermediate term and long term difficulties for the program. In the short term, Medicare Part B represents a major drain on the budget since three-quarters of its spending is financed from general revenue. This spending exacerbates the deficit and makes it more difficult to reach a balanced budget. In the intermediate term, the Hospital Insurance (HI) Trust Fund will become bankrupt in the next four years and under current projections will accumulate enormous deficits over the next ten years. In the longer term, Medicare is not financially viable and with the impending retirement of the baby boomers and the future insolvency that implies, serious questions must be raised about the design of a Medicare program that will be sustainable in the 21st Century.
Spending Rates and Solvency Issues
At a time when spending in the private sector has slowed significantly, spending on Medicare continues at unsustainable rates. Private sector growth rates which exceeded Medicare rates in the 1980’s have been growing at a slower rate than Medicare since the early 1990’s, even after adjusting for population growth. In 1996, private sector spending increased at a rate of 3.2 percent; Medicare at a rate of 8.5 percent.
Using the recently released Congressional Budget Office January 1997 baseline
estimates, Medicare is still projected to grow at a rate of almost 8.5 percent
per year over the next five year budget period. Comparatively, during this same
period, total Federal Budget Outlays are only projected to grow at an average
annual rate of 5.2 percent and the Gross Domestic Product is projected to only
grow at an average annual rate of 4.8 percent.
The projections for the solvency of the HI Trust Fund are alarming. Most of the lower spending growth (.5 percent per year) projected for Medicare from the 1997 CBO baseline came from Part B reductions. The Trust Fund is still projected to be bankrupt in 2001, with accumulated deficits of more than half a trillion dollars by 2007 (see Chart 1).
In order for the Trust Fund not to be completely exhausted before the end of 2007, there needs to be $450 billion dollars of accumulated policy changes. As a CBO memo dated Jan. 29, 1997 indicates, there are a variety of ways this could be accomplished but all of them require a dramatic departure from present spending levels or a substantial infusion of new funds.
As shown in chart 2, if the growth rate in spending for the Trust Fund were reduced from the expected level of 7.7 percent to 3.4 percent for the entire period, 1998 to 2007, solvency would continue until 2007. Reductions in the growth rate could be postponed until 1999 or 2000 but the subsequent rates of growth would have to be reduced even further in order to maintain solvency through 2007. Alternatively, the combined employer-employee HI payroll tax could be increased by one-third, starting in 1998. All of these proposals involve a more radical change than any of the proposals of the last session had contemplated.
Yet another alternative is to transfer a portion of the current obligations of the Trust Fund to another source of funding, as has been proposed by the Clinton Administration. The main appeal of the transfer is that it “buys time” by extending the life of the Trust Fund without having either to reduce spending or raising taxes to the degree otherwise needed. The transfer of a portion of the home health care benefit into Part B has been justified at a policy level on the grounds that approximately half of home care is no longer associated with a hospital stay and is therefore no longer logically associated with Part A.
However, the terms of the transfer of $80 billion of home care should be considered carefully because of the precedent it sets in transferring an obligation into what effectively is the general revenue of the Treasury. Normally, when an expense is brought into Part B, a portion of the total spending becomes part of the premium paid by the elderly and the expense itself is subjected to a 20 percent coinsurance charge. This is not being done for the home health care transfer. While an argument can be made that the separation of Medicare into Parts A and B, with two separate streams of funding is an archaic holdover from Medicare’s inception, removing the limited cost constraints that now exist without reforming the entire program is very risky.
The problems which have been receiving the most attention involve financing Medicare until 2002 and the implications of keeping the Trust Fund solvent for the next decade. Although the problems are less immediate, the implications of the impending retirement of the baby boomers are profound. In 1995, Medicare enrollees represented 13.6 percent of the population and Medicare spending as a percentage of GDP was 2.6 percent. In 2010, when the first of the boomers start to retire, Medicare enrollees will be 15.1 percent of the population and spending on Medicare is expected to be 4.5 percent of GDP. By 2030, when the last of the boomers will be retiring, Medicare enrollees are projected to represent 22 percent of the population and Medicare spending as a percentage of GDP is projected to be at 7.5 percent or almost three times what it was in 1995. These are shown in chart 3.
