Elder

For patients with certain cancers, out-of-pocket spending can exceed $15,000 a year. Legislation could take aim at prices and the amounts Medicare patients are charged.

Negotiators were closing in on a deal that could spend around $1.75 trillion, but lawmakers were still haggling over critical disagreements on the sprawling social policy bill.

Democrats have made giving government the power to negotiate drug prices a central campaign theme for decades. With the power to make it happen, they may fall short yet again.

The drug, Aduhelm, brought in $300,000 in revenue in its first full three months of availability. The company expects the drug to generate minimal revenue for the rest of the year.

The increase, a cost-of-living adjustment that applies to about 70 million Americans, comes as consumer prices have jumped sharply.

By Andre M. Perry, Joia Crear-Perry, Carl Romer, Nana Adjeiwaa-Manu

Higher rates of COVID-19 infection among essential and frontline workers put a spotlight on underinsured laborers. Essential workers—those who perform a range of jobs and services that are necessary for society to function well, including but not limited to occupations in health care, food service, and public transportation—are less likely to have insurance and are more likely to be underinsured than non-essential workers. However, a 2020 Brookings report found that Black essential workers are more likely to be uninsured than white essential workers. Similarly, an Urban Institute analysis found that Black workers are more likely to be essential and frontline workers (a sub-category of essential workers comprised of people who cannot work from home), and they are more likely to be underinsured. The Urban Institute study adds that the problem of not having adequate insurance is even more acute for American Indian or Alaska Native and Latino or Hispanic workers. In order to achieve equity for the lowest paid and most essential frontline workers of color, the American health insurance and health care systems need a radical restructuring.

The concentration of Black people in essential jobs did not develop through happenstance. Racism in labor markets is revealed in racial disparities in occupational concentration, employment rates, and pay. For instance, Black people in Minneapolis, as in much of the nation, are more likely to work in jobs considered essential—transit, factories, retail, health care facilities, and childcare—which increases their exposure to COVID-19. In the state of Minnesota, Black people make up 7% of the total population, and account for approximately 25% of all COVID-19 infections as of the summer of 2020, according to a  University of Minneapolis study. There is a causal relationship between wealth and quality of life outcomes, including health. Wealth is the sum of all assets owned minus debt held—a person’s net worth. Occupational discrimination factors into how much wealth a family has and the resultant degree of protection a family has to withstand inevitable economic shocks.

Medical debt among Black workers adds insult to injury. An examination of debt as a function of wealth provides insights into structural racism—the policies and practices that produce racial disparities. Therefore, we introduce evidence that by reducing the amount of medical debt held by all households, we are disproportionately helping Black people. This will signal that we are mitigating structural racism and improving conditions so that Black workers and their families can thrive. This report examines medical debt and its racial distribution with a focus on how it’s accrued, including failures in the insurance market and malign medical billing practices. Following that discussion, we review a number of policy reforms to reduce health care cost sharing that broadly would move the nation further toward universal health care.

Ways that people accrue medical debt

According to a study from the Journal of General Internal Medicine, 137 million adults experienced difficulty paying medical bills in 2017, and young uninsured adults were about twice as likely to face hardship paying for health care compared to those with some public or private insurance. Kaiser Family Foundation found that about one in four adults aged 18-64 had trouble paying a medical bill over the last 12 months.

Many workers would not stay in riskier, low wage jobs if they had better health insurance options. Workers, essential and otherwise, stay in suboptimal employment because their employment is tied to their health insurance. “Job lock” is a phrase used to describe how workers feel tied to imperfect employment. According to Gallup, one in six workers experience job lock due to their health insurance coverage. Decoupling employment and health insurance could reduce job lock, which would free up people to start businesses and would increase wages because employers could reallocate insurance costs toward employee pay.

But not all workers receive health insurance from their job to even experience job lock, especially low wage essential and frontline workers. In fact, even after the Affordable Care Act, in the first half of 2020, 30 million Americans were without health insurance entirely, and Black, Hispanic or Latino, and American Indian or Alaska Native people are more likely to be uninsured. Living without health insurance was a cause of a great deal of stress for many Americans even before the pandemic. During the pandemic, states with higher rates of uninsured populations saw worse outcomes and uninsured Americans are half as likely to get the COVID-19 vaccine even though it’s free.

Uninsured Americans may be right in being distrustful of so-called “free” healthcare. Private nonprofit hospitals often do not treat people who are unable to pay as charitably as policymakers may hope. Studies by National Nurses United found that Johns Hopkins Hospital, a private nonprofit hospital, received over $164 million in tax exemptions in 2017. The tax exemptions for were created to remove the profit motive of medical care  and instead instill a motive of community and individual care. Instead, Johns Hopkins Hospital sued patients resulting in wage and property garnishments to collect a median medical debt of $1,089.

Health debt is associated with decreased use of medical services. According to NORC at the University of Chicago, Americans are more afraid of the cost of the medical coverage than the underlying illness. Due to cost sharing, low-income individuals are particularly averse to using health services, and, if and when they do, their symptoms and diagnoses have worsened, increasing health expenditures. According to our analysis, 4.4% of all households and 6.2% of Black households have high medical debt (defined as medical debt of over 20% of yearly household income). These households with high medical debt are at acute risk of decreased medical usage. Seniors, and particularly low-income seniors with chronic diseases, are more likely to become nonadherent to medical and medication prescriptions due to costs.

