Since taking office just two years ago, the Trump administration has done all it legally could to undermine Obamacare. The share of the US population without health insurance had been brought down to historic lows under Obama, but they have now moved back up, with roughly half of the gains now lost. The chart above (from Gallup) traces its path.
This vulnerability of health cover gains to an antagonistic administration has led many Democrats to look for a more fundamental reform that would be better protected. Many are now calling for an expansion of the popular and successful Medicare program to the full population – it is currently restricted just to those aged 65 and above. Some form of Medicare-for-All has now been endorsed by most of the candidates that have so far announced they are seeking the Democratic nomination to run for president in 2020, although the specifics differ.
But while Medicare-for-All is popular as an ultimate goal, the path to get there as well as specifics on what the final structure might look like are far from clear (and differ across candidates, even when different alternatives are each labeled “Medicare-for-All”). There are justifiable concerns on whether there will be disruptions along the way. And the candidates favoring Medicare-for-All have yet to set out all the details on how that process would work.
But there is no need for the process to be disruptive. The purpose of this blog post is to set out a possible path where personal choice in a system of market competition can lead to a health insurance system where Medicare is at least available for all who desire it, and where the private insurance that remains will need to be at least as efficient and as attractive to consumers as Medicare.
The specifics will be laid out below, but briefly, the proposal is built around two main observations. One is that Medicare is a far more efficient, and hence lower cost, system than private health insurance is in the US. As was discussed in an earlier post on this blog, administrative expenses account for only 2.4% of the cost of traditional Medicare. All the rest (97.6%) goes to health care providers. Private health insurers, in contrast, have non-medical expenses of 12% of their total costs, or five times as much. Medicare is less costly to administer as it is a simpler system and enjoys huge economies of scale. Private health insurers, in contrast, have set up complex systems of multiple plans and networks of health care providers, pay very generous salaries to CEOs and other senior staff who are skilled at operating in the resulting highly fragmented system, and pay out high profits as well (that in normal years account for roughly one-quarter of that 12% margin).
With Medicare so much more efficient, why has it not pushed out the more costly private insurance providers? The answer is simple: Congress has legislated that Medicare is not allowed to compete with them. And that is the second point: Remove these legislated constraints, and allow Medicare-managed plans to compete with the private insurance companies (at a price set so that it breaks even). Americans will then be able to choose, and in this way transition to a system where enrollment in Medicare-managed insurance services is available to all. And over time, such competition can be expected to lead most to enroll in the Medicare-managed options. They will be cheaper for a given quality, due to Medicare’s greater efficiency.
There will still be a role for private insurance. For those competing with Medicare straight on, the private insurers that remain will have to be able to provide as good a product at as good a cost. But also, private insurers will remain to offer insurance services that supplement what a Medicare insurance plan would provide. Such optional private insurance would cover services (such as dental services) or costs (Medicare covers just 80% after the deductible) that the basic Medicare plan does not cover. Medicare will then be the primary insurer, and the private insurance the secondary. And, importantly, note that in this system the individual will still be receiving all the services that they receive under their current health plans. This addresses the concern of some that a Medicare-like plan would not be as complete or as comprehensive as what they might have now. With the optional supplemental, their insurance could cover exactly what they have now, or even more. Medicare would be providing a core level of coverage, and then, for those who so choose, supplemental private plans can bring the coverage to all that they have now. But the cost will be lower, as they will gain from the low cost of Medicare for those core services.
More specifically, how would this work?
B. Allow Medicare to Compete in the Market for Individual Health Insurance Plans
A central part of the Obamacare reforms was the creation of a marketplace where individuals, who do not otherwise have access to a health insurance plan (such as through an employer), could choose to purchase an individual health insurance plan. As originally proposed, and indeed as initially passed by the House of Representatives, a publicly managed health insurance plan would have been made available (at a premium rate that would cover its full costs) in addition to whatever plans were offered by private insurers. This would have addressed the problem in the Obamacare markets of often excessive complexity (with constantly changing private plans entering or leaving the different markets), as well as limited and sometimes even no competition in certain regions. A public option would have always been available everywhere. But to secure the 60 votes needed to pass in the Senate, the public option had to be dropped (at the insistence of Senator Joe Lieberman of Connecticut).
