A new report from the Center for American Progress focuses on Medicare as a great American success story. Yet, it recognizes that Medicare needs improvements for its long-term sustainability, for easy access to affordable care for the tens of millions of older adults and people with disabilities it serves, for promoting health equity, for improving population health and more.
Traditional Medicare comes with high cost-sharing and no out-of-pocket cap, as well as a fragmented structure that requires the separate purchase of Part D prescription drug coverage and supplemental coverage to fill gaps in Medicare. Medicare Advantage comes with a defective payment system that leads to massive overpayments and incentivizes insurers to design their health plans to attract the healthy and avoid the sick in order to maximize profits.
The authors of this report believe that strengthening and improving Medicare benefits would offer a strong counterbalance to opposition from health insurers over ending their overpayments. The goal therefore is to link Medicare enhancements to reform of the Medicare Advantage payment system.
The new Medicare would guarantee people easy affordable access to the care they need, including prescription drugs and primary care, while promoting population health and health equity. In Medicare Advantage, people and providers often face inappropriate denials of care and coverage. People also face inadequate provider networks that keep them from getting the care they need.
A stronger Medicare would also cover in-home and community long term services and supports. Today, Medicare only covers skilled nursing home care for people who have been hospitalized for at least three days prior to admission and need daily skilled care. And, coverage is for no more than 100 days. Medicare Advantage plans tend to limit that coverage to a few days at most.
Vision, hearing and dental care would also be part of the Medicare benefit package. While some Medicare Advantage plans claim to cover one or more of these services, people in Medicare Advantage don’t tend to receive them any more than people in Traditional Medicare because out-of-pocket costs are still very high and network providers are limited. People in Medicare Advantage pay 65 percent of vision costs, 76 percent of dental costs, and 79 percent of hearing costs.
To lower administrative expenses for providers and payers and ensure people in Medicare Advantage actually get the Medicare benefits to which they are entitled, the authors propose that Medicare Administrative Contractors—which today process claims in traditional Medicare—do so for Medicare Advantage plans as well.
The authors further propose lower out-of-pocket costs in traditional Medicare. Lower costs would make it much easier for people to move from Medicare Advantage to Traditional Medicare. Currently, most people are locked into Medicare Advantage because they cannot afford or cannot secure supplemental coverage to limit their financial risk in traditional Medicare, which lacks an out-of-pocket cap.
With regard to prescription drugs, the authors say that drug pricing must be fair and reward meaningful innovation. They point out that insurers offering Medicare Advantage plans create drug formularies that are especially costly for people with expensive conditions in order to keep these high-cost individuals from enrolling. The authors recommend no cost or low copays for drugs that are of critical benefit to patients.
The authors envision promoting population health through “a payment policy oriented toward medical and social needs [that] would pay providers more for [a] patient[s] [who is vulnerable] to enable what [he] really needs—for instance, his clinic builds a diabetes registry, a population health manager identifies that he has not had a recent visit, a community health worker calls him and helps him arrange a free ride to the clinic through a local program, and his doctor checks his lab work and starts him back on medications for his diabetes. A nurse calls him afterward to make sure he was able to start taking the medication and to review his follow-up plan. The infrastructure that helps this patient—chronic disease registries, population health managers, community health workers, community partnerships, team-based care—enables the health care organization to manage population health for the community it serves.”
Here’s more from Just Care:
- If you need long-term care services, how will you get them?
- How to get free or low-cost dental care
- Free and low-cost ways to address hearing loss
- Protect your eyesight: Free and low-cost vision care
- 2023: Five things to think about when choosing between traditional Medicare and a Medicare Advantage plan
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