For those who are insured, medical bills, particularly through surprise billing, may also keep many from getting the care they need, including getting vaccinated. Surprise billing—when insured people unknowingly get care (and bills) from providers that are outside of their health plan’s network for emergency care—was common until the passage of the No Surprises Act at the end of 2020. A study from Health Affairs found that, while insurance companies will pay for larger medical expenditures, “the more modest amounts—for which patients are responsible, under common forms of coinsurance—may still be unaffordable to many people.” According to our analysis, 17.4% of households with insurance have medical debt compared to 27.9% of households without insurance. Conditional on having medical debt, households with health insurance have an average of $18,827.25, while households without health insurance have an average of $31,947.87. Clearly, having health insurance lowers the likelihood of medical debt and lowers the amount owed, but even households with health insurance are at risk of becoming indebted due to an illness or injury.

The extent of the medical debt problem is not well known nationally because there is not a centralized location where medical debt is held. The easiest place to look is collection tradelines—when hospitals and other medical providers send unpaid bills to debt collectors.  According to the CFPB, roughly half of all collections tradelines are due to medical bills, affecting nearly one in five consumers in the credit reporting system. Medical debt is a leading cause of consumer bankruptcy. In 2007, at least 62% of bankruptcies were, at least partially, attributable to medical debt. Even after the advent of the Affordable Care Act in 2010, that number has not decreased significantly.

An article published in JAMA, looking only at these collections tradelines , found that in 2020 the average medical debt in collections was only $429. Not included in researchers’ calculations are medical bills that patients owe directly to providers, long-term payment plans, debts paid with credit cards, and arrears in litigation. In general, healthcare services researchers rely heavily on these collections claims data, which as stated earlier, offer an incomplete picture of the total medical debt held by households.  So, the extent of the problem is significantly underestimated in the JAMA study as well as in most studies using collections tradelines. Therefore, more robust data collection methods for patient billing, expenditures, and payments are critical to understanding the barriers to achieving quality public health.

For this analysis, we use survey data to estimate the amount of medical debt held by American households. Summary statistics from the Census Bureau, whose data we use in our analysis, show that nearly one in five households have medical debt. And most estimates put the number between $81 and $140 billion, although some put it as high as $1 trillion. According to our analysis, 18.5% of households have medical debt. Conditional on having medical debt, the average amount of medical debt is approximately $20,500 and the median amount of medical debt is about $2,000. This suggests that while most households with medical debt have a relatively small amounts of medical debt, some households carry significantly higher liabilities. The consequences often lead to seeking less medical attention in the future. In the wake of the COVID-19 pandemic, individuals not getting the care they need can have societal implications. The extent of the problem may not be fully understood, but the consequences can be devasting to individuals and society.

Findings

Nearly 80% of medical debt is held by households with zero or negative net worth. The blame for a lack of health care coverage should not be rigidly characterized as a class issue. Black households are more likely to hold medical debt. Twenty-seven percent of Black households hold medical debt compared to 16.8% of non-Black households. These findings corroborate a 2020 Urban Institute report that found medical debt was also higher and more concentrated in communities of color than in white communities.

As we have said, having health insurance does not mean that hosuseholds are able to pay their medical bills. Non-Black households without health insurance are only slightly more likely to have medical debt than Black households with health insurance.

Black households are much less likely to have private health insurance. Conditional on having private health insurance, Black households are about as likely as non-Black households to receive their insurance through work. On average, employers pay 82% of workers’ health insurance premiums and 70% of workers’ families’ health insurance premiums. But Black employees are more than 70% more likely (11.5% vs. 6.7%) to work for employers that do not contribute to their insurance premiums.

Households with medical debt are significantly less wealthy than households without medical debt. Non-Black households with a positive net worth, regardless of medical debt status, have a higher net worth than Black households. This disparity reflects how the vast majority of medical debt is held by households with negative net worth.

Black households are more likely to have medical debt at every age, but this debt disparity is particularly acute for Black households past retirement age, when households have access to Medicare. Black households past retirement age still holding medical debt reflects how Black seniors have been denied the ability to build wealth.

Eliminating medical debt has a small ameliorating effect on the racial wealth gap, benefiting Black people the most. Here, we repeat the methodology from our analysis of student debt. Cancelling medical debt shifts wealth up more for Black households than non-Black households, possibly revealing the impact of anti-Black racism on health outcomes, but certainly reveleaing the impact of anti-Black racism on access and coverage.

Eliminating medical debt decreases the numerical racial wealth gap most for low and negative wealth households. There is little difference for households above the 25th percentile.

To really understand the racial wealth gap, the relevant metric is the wealth ratio—for example, when our colleagues wrote that “the median white household has a net worth 10 times that of the median Black household.” We plotted the ratio of the racial wealth gap at every wealth percentile to examine the relative effects of eliminating medical debt and find that the elimination of medical debt does decrease the racial wealth gap, albeit much less than the elimination of student loans. Again, this relative reduction in the racial wealth gap was most pronounced for low-wealth households.

Policy recommendation

During his 2020 presidential campaign, Sen. Bernie Sanders proposed eliminating medical debt. While congressional action to eliminate medical debt would be welcome, and the authors would support such action, unlike student debt, which is held mainly by the federal government, it is much more difficult to assess the size of the medical debt problem, where such debt is held, and how cancelling medical debt would work in practice. We argued for student debt cancellation because the vast majority of student debt is held by the federal government, and Congress has already given the Secretary of the Department of Education the authority to cancel student debt unilaterally. Similar action for medical debt would require that the government purchase medical debt held by hospitals, colleciton agencies, credit card companies, and banks. Nevertheless, there are more realistic and achievable policy solutions that prevent families from acquiring the medical debt that has such deleterious affects on their health and lives. We’ve been thankful for essential workers for the last 18 months, but we have not demonstrated our appreciation to them. Providing universal health care that does not require significant cost-sharing, as we will outline, will be a first step in thanking these workers.