It could, and should, be introduced now. Such a public option could be managed by Medicare, and could then piggy-back on the management systems and networks of hospitals, doctors, and other health care providers who already work with Medicare. However, the insurance plan itself would be broader than what Medicare covers for the elderly, and would meet the standards for a comprehensive health care plan as defined under Obamacare. Medicare for the elderly is, by design, only partial (for example, it covers only 80% of the cost, after a modest deductible), plus it does not cover services such as for pregnancies. A public option plan administered by Medicare in the Obamacare marketplace would rather provide services as would be covered under the core “silver plan” option in those markets (the option that is the basis for the determination of the subsidies for low-income households). And one might consider offering as options plans at the “bronze” and “gold” levels as well.
Such a Medicare-managed public option would provide competition in the Obamacare exchanges. An important difficulty, especially in the Republican states that have not been supportive of offering such health insurance, is that in certain states (or counties within those states) there have been few health insurers competing with each other, and indeed often only one. The exchanges are organized by state, and even when insurers decide to offer insurance cover within some state, they may decide to offer it only to residents of certain counties within that state. The private insurers operate with an expensive business model, built typically around organizing networks of doctors with whom they negotiate individual rates for health care services provided. It is costly to set this up, and not worthwhile unless they have a substantial number of individuals enrolled in their particular plan.
But one should also recognize that there is a strong incentive in the current Obamacare markets for an individual insurer to provide cover in a particular area if no other insurer is there to compete with them. That is because the federal subsidy to a low-income individual subscribing to an insurance plan depends on the difference between what insurers charge for a silver-level plan (specifically the second lowest cost for such a plan, if there are two or more insurers in the market) and some given percentage of that individual’s household income (with that share phased out for higher incomes). What that means is that with no other insurer providing competition in some locale, the one that is offering insurance can charge very high rates for their plans and then receive high federal subsidies. The ones who then lose in this (aside from the federal taxpayer) are households of middle or higher income who would want to purchase private health insurance, but whose income is above the cutoff for eligibility for the federal subsidies.
The result is that the states with the most expensive health insurance plan costs are those that have sought to undermine the Obamacare marketplace (leading to less competition), while the lowest costs are in those states that have encouraged the Obamacare exchanges and thus have multiple insurers competing with each other. For example, the two states with the most expensive premium rates in 2019 (average for the benchmark silver plans) were Wyoming (average monthly premium for a 40-year-old of $865, before subsidies) and Nebraska (premium of $838). Each had only one health insurer provider on the exchanges. At the other end, the five states with the least expensive average premia, all with multiple providers, were Minnesota ($326), Massachusetts ($332), Rhode Island ($336), Indiana ($339), and New Jersey ($352). These are not generally considered to be low-cost states, but the cost of the insurance plans in Wyoming and Nebraska were two and a half times higher.
The competition of a Medicare-managed public provider would bring down those extremely high insurance costs in the states with limited or no competition. And at such lower rates, the total being spent by the federal government to support access by individuals to health insurance will come down. But to achieve this, Congress will have to allow such competition from a public provider, and management through Medicare would be the most efficient way to do this. One would still have any private providers who wish to compete. But consumers would then have a choice.
C. Allow Medicare to Compete in the Market for Employer-Sponsored Health Insurance Cover
While the market for individual health insurance cover is important to extending the availability of affordable health care to those otherwise without insurance cover, employer-sponsored health insurance plans account for a much higher share of the population. Excluding those with government-sponsored plans via Medicare, Medicaid, and other such public programs, employer-sponsored plans accounted for 76% of the remaining population, individual plans for 11%, and the uninsured for 14%.
These employer-sponsored plans are dominant in the US for historical reasons. They receive special tax breaks, which began during World War II. Due to the tax breaks, it is cheaper for the firm to arrange for employee health insurance through the firm (even though it is in the end paid for by the employee, as part of their total compensation package), than to pay the employee an overall wage with the employee then purchasing the health insurance on his or her own. The employer can deduct it as a business expense. But this has led to the highly fragmented system of health insurance cover in the US, with each employer negotiating with private insurers for what will be provided through their firm, with resulting high costs for such insurance.
As many have noted, no one would design such a health care funding system from scratch. But it is what the US has now, and there is justifiable concern over whether some individuals might encounter significant disruptions when switching over to a more rational system, whether Medicare-for-All or anything else. It is a concern which needs to be respected, as we need health care treatment when we need it, and one does not want to be locked out of access, even if temporarily, during some transition. How can this risk be avoided?