Present Structure of Medicare
There has been an enormous change in the organization and delivery of health services in the private sector. While not all of the changes have been regarded as desirable, there has been a noticeable decline in spending growth for the private sector already noted. And CBO projects that a decade from now, private sector spending will be increasing at a rate of 5.5 percent while Medicare spending will increase at a growth rate of 9.1 percent. Even adjusting for the expected Medicare enrollee growth, this suggest a growth in spending of almost 7.5 percent.
Despite all of the changes now occurring in the private sector, Medicare continues to remain primarily a fee-for-service program, with limited availability of and participation in any form of managed care. The projections for 1997 indicate an expected enrollment of 4.4 million seniors in risk-based HMO’s, representing 12 percent of all enrollees. While the enrollment in HMO’s has grown rapidly over the last several years, and is expected to continue growing rapidly for the next decade, even by 2007, it is expected that two thirds of the Medicare population will still remain in the traditional program.
There are several reasons that explain the relatively small numbers of seniors in managed care, but one of the most important reasons is the limited types of non-HMO managed care options available to the Medicare population, the very population that most needs and probably most desires flexibility. Medicare Select, a PPO offering for Medigap, is finally available across the country and a heavily regulated type of point-of-service plan was made available in 1996 but is not yet available everywhere. A Medicare Choices demonstration is setting up a number of provider service network and partial capitation models of managed care, but it will be years before an evaluation of this limited set of options is likely to be available. Even promising demonstrations may not result in changed legislation.
In addition to the limited options that have been available and the lack of incentives for the elderly to be cost conscious, there are also some significant problems with the way payments are made to HMO’s. These problems relate both to the geographic variations that occur across the country and the lack of adequate risk selection adjustments.
Payments to HMO’s reflect the Medicare spending per capita that occurs within the geographic area. These payments, called the Adjusted Average Per Capita Cost (AAPCC), vary enormously from a high of more than $750 per person per month to a low of $220 per person per month.
Differences in the AAPCC reflect different practice styles and different health risks both of which lead to different volumes of services used. To a small extent, they also reflect differences in costs of living. Not surprisingly, HMO growth has been greatest in the areas where the capitation rate is very high and HMO’s are able to offer many extra benefits at no additional cost to the senior.
By setting the capitation payment rate at 95% of the rate of spending that occurs under the traditional program and having the traditional program operate as an open-ended entitlement, the government guarantees it cannot save money by having seniors choose an HMO, other than the 5% it would save assuming there was no favorable risk selection. The issue of risk selection, however, has raised the possibility that the capitation payment may actually cost the government money. This would happen if the elderly choosing HMO’s are healthier than the elderly in their same age/sex categories and if they would spend less than 95% of the average were they to stay in traditional Medicare. While it appears that the elderly choosing an HMO use less services and are healthier the year before they enter an HMO, it is unclear how much favorable selection persists over time for the vast majority of seniors who remain in HMO’s.
In sum, the present structure of Medicare hardly makes it surprising that it is facing financing problems. The elderly have limited options in the health care plans available to them. Medicare pays most of the costs for the services it covers and almost all of the elderly have coverage that is supplemental to Medicare, either privately purchased Medigap or Medicaid. That means there is little reason for an elderly person to seek out cost-effective physicians or hospitals, or to use lower cost durable medical equipment, laboratories or outpatient hospitals.
Under traditional Medicare, physicians, outpatient clinics, home care providers,
skilled nursing facilities and other providers also have little reason to provide
cost-effective care if there is any medical gain to be had from providing more
services or even only some reason to fear legal repercussions if they do less
than they might have done and the patient has an adverse outcome. Payments to
capitation plans follow payments in fee for service and to the extent risk selection
occurs, enrollment in HMO’s could even cost the government money. Ultimately,
we need to reward the elderly for choosing more cost-effective health care,
to provide incentives for physicians and hospitals to order and prescribe cost-effective
medicine, and a willingness to share the savings which an aggressive reorganization
of health care can produce. The only other choice is to invoke sufficiently
tight controls on spending so that Medicare spending can be guaranteed to grow
at more sustainable rates despite the perverse incentives currently associated
with the program.