Separate health insurance from employment

Employer-sponsored health insurance ties health to labor, reinforcing the centrality of profit over well-being. Incentivizing employers to sponsor health insurance has only served to widen racial, ethnic, and income inequities in access to health care—a direct result of systemic racism. Low-wage essential and frontline workers  are chronically underinsured, often because they work in low-wage jobs that do not provide fringe benefits such as health insurance or paid sick leave. As a result, high out-of-pocket medical costs such as co-payments, insurance premiums, and deductibles disproportionately affect these communities. Additionally, the drawbacks of employer-sponsored health plans often supersede their advantages—disadvantaging not only employees but also employers. In particular, employer-sponsored plans tend to be buried in bureaucracy and red tape, given that they are often complex and require administrators to oversee and define employees’ coverage.

The current system of employer provided health insurance shields households from paying taxes on their earned health insurance benefit. Employer provided premiums are shielded from income taxes, reducing workers taxable income. According to the Urban-Brookings Tax Policy Center, “The ESI exclusion will cost the federal government an estimated $273 billion in income and payroll taxes in 2019, making it the single largest tax expenditure.” This tax deduction is worth significantly more to workers in higher-income [and thus higher tax] brackets than workers in lower-income [and correspondingly lower tax] brackets. Further, according to study in the National Tax Journal, “five-sixths of the benefits [flow] to the top half of the income distribution.”

In order to separate health insurance from employment, Congress should continue to improve the online health insurance marketplaces created by the Affordable Care Act, empowering consumers—rather than employers—to choose their health care coverage. By design, online health insurance marketplaces are able to provide the same benefits to all who need coverage, which can substantially reduce inequities in access to care and job lock. Improvements in health insurance marketplaces can make them an even more viable option for coverage, rather than a last resort. Making health insurance marketplaces more viable, providing a subsidized public option, and expanding existing health insurance subsidies will both protect and empower consumers as they seek health care.

Other OECD countries have helpful models of universal health care coverage. Germany’s Bismarck health coverage model of insurance nonprofits has similarities to the United States’ system, yet it places less financial burden on consumers. The Bismarck model is a multi-payer system in which employers and employees finance health insurance. However, the government controls much of the cost-sharing. Further, the Bismarck model must cover everyone, and does not make a profit on offering coverage. In turn, the Bismarck model takes steps toward providing universal health care without financially burdening the consumer.

The United Kingdom’s National Health System (NHS) has publicly run hospitals that function essentially as a Veterans Administration (VA) for all. Right now public hospitals exist only as safety net providers such as community clinics and health centers that meet critical gaps in health care coverage for uninsured and underinsured people, even if they are not able to pay for the service. Yet these safety net providers tend to have fewer resources and capacity to serve people. If we were to transition to a public hospital system like the NHS, Congress must ensure that these public institutions have enough resources and capacity to ensure access to quality health care for uninsured and underinsured people.

In a single-payer system, one public or semi-public entity would finance health care for all. For instance, Canada’s federal government and the country’s 13 provinces and territories co-fund the country’s health system, known as Canadian Medicare. Each government in Canada’s 13 provinces and territories is responsible for administering insurance plans, health services and supervising health care providers in their respective areas. Under the Canada Health Act, each province and territories’ health insurance plans must be “publicly administered, comprehensive in coverage conditions, universal, portable across provinces, and accessible.” These regulations ensure that there is equity among local insurance plans. Further, there is no cost-sharing in the Canadian Medicare system, as physicians cannot charge patients above the government’s negotiated fee schedule. Despite its largely universal coverage, Canadian Medicare coverage excludes oral and vision care, prescription medication, and rehabilitation services. Employer-based insurance, which about two-thirds of Canadians hold, helps supplement these services. Nonetheless, all Canadian citizens and permanent residents have free access to medically necessary health care services upon the time of use.

Public hospitals, universal single-payer health insurance, or a German-style Bismarck system of insurance nonprofits are all feasible options that take first steps toward universal low-cost health care in the United States. We call on Congress to empower and protect consumers seeking health care coverage by continuing to work toward universal health care regardless of the model.

As we have shown, having health insurance does not guarantee access to quality health care if it goes unused due to fear of costs. Correspondingly, health insurance, private or public, does not insulate households from medical debt. The American health system has made two choices that ought to be rethought.

First, American health care system uses a fee for service model. Writing for Brookings, scholars at Duke University and the World Economic Forum said that “variation in quality and access across systems shows that paying providers for traditional service delivery is not sufficient for meeting [universal health care] goals.” Our former Brookings colleagues suggested several models for rethinking payment schemes. Whatever choice that policymakers make has consequences and trade offs, but its vital to understand that retaining the status quo is a choice with trade offs as well.

Second, American health care shares costs. Cost sharing impacts equitable access to care. Different health systems have different methodologies for cost sharing, but one thing in common amongst most other OECD countries is that the cost at point of service is either free, very low, or a percentage of household income. Financial incentives for health services are not standardized among health care providers, and providers tend to use expensive services or items when they are not medically necessary. As a result, patients may receive care that they do not need or want. Cost sharing hurts patients, again centering profit over well-being.

As we contemplate universal health care, which President Joe Biden has said is a basic right, we should also consider how our cost sharing methods push low-wealth households further into debt and bankruptcy. Within this new system, consumers could have less financial burden as they access health care.

Hold nonprofit hospitals accountable for providing community benefit services

Congress should ensure that there is greater federal oversight around community benefit services, which are intended to offer funding to nonprofit hospitals that provide free or reduced cost health services to low-income and medically indigent people. Congress should work toward establishing measures that increase hospital transparency around using community benefits. Congress should also require that providers discuss hospital financial assistance options as well as billing and collection policies with patients receiving care under community benefits. Federal policymakers should also ensure that nonprofit hospitals are using precise accounting standards for community benefit services and have a minimum threshold for community benefit spending. Further, nonprofit hospitals should be required to spend community benefit dollars on identified community needs and provide detailed explanations of the types of activities that qualify for community benefit spending. These measures can ensure that nonprofit hospitals are held accountable for providing care to the communities that will not be able to access it elsewhere.

Further, we recommend that states offer a similar level of oversight to the federal government in nonprofit hospitals. For instance, states can enact audits to determine how community benefit spending has impacted communities, require hospitals to contribute to community service efforts, require transparent reporting on community benefit uses, and count community investments in housing, economic development, child care, and mentoring as community benefits. States can include community benefit requirements in their hospital licensing programs and consider requiring minimum community spending thresholds for hospitals. These strategies, along with clear reporting requirements, can encourage hospitals to truly invest in the communities they serve.

In addition, the Affordable Care Act requires nonprofit hospitals to conduct community health needs assessments, which allows hospitals to identify organizations to which they can provide community benefit funding. We recommend that hospitals with community benefits provide unrestricted funding to community-based organizations led by people of color, as they tend to be more established in the community and offer a variety of health, social, and behavioral health services to community members. Such an approach allows for hospitals to collaborate with the communities they serve and engage in trust-based giving. Finally, there should be oversight at the state and federal level to ensure that there is adequate funding for safety net providers, such as community health workers and Federally Qualified Health Centers. Further, policymakers should put measures in place to ensure that safety net providers are not able to sue underserved or low-income patients for not being able to pay their medical bills.

Remedies for surprise billing

Congress should ensure that health care providers and insurers prioritize patient health and well-being over individual profit. Prioritizing individual profit over health and well-being has resulted in the consumer bearing the burden of health care costs—rather than addressing the ways that insurance companies, provider billing policies, and the federal government have impacted access to affordable care.

Congress has made strides toward centering patient well-being by enacting policy to protect patients from unanticipated medical costs. The No Surprises Act, which became law as a part of last year’s omnibus spending bill, includes critical protections to protect consumers from unexpected out-of-network health care bills. Effective January 2022, health plans will be required to cover surprise bills using in-network, rather than out-of-network, rates. Further, out-of-network providers for emergency services will not be allowed to balance bill, which refers to billing patients the difference between the provider’s charge and the allowable service fee, beyond the applicable in-network cost sharing amount for surprise bills. Among other provisions, providers who are out-of-network will not be able to send patient bills for extra charges. Further, out-of-network providers cannot send patients bills for excess charges.

Policymakers should continue to ensure that there are measures in place to maintain oversight on consumer protections. Such measures should include ensuring that hospitals are transparent in their reporting, requiring hospital audits, and carefully reviewing any complaints of health care providers or issuers violating surprise billing protections.

Build more robust data collection systems

As noted earlier, it is challenging to uncover the extent of the nation’s medical debt problem, because, unlike student debt, there is no centralized system or database  where debt is held. Health care data are similarly decentralized. Typically, research on access to health care services uses administrative claims data, which is notoriously complex, incomplete, and unstandardized. Further, health data exists in many different formats, including images, videos, text, and scans, again making centralizing information challenging. In order to better understand the nation’s medical debt, stronger, more transparent, and centralized data collection methods are critical to protecting patients’ health.

We call on Congress to take steps toward standardizing assessment and quality improvement measures, requiring data collection and disaggregation by race and ethnicity, and increasing surveillance and research on health outcomes.  Policymakers should ensure that hospital providers collect patient data by directly asking patients, rather than only gathering information through observation alone. Further, steps should be taken to standardize billing codes across health providers and health insurers—which can prevent creative coding, a method of medical billing which often results in health providers receiving increased or exaggerated profits rather than a fair rate for their service.

Finally, policymakers should support efforts toward establishing a centralized, streamlined data-sharing system that houses hospital and health care plan data within an entity such as the National Institutes of Health. Such a system would allow for analysts and policymakers to better uncover the extent of medical debt in the nation along with gaps in health care coverage. The National Institutes of Health’s launch of the National COVID Cohort Collaborative (N3C) during the pandemic to help advance research on the virus. Members of the N3C collaborative are currently building a data enclave that will allow for rapid data collection from hospitals and health care plans. N3C illustrates that centralizing health care data sharing is possible. Congress should work toward expanding funding to support such efforts, not only for research on COVID-19, but also for all health outcomes data.

Conclusion

President Joe Biden has stated, “Health care is a right … not a privilege”—a theme that was repeated on the campaign trail and during his presidency. However, maintaining a health care system that ensures that many take on debt while others don’t ensures that it will be a privilege. Employer-based health care facilitates unequal treatment. As with many issues, the pandemic simply exacerbated existing inequalities. Essential and frontline workers, mothers and others knew too well, long before the pandemic that their work is significantly underappreciated. Providing universal health care that does not require significant cost-sharing would be a first step in thanking these workers as well as others who deserve more than our applause.

      

An analysis published by the Department of Health and Human Services said that Covid shots had also prevented about 265,000 cases and 107,000 hospitalizations.

Why don't those who used to obsess over debt seem to care about the future?

Under pressure to cut the bill’s cost, Democrats disagree over whether to offer more benefits to older Americans or to cover more of the working poor.

Professors and a recent college graduate respond to a guest essay. Also: Vaccine mandates; erosion of democracy; dental benefits.

Burned-out health professionals and overwhelmed hospitals. Also: The child tax credit; counterterrorism; Democrats and taxes; "Medicare for all."

By Christopher Miller

Richard G. Frank, Ph. D., is a senior fellow in Economic Studies and director of the USC-Brookings Schaeffer Initiative on Health Policy. He is the Margaret T. Morris Professor of Health Economics, Emeritus, in the Department of Health Care Policy at Harvard Medical School. From 2014 to 2016 he served as Assistant Secretary for Planning and Evaluation in the Department of Health and Human Services. His research is focused on the economics of mental health and substance abuse care, long term care financing policy, health care competition, implementation of health reform and disability policy. Dr. Frank served as an editor for the Journal of Health Economics from 2005 to 2014. Dr. Frank was awarded the Georgescu-Roegen Prize from the Southern Economic Association, the Carl A. Taube Award from the American Public Health Association, and the Distinguished Investigator Award from AcademyHealth. He was elected to the Institute of Medicine (National Academy of Medicine) in 1997. He is co-author with Sherry Glied of the book “Better but Not Well” (Johns Hopkins Press).

      

At least 21 percent of nursing home residents are on antipsychotic drugs, a Times investigation found.

By Matthew Fiedler

Options for containing the cost of a new Medicare dental, hearing, and vision benefit

Options for containing the cost of a new Medicare dental, hearing, and vision benefit Matthew Fiedler September 10, 2021

Editor’s Note: This analysis is part of the USC-Brookings Schaeffer Initiative for Health Policy, which is a partnership between Economic Studies at Brookings and the University of Southern California Schaeffer Center for Health Policy & Economics. The Initiative aims to inform the national health care debate with rigorous, evidence-based analysis leading to practical recommendations using the collaborative strengths of USC and Brookings. This work was supported in part by a grant from the Robert Wood Johnson Foundation.

Congress is likely to consider adding dental, hearing, and vision coverage to Medicare in upcoming reconciliation legislation. While the precise design of these new benefits is still being negotiated, adding this coverage to Medicare is likely to have a substantial fiscal cost. For example, a proposal to add this coverage passed by the House of Representatives in 2019 was estimated to cost $358 billion over ten years. The draft reconciliation recommendations unveiled by the Chairman of the House Ways and Means Committee earlier this week closely resemble the 2019 House bill when fully phased in.

Importantly, expanding dental, hearing, and vision coverage will not be policymakers’ only goal for a reconciliation package. Within the health policy domain, policymakers appear likely to try to extend the recent temporary expansion of the Affordable Care Act’s premium tax credits and to provide coverage for low-income people who live in states that have not adopted the Affordable Care Act’s Medicaid expansion. Policymakers will also likely have objectives outside of health care, including continuing the temporary child tax credit expansion enacted earlier this year and expanding access to preschool. Achieving all of these objectives may be challenging given political constraints on the size of the package and on the menu of potential “pay-fors.” For this reason, reducing the cost of adding dental, hearing, and vision coverage to Medicare could increase the likelihood that the new benefits are included in a final package, reduce the risk that their inclusion crowds out other policies, or both.

This piece analyzes two ways that policymakers could reduce the cost of adding this new coverage to Medicare without reducing the generosity of that coverage, neither of which was included in either the 2019 House bill or the recent Ways and Means Committee draft. The topline fiscal effects of these two approaches—as well as the effect of combining them—are shown in Table 1.

The first option I consider is excluding what traditional Medicare spends on the new benefits from the “benchmarks” that Medicare uses to determine payment rates for private Medicare Advantage (MA) plans. I estimate that this step would reduce the fiscal cost of introducing a benefit similar to the one in the 2019 House bill by 41%. This is because federal payments to MA plans would rise only modestly if the benchmarks excluded the new benefits, whereas they would rise substantially if the benchmarks included them. The effect on federal costs is so large because of the large and growing share of Medicare enrollment accounted for by MA. I estimate that this step would also modestly reduce the Medicare Part B premium relative to what it would be if these costs were included in the benchmarks.

The smaller increase in MA payments when the new benefits are excluded from the benchmarks would not prevent MA enrollees from receiving those benefits, which MA plans would be required to provide regardless. Rather, I estimate that MA plans would accept lower profit margins (or reduce their costs) if benchmarks excluded the new benefits, whereas those margins (or costs) would rise modestly if benchmarks included the new benefits. This is consistent with research finding that lower benchmarks cause MA plans to price more aggressively, a consequence of the imperfectly competitive nature of MA markets. Notably, MA plans currently earn healthy profits, which averaged 4.5% of revenue in 2019.

Additionally, I estimate that MA plan spending on supplemental benefits other than dental, hearing, and vision coverage would change little relative to the status quo if benchmarks excluded the new benefits. This is possible in part because MA plans would accept lower margins (or lower their costs) relative to the status quo, as noted above, and in part because MA plans could reallocate dollars they currently spend on dental, hearing, and vision coverage to other types of supplemental benefits. By contrast, spending on these other supplemental benefits would rise if spending on the new dental, hearing, and vision coverage was included in the benchmarks, primarily because MA plans would reallocate dollars they currently spend on dental, hearing, and vision coverage to other supplemental benefits.

The second option I consider is to include the new benefits in the calculation of the Medicare Part B premium, just like other Part B benefits. Most beneficiaries pay premiums that cover 25% of the cost of Part B benefits, although low-income beneficiaries with limited assets are eligible to have their premiums paid by Medicaid and some higher-income beneficiaries pay higher premiums. Correspondingly, I estimate that applying the usual Part B premium rules to the new benefit would reduce the fiscal cost of creating the new benefit by 22%. Taking this step together with excluding the new benefit from MA benchmarks would reduce the fiscal cost of the new benefit by 64%. Notably, across all policy scenarios I consider, the increase in benefit spending on behalf of enrollees would greatly exceed the increase in premium payments—both in traditional Medicare and MA. This strongly suggests that the new coverage would make Medicare beneficiaries better off even if the usual Part B premium rules apply.

The remainder of this piece examines these two policy options in greater detail.

Excluding spending on the new benefit from MA benchmarks

I begin by analyzing how adding these new benefits to Medicare would affect payments to MA plans, plans’ spending on various types of benefits, and overall federal costs—and how those effects would depend on whether the cost of the new benefits was included in the MA benchmarks. The estimates I present in this section are derived from a model that is fully described in the appendix. Importantly, the model allows me to account for how the bids MA plans submit would change under different policies, which plays an important role in determining the effects of the policies examined here.

Background on payments to MA plans

Before proceeding, I provide a brief overview of the current MA payment system. Under this system, each plan submits a bid that reflects the price at which it is willing to cover the basic package of Medicare Part A and B benefits. The plan’s bid is then compared to payment benchmarks that are set as a multiple of per beneficiary spending under traditional Medicare; the precise multiple varies by region and depends on the plan’s performance on certain quality measures. For a plan that submits a bid below the benchmark (which almost all plans do), the government pays the plan its bid plus a rebate equal to a percentage of the difference between its bid and the benchmark.[1] The rebate percentage varies based on plan quality measure performance. Plans must spend the rebate on providing supplemental benefits to enrollees.

Figure 1 illustrates this system for 2021. Bids average 90% of per enrollee traditional Medicare spending, while benchmarks average 111% of traditional Medicare spending, according to estimates produced by the Medicare Payment Advisory Commission (MedPAC).[2] In 2021, the average rebate percentage is 65%, so this combination of bids and benchmarks generates rebates averaging 14% of traditional Medicare spending. Total payments to MA plans are thus 104% of traditional Medicare spending.

MedPAC’s analysis of plan bids indicates that MA plans are using most rebate dollars to reduce enrollee cost-sharing and premiums. However, plans are using around one-fifth of rebate dollars to provide other supplemental benefits, notably including dental, hearing, and vision coverage. Indeed, virtually all MA plans offer at least some dental, hearing, and vision coverage in 2021, although that coverage is often less generous than the coverage envisioned in prominent Congressional proposals.

Effects on MA payments, benefit spending, and net revenues under different benchmark approaches

Figure 2 reports estimates of how adding dental, hearing, and vision coverage to Medicare would change what MA plans are paid, how those funds would ultimately be used, and how those effects would depend on whether the cost of the new benefits was incorporated in MA benchmarks. Full details on my methods are in the appendix, but I describe the main factors that shape these estimates below.

I note that the estimates presented in Figure 2 and throughout the rest of the main text are for a dental, hearing, and vision benefit similar in generosity to the one that would be have been created by legislation passed by the House in 2019 (once that legislation was fully phased in).[3] The basic structure of that benefit is similar to the benefit included in draft reconciliation recommendations unveiled by the Chairman of the House Ways and Means Committee earlier this week, at least in the long-run. However, as discussed in detail in the appendix, the effects of a new benefit on MA payments and federal costs would generally scale roughly in proportion (and, in some cases, exactly in proportion) to the generosity of the new benefit. For that reason, I express all of my estimates as a fraction of the per enrollee cost of the new benefit in traditional Medicare so that the estimates can be easily applied to proposals of different sizes.

I first discuss outcomes when traditional Medicare spending on the new benefits is included when calculating MA benchmarks. Outcomes for this scenario are depicted in Panel A of Figure 2:

• Payments to plans: I estimate that average MA plan bids would rise by 100% of traditional Medicare’s cost of providing the new benefit. Part of this increase reflects the fact that dental, hearing, and vision benefit would now be part of the basic Medicare benefit, so MA plans would now reflect the cost of providing those benefits in their bids. I estimate that MA plans’ cost of providing the new benefits would be 89% of traditional Medicare’s cost (reflecting an assumption that MA plans would use a range of tools to reduce utilization of the new benefits relative to traditional Medicare, in line with the reductions they achieve for current outpatient services).
  
  The remaining increase in plan bids arises because benchmarks (which, as noted above, are set as a multiple of traditional Medicare costs that currently averages 111%) would rise by more than MA plans’ costs. There is considerable  empirical  evidence  that higher benchmarks lead MA plans to submit higher bids, likely reflecting market power held by MA plans. Drawing on this evidence base, CBO has previously estimated that a one dollar increase in the benchmark causes a $0.50 increase in plans bids, and my model incorporates the CBO estimate. The increase in benchmarks in excess of the increase in plans’ costs of providing the basic benefit would function essentially like a standalone benchmark increase, driving the additional 11 percentage point increase in bids.
  
  In total, bids would rise somewhat less than the benchmark, so rebates would rise modestly as well. Taking account of changes in both bids and rebates, per enrollee payments to MA plans would rise by 107% of traditional Medicare’s cost of providing the new benefit.

• Benefit spending and net revenues: The higher payments to MA plans would flow to a few different purposes. A portion would finance expanded dental, hearing, and vision coverage for MA enrollees, as MA plans would now spend substantially more on these services under the basic Medicare benefit. However, this additional spending would be partially offset by the fact that plans would no longer spend rebate dollars on providing these benefits.
  
  The size of this offset is uncertain because there is limited data on how much plans are currently spending on these benefits. The appendix reviews the available evidence and concludes that, for a new benefit of the size considered in this analysis, redirecting plans’ current spending on dental, hearing, and vision coverage would produce an offset of around 26% of traditional Medicare’s cost of providing the new benefit; however, in light of the limitations of the available data, this estimate is subject to meaningful uncertainty.[4] This estimate implies that the net increase in MA plans’ per enrollee spending on dental, hearing, and vision coverage would be around 63% of the increase in per enrollee spending on these services in traditional Medicare.
  
  The remainder of the increase in payments to MA plans would flow to purposes unrelated to the underlying goal of expanding dental, hearing, and vision coverage in Medicare. Spending on supplemental benefits other than dental, hearing, and vision coverage would rise by an amount equivalent to 33% of the cost of the new benefit in traditional Medicare. This is because plans could now reallocate rebate dollars currently spent on dental, hearing, and vision coverage and because the overall size of the rebate would rise relative to the status quo.
  
  The rest of the increase in payments—a per enrollee amount equivalent to 11% of traditional Medicare’s cost of the new benefits—would constitute new net revenue to MA plans. Some of this additional revenue might ultimately translate into higher profit margins for MA plans. Some might also be dissipated by higher costs. For example, Duggan, Starc, and Vabson find that higher payments to MA plans are partly offset by higher marketing spending.[5]

I now turn to the scenario in which spending on the new benefits under traditional Medicare is excluded when calculating the MA benchmarks. This scenario is depicted in Panel B of Figure 2:

• Payments to plans: I estimate that MA plans would submit lower bids if spending on the new benefits was excluded from MA benchmarks relative to if that spending was included, consistent with the evidence discussed above on how benchmark changes affect plan bids. Specifically, I estimate that plan bids would now rise by only 44% of traditional Medicare’s cost of providing the new benefit. Additionally, because the benchmarks would not increase in this policy scenario, the increase in plan bids relative to the status quo would translate into a reduction in rebate payments. On net, per enrollee payments to MA plans would now rise only modestly, by an estimated 16% of traditional Medicare’s cost of providing the new benefit.

• Benefit spending and net revenues: This smaller increase in plan payments in this scenario relative to scenario in which the new benefits were included in the MA benchmarks would not affect MA plan spending on dental, hearing, and vision benefits because MA plans would remain required to cover all benefits included in the basic Medicare benefit—including the new dental, hearing, and vision benefits—regardless of where the benchmark was set. Rather, MA plans’ net revenue would now fall, by an estimated 44% of traditional Medicare’s cost of providing the new benefit. Additionally, the reduction in rebate payments relative to the status quo would mean that plans’ spending on supplemental benefits other than dental, hearing, and vision coverage would now fall slightly because the decline in rebate payments would slightly exceed the amount plans are currently spending on supplemental dental, hearing, and vision coverage.[6]

Effects on federal spending under different benchmark approaches

Figure 3 presents estimates of how the treatment of spending on the new benefits in MA benchmarks would affect the overall fiscal cost of adding those benefits. I focus first on Panel C of Figure 3, which reports estimates of how total federal outlays would change in various policy scenarios. Taken together, the estimates in Row 1 and Row 2 indicate that the overall federal cost of adding the new benefits to Medicare would be 41% lower in a scenario in which spending on the new benefits was excluded from MA benchmarks relative to if spending on the new benefits was included in the benchmarks.

This large effect reflects the large and growing share of overall Medicare enrollment now accounted for by MA plans. Under CBO’s most recent baseline projections, which I use to calibrate my model, private health plans will account for 55% of all Medicare enrollment (among people who hold both Part A and Part B coverage, the relevant population for these purposes) on average over the 2022-2031 period.[7]

Panel B of Figure 3 illustrates that decisions about whether to include the new benefits in MA benchmark calculations would also affect the Medicare Part B premium. This is the case even in policy scenarios like those depicted in Row 1 and Row 2 of Figure 3 where the costs of providing the new benefit are notionally excluded from Part B premium calculations.

This is because only the amounts that traditional Medicare or MA plans directly spend on the new benefits are likely to be excluded from premium calculations in practice. As the results in Figure 2 demonstrate, the change in MA plan payments caused by adding the new benefits would generally differ from the amounts that MA plans actually spend on the new benefits. In the scenario where the costs of the new benefits are included in the benchmarks, payments to MA plans would rise by more than plans’ costs of providing the new benefits, so the Part B premium would rise slightly. On the other hand, in the scenario  where the cost of the new benefits is excluded from the MA benchmarks, payments to MA plans would rise by less than MA plans’ cost of providing the new benefits, so the Part B premium would fall.

A note on related policy approaches

Before proceeding, I note that the effect of excluding the new benefits from MA benchmarks would be essentially identical to the effect of adopting other policies that reduced benchmarks by similar amounts. A range of other policies for reducing MA benchmarks are commonly discussed. For example, MedPAC has proposed increasing the coding intensity adjustment (which is intended to offset MA plans’ efforts to secure larger payments by coding diagnoses more aggressively for risk adjustment purposes) or simply setting MA benchmarks as lower multiples of traditional Medicare spending than under current law.

These alternative policy approaches would have the advantage that they would avoid adding an ad hoc exclusion into the benchmark methodology. On the other hand, adopting unrelated MA payment policy changes could be more politically challenging than just excluding spending on a new benefit from the benchmark, which offers a reason that policymakers might prefer the approach considered here.

I also note that this analysis considers an approach under which spending on the new benefits would be fully excluded from the MA benchmarks. Policymakers could, of course, opt to exclude only part of the cost of the new benefits from the MA benchmarks. Outcomes under that approach would generally fall in between the two policy scenarios that I consider in this analysis, with the precise results depending on what share of the cost of the new benefits was excluded from the benchmarks.

Apply the usual Part B premium rules

Another way policymakers could contain the cost of adding dental, hearing, and vision coverage to Medicare would be to apply the usual Medicare Part B premium rules to the new benefit. The proposal passed by the House in 2019 would have excluded the new benefit from Part B premium calculations, as do the draft reconciliation recommendations released by the House Ways and Means Committee.

The base Part B premium is set to cover 25% of the cost of Part B benefits. Beneficiaries with incomes above a threshold ($176,000 for a married couple in 2021) pay higher “income-related” premiums, while beneficiaries with incomes below a threshold ($23,760 for a married couple in 2021) and limited assets are eligible to have their Part B premiums paid by Medicaid (although not all people eligible for premium assistance through Medicaid actually sign up to receive it). Taking account of both the income-related premiums contributed by higher-income Medicare beneficiaries and the premiums that the federal government pays itself via Medicaid, I estimate in the appendix that the federal government recovers almost exactly 25% of the cost of additional Part B benefit costs via premiums.

Applying these premiums to a new dental, hearing, and vision benefit could, therefore, substantially reduce the cost of such a benefit to the federal government, as shown in Panel C of Figure 3. Comparing the estimates in Row 1 and Row 3 indicates that simply applying premiums to the new benefits would reduce the overall fiscal cost of the new benefits by 22%.[8] Policymakers could also choose to both apply premiums and exclude the cost of the new benefits from MA benchmarks. Comparing Rows 1 and 4 indicates that this combination would reduce the federal cost of the new benefits by 64%.

Figure 4 places the estimated changes in premium payments in the context of the estimated changes in benefit spending on beneficiaries’ behalf. Notably, across all of the policy scenarios considered in this analysis—including scenarios where the cost of the new benefits is excluded from MA benchmarks—the increase in benefit spending would substantially exceed the increase in premium payments. One implication is that, unless Medicare beneficiaries valued the new benefits at far less than the cost of providing them, adding these new benefits to Medicare would leave Medicare beneficiaries better off even if they paid for a portion of the cost of the new coverage through higher premiums.

Conclusion

I close with some thoughts on how policymakers should decide whether to adopt the options considered in this piece. The first—and perhaps most important—question is what these policies are trading off against. Because the overall size of the reconciliation legislation is likely to be constrained, spending more on dental, hearing, and vision coverage means spending less in some other part of that legislation (unless it results in the new coverage itself being excluded from the package). The higher the value of the policies that get crowded out, the more attractive the policy options considered here should be.

The second question is how policymakers should weigh the potential downsides of the policy options considered here. With respect to excluding the new benefits from the MA benchmarks, there are two main downsides to consider. First, MA plans’ profit margins would be lower if the benefits are excluded from the benchmarks, whether measured relative to the status quo or relative to if those benefits were included in the benchmarks (provided that MA plans do not reduce their costs). Unless policymakers value MA plan profits per se, the main downside of lower MA profit margins is that fewer insurers might participate in MA. However, MedPAC estimates that MA plans’ margins averaged a healthy 4.5% in 2019 and that MA plan participation is currently very robust (and becoming more so). This suggests that a major exodus from the MA program—or, at a minimum, a damaging exodus—is unlikely. Of course, MA plans are likely to oppose policies that reduce their profits regardless, which could pose political challenges.

Second, MA coverage would include fewer supplemental benefits other than dental, hearing, and vision coverage if the cost of the new benefits were excluded from the benchmarks than if the new benefits were included. Importantly, however, the decline relative to the status quo would be very slight, as this would largely just unwind an expansion in supplemental benefits that would occur if the cost of the new dental, hearing, and vision coverage was included in the benchmarks. As a substantive matter, this suggests that the forgone supplemental benefits would be less valuable to enrollees on a dollar-for-dollar basis than existing supplemental benefits (since plans would otherwise offer the forgone benefits instead of what they offer today). As a political matter, the fact that MA enrollees would not lose much in supplemental benefits relative to the status quo (and, indeed, would gain more robust dental, hearing, and vision coverage in the base benefit) likely mitigates the risk of adverse beneficiary reactions.

With respect to including the new benefits in Part B premium calculations, the main downside is obvious: Medicare beneficiaries (except low-income beneficiaries whose premiums are paid by Medicaid) would pay somewhat higher premiums. However, two factors would likely attenuate any political sting of these premiums. First, as I discuss in the main text, Medicare beneficiaries would still be made substantially better off by the addition of dental, vision, and hearing coverage even if asked to contribute to the new coverage via premiums. Second, particularly if a new benefit is phased in gradually over time, additional premiums attributable to the new benefit might not be particularly salient to beneficiaries.

Methodological Appendices file-pdf Download this file Footnotes

[1] The small number of plans that submit bids above the benchmark are paid the benchmark and collect a supplemental premium from enrollees equal to the difference between the bid and the benchmark.

[2] These estimates adjust for differences in health status between MA and traditional Medicare enrollees to the extent that those differences are captured by the MA risk adjustment system (after applying MedPAC’s best estimate of coding intensity differences between MA and traditional Medicare). Thus, they are expressed as a percentage of the cost that MA enrollees specifically would incur if enrolled in traditional Medicare. However, some evidence suggests that the MA risk adjustment system does not fully offset health status differences between MA and traditional Medicare, even with a larger coding intensity adjustment, in which case MA payments and benchmarks would be higher in relation to traditional Medicare costs than they are in the MedPAC estimates.

[3] Specifically, they reflect a scenario in which the new benefit increases per enrollee spending in traditional Medicare by 6%. The Congressional Budget Office estimated that