One could manage this by avoiding a compulsory switch in insurance plans, but rather provide as an option insurance through a Medicare-managed plan. That is, a Medicare-managed insurance plan, similar in what is covered to current Medicare, would be allowed to compete with current insurance providers, and employers would have the option to switch to that Medicare plan, either immediately or at some later point, as they wish, to manage health insurance for their employees.
Furthermore, this Medicare-managed insurance could serve as a core insurance plan, to be supplemented by a private insurance plan which could cover costs and health care services that Medicare does not cover (such as dental and vision). These could be similar to Medicare Supplement plans (often called a Medigap plan), or indeed any private insurance plan that provides additional coverage to what Medicare provides. Medicare is then the primary insurer, while the private supplemental plan is secondary and covers whatever costs (up to whatever that supplemental plan covers) that are not paid for under the core Medicare plan.
In this way, an individual’s effective coverage could be exactly the same as what they receive now under their current employer-sponsored plan. Employers would still sponsor these supplemental plans, as an addition to the core Medicare-managed plan that they would also choose (and pay for, like any other insurance plan). But the cost of the Medicare-managed plus private supplemental plans would typically be less than the cost of the purely private plans, due to the far greater efficiency of Medicare. And with this supplemental coverage, one would address the concern of many that what they now receive through their employer-sponsored plan is a level of benefits that are greater than what Medicare itself covers. They don’t want to lose that. But with such supplemental plans, one could bring what is covered up to exactly what they are covering now.
This is not uncommon. Personally, I am enrolled in Medicare, while I have (though my former employer) additional cover by a secondary private insurer. And I pay monthly premia to Medicare and through my former employer to the private insurer for this coverage (with those premia supplemented by my former employer, as part of my retirement package). With the supplemental coverage, I have exactly the same health care services and share of costs covered as what I had before I became eligible for Medicare. But the cost to me (and my former employer) is less. One should recognize that for retirees this is in part due to Medicare for the elderly receiving general fiscal subsidies through the government budget. But the far greater efficiency of Medicare that allows it to keep its administrative costs low (at just 2.4% of what it spends, with the rest going to health care service providers, as compared to a 12% cost share for private insurance) would lead to lower costs for Medicare than for private providers even without such fiscal support.
Such supplemental coverage is also common internationally. Canada and France, for example, both have widely admired single-payer health insurance systems (what Medicare-for-All would be), and in both one can purchase supplemental coverage from private insurers for costs and services that are not covered under the core, government managed, single-payer plans.
Under this proposed scheme for the US, the decision by a company of whether to purchase cover from Medicare need not be compulsory. The company could, if it wished, choose to remain with its current private insurer. But what would be necessary would be for Congress to remove the restriction that prohibits Medicare from competing with private insurance providers. Medicare would then be allowed to offer such plans at a price which covers its costs. Companies could then, if they so chose, purchase such core cover from Medicare and additionally, to supplement such insurance with a private secondary plan. One would expect that given the high cost of medical services everywhere (but especially in the US) they will take a close look at the comparative costs and value provided, and choose the plan (or set of plans) which is most advantageous to them.
Over time, one would expect a shift towards the Medicare-managed plans, given its greater efficiency. And private plans, in order to be competitive for the core (primary) insurance available from Medicare, would be forced to improve their own efficiency, or face a smaller and smaller market share. If they can compete, that is fine. But given their track record up to now, one would expect that they will leave that market largely to Medicare, and focus instead on providing supplemental coverage for the firms to select from.
D. Avoiding Cherry-Picking by the Private Insurers
An issue to consider, but which can be addressed, is whether in such a system the private insurers will be able to “cherry-pick” the more lucrative, lower risk, population, leaving those with higher health care costs to the Medicare-managed options. The result would be higher expenses for the public options, which would require them either to raise their rates (if they price to break even) or require a fiscal subsidy from the general government budget. And if the public options were forced to raise their rates, there would no longer be a level playing field in the market, effective competition would be undermined, and lower-efficiency private insurers could then remain in the market, raising our overall health system costs.
This is an issue that needs to be addressed in any insurance system, and was addressed for the Obamacare exchanges as originally structured. While the Trump administration has sought to undermine these, they do provide a guide to what is needed.
Specifically, all insurers on the Obamacare exchanges are required to take on anyone in the geographic region who chooses to enroll in their particular plan, even if they have pre-existing conditions. This is the key requirement which keeps private insurers from cherry-picking lower-cost enrollees, and excluding those who will likely have higher costs. However, this then needs to be complemented with: 1) the individual mandate; 2) minimum standards on what constitutes an adequate health insurance plan; and 3) what is in essence a reinsurance system across insurers to compensate those who ended up with high-cost enrollees, by payments from those insurers with what turned out to be a lower cost pool (the “risk corridor” program). These were all in the original Obamacare system, but: 1) the individual mandate was dropped in the December 2017 Republican tax cut (after the Trump administration said they would no longer enforce it anyway); 2) the Trump administration has weakened the minimum standards; and 3) Senator Marco Rubio was able in late 2015 to insert a provision in a must-pass budget bill which blocked any federal spending to even out payments in the risk corridor program.
Without these measures, it will be impossible to sustain the requirement that insurers provide access to everyone, at a price which reflects the health care risks of the population as a whole. With no individual mandate, those who are currently healthy could choose to free-ride on the system, and enroll in one of the health care plans only when they might literally be on the way to the hospital, or, in a less extreme example, only aim to enroll at the point when they know they will soon have high medical expenses (such as when they decide to have a baby, or to have some non-urgent but expensive medical procedure done). The need for good minimum standards for health care plans is related to this. Those who are relatively healthy might decide to enroll in an insurance plan that covers little, but, when diagnosed with say a cancer or some other such medical condition, then and only then enroll in a medical insurance plan that provides good cover for such treatments. The good medical insurance plans would either soon go bankrupt, or be forced also to reduce what they cover in a race to the bottom.
Finally, risk sharing across insurers is in fact common (it is called reinsurance), and was especially important in the new Obamacare markets as the mix of those who would enroll in the plans, especially in the early years, could not be known. Thus, as part of Obamacare, a system of “risk corridors” was introduced where insurers who ended up with an expensive mix of enrollees (those with severe medical conditions to treat) would be compensated by those with an unexpectedly low-cost mix of enrollees, with the federal government in the middle to smooth out the payments over time. The Congressional Budget Office estimated in 2014 that while the payment flows would be substantial ($186 billion over ten years) the inflows would match the outflows, leaving no net budgetary cost. However, Senator Rubio’s amendment effectively blocked this, as he (incorrectly) characterized the risk corridor program to be a “bailout” fund for the insurers. But the effect of Rubio’s amendment was to lead smaller insurers and newly established health care coops to exit the market (as they did not have the financial resources to wait for inflows and outflows to even out), reducing competition by leaving only a limited number of the large, deep pocket, insurers who could survive such a wait, and then, with the more limited competition, jack up the insurance premia rates. The result, as we will discuss immediately below, was to increase, not decrease, federal budgetary costs, while pricing out access to the markets of those with incomes too high to receive the federal subsidies.
Despite these efforts to kill Obamacare and block the extension of health insurance coverage to those Americans who have not had it, another provision in the Obamacare structure has allowed it to survive, at least so far and albeit in a more restrictive (but higher cost) form. And that is due to the way the system of federal subsidies are provided to those of lower-income households in order to make it possible for them to purchase health insurance at a price they can afford. As discussed above, these federal subsidies cover the difference between some percentage of a household’s income (with that percentage depending on their income) and the cost of a benchmark silver-level plan in their region.
More specifically, those with incomes up to 400% of the federal poverty line (400% would be $49,960 for an individual in 2019, or $103,000 for a family of four) are eligible to receive a federal subsidy to purchase a qualifying health insurance plan. The subsidy is equal to the difference between the cost of the benchmark silver-level plan and a percentage of their income, on a sliding scale that starts at 2.08% of income for those earning 133% of the poverty line, and goes up to 9.86% for those earning 400%. The mathematical result of this is that if the cost of the benchmark health insurance plan goes up by $1, they will receive an extra $1 of subsidy (as their income, and hence their contribution, is still the same).
The result is that measures such as the blocking of the risk corridor program by Senator Rubio’s amendment, or the Trump administration’s decision not to enforce (and then to remove altogether) the individual mandate, or the weakening the standards of what has to be covered in a qualifying health insurance plan, have all had the effect of the insurance companies being forced to raise the insurance premium rates sharply. While those with incomes up to 400% of the poverty line were not affected by this (they pay the same share of their income), those with incomes higher than the 400% limit have been effectively priced out of these markets. Only those (whose incomes are above that 400%) with some expensive medical condition might remain, but this then further biases the risk pool to those with high medical expenses. Finally and importantly, these measures to undermine the markets have led to higher, not lower, federal budgetary costs, as the federal subsidies go up dollar for dollar with the higher premium rates.
So we know how to structure the markets to ensure there will be no cherry-picking of low risk, low cost, enrollees, leaving the high-cost patients for the Medicare-managed option. But it needs to be done. The requirement that all the insurance plans accept any enrollee will stop this. This then needs to be complemented with the individual mandate, minimum standards for the health insurance plans, and some form of risk corridors (reinsurance) program. The issue is not that this is impossible to do, but rather that the Trump administration (and Republicans in Congress) have sought to undermine it.
This discussion has been couched in terms of the market for individual insurance plans, but the same principles apply in the market for employer-sponsored health insurance. While not as much discussed, the Affordable Care Act also included an employer mandate (phased in over time), with penalties for firms with 50 employees or more who do not offer a health insurance plan meeting minimum standards to their employees. There were also tax credits provided to smaller firms who offer such insurance plans.
But the cherry-picking concern is less of an issue for such employer-based coverage than it is for coverage of individuals. This is because there will be a reasonable degree of risk diversification across individuals (the mix of those with more expensive medical needs and those with less) even with just 100 employees or so. And smaller firms can often subscribe together with others in the industry to a plan that covers them as a group, thus providing a reasonable degree of diversification. With the insurance covering everyone in the firm (or group of firms), there will be less of a possibility of trying to cherry-pick among them.
The possibility of cherry-picking is therefore something that needs to be considered when designing some insurance system. If not addressed, it could lead to a loading of the more costly enrollees onto a public option, thus increasing its costs and requiring either higher premia to subscribe to it or government budget support. But we know how to address the issue. The primary tool, which we should want in any case, is to require health insurers to be open to any enrollees, and not block those with pre-existing conditions. But this then needs to be balanced with the individual mandate, minimum standards for what qualifies as a genuine health insurance plan, and means to reinsure exceptional risks across insurers. The Obamacare reforms had these, and one cannot say that we do not know how to address the issue.
These proposals are not radical. And while there has been much discussion of allowing a public option to provide competition for insurance plans in the Obamacare markets, I have not seen much discussion of allowing a Medicare-managed option in the market for employer-sponsored health insurance plans. Yet the latter market is far larger than the market for private, individual, plans, and a key part of the proposal is to allow such competition here as well.
Allowing such options would enable a smooth transition to Medicare-managed health insurance that would be available to all Americans. And over time one would expect many if not most to choose such Medicare-managed options. Medicare has demonstrated that it is managed with far great efficiency than private health insurers, and thus it can offer better plans at lower cost than private insurers currently do. If the private insurers are then able to improve their competitiveness by reducing their costs to what Medicare has been able to achieve, then they may remain. But I expect that most of them will choose to compete in the markets for supplemental coverage, offering plans that complement the core Medicare-managed plan and which would offer a range of options from which employers can choose for their employer-sponsored health insurance cover.
Conservatives may question, and indeed likely will question, whether government-managed anything can be as efficient, much less more efficient, than privately provided services. While the facts are clear (Medicare does exist, we have the data on what it costs, and we have the data on what private health insurance costs), some will still not accept this. However, with such a belief, conservatives should not then be opposed to allowing Medicare-managed health insurance options to compete with the private insurers. If what they believe is true, the publicly-managed options would be too expensive for an inferior product, and few would enroll in it.
But I suspect that the private insurers realize they would not be able to compete with the Medicare-managed insurance options unless they were able to bring their costs down to a comparable level. And they do not want to do this as they (and their senior staff) benefit enormously from the current fragmented, high cost, system. That is, there are important vested interests who will be opposed to opening up the system to competition from Medicare-managed options. It should be no surprise that they, and the politicians they contribute generously to, will be opposed.