The use of a better designed AAPCC, the payment currently used for HMO’s, could become the basis for a voucher type payment which would encourage more cost-effective choices by seniors. In order to make this transformation, it would be necessary to redesign the determinants of the AAPCC to make it more stable than it is now and to take better account of risk selection than appears to occur. It also needs to be unlinked from spending in an open-ended entitlement, either being set by competitive bid or by administrative fiat. Government spending in the traditional Medicare program also needs to be limited to the same rate of increase as occurs in the capitated plans if seniors are to be encouraged to choose between traditional Medicare and capitated plans and among capitated plans on the basis of their cost-effectiveness and the seniors’ own preferences
The closest approximation of the structure implied by this alternative model for Medicare is the Federal Employees Health Benefits Plan (FEHB). In such a reformed Medicare, traditional Medicare would become one of the plan offerings and the premium payment by the government would be the same irrespective of the choice made. This model assumes many more choices available to seniors than is currently available, an annual enrollment process, more information available to seniors about the choices available, monitoring or control of the enrollment process and oversight of plan performance. The level of payment made by the government could be set by a weighted average of plans available, by a competitive bid of plans in an area or as a percentage increase over existing rates.
Some Specific Medicare Problems
Aside from the more general issues of restructuring Medicare, there are some specific problems currently facing the Medicare program which need to be resolved.
In the near term, it is important to recognize that 88 percent of Medicare enrollees are in traditional Medicare and if current law were to continue, CBO estimates two thirds of Medicare enrollees would remain in the traditional program in 2007. There are management strategies which are routinely used by the private sector to improve efficiency which also could be used in Medicare. These include physician profiling, case management, practice guidelines and the bundling of payments. Several of these have or are currently being tried by HCFA as part of a demonstration but HCFA needs to be able to take the early results of demonstrations and move on them more rapidly than has seemed possible in the past.
There are several areas in Part A of Medicare that also need to be addressed in the near term. These include strategies for slowing the growth in home health, hospice and other non-hospital services through prospective payment, co-payments or other policies, and reforming payment methodologies for hospital outpatient departments. In its recent budget submission, the Clinton Administration has proposed using prospective payment, at least in principle, for outpatient visits, home care and skilled nursing visits. Although it is not yet clear precisely how these payment changes would be implemented, the use of prospective payment should reduce the incentives for additional visits within each episode or case. Prospective payment will not directly affect the increasing numbers of people who have been receiving home care or outpatient care and may even exacerbate the likelihood of volume increases in these areas.
One way to address the volume problem observed in outpatient, home health and skilled nursing home visits in a direct control environment is to link the level of reimbursement paid to overall spending in each sector. This could be done whether or not prices are set on a unit basis, an episode basis, or a case basis. This type of strategy underlies the linkage between the volume performance standard, that is the physician spending goal set by Congress each year, and the subsequent change in fees paid to physicians. It has been an effective direct control strategy in slowing down physician spending and could be used elsewhere in Medicare
There are also several areas concerning the AAPCC that need to be addressed, regardless of whether it becomes the basis for restructuring the entire Medicare program. These include limiting the extreme variations in the AAPCC and introducing better risk adjusters. Also both as part of the AAPCC and as a more general issue in Medicare, reforms need to be made in the payments that are being made for graduate medical education.
Much of the attention in the months ahead will be on ways to produce Medicare
savings needed for a balanced budget bill. It will be very important that the
Congress be selective about the types of short term savings that are pursued
to be sure that they are consistent with a reformed Medicare structure, including
making the direct control aspect of traditional Medicare more effective then
it has been in the past.
It is possible to accommodate the need for short-term revenue increases and also set the stage for the more fundamental changes in the incentives, information and options that are needed to reform the Medicare program. Since it will take some time to restructure Medicare and to realize the gains from reforming Medicare, it is important that these reforms be started as soon as possible. This session of Congress is none too soon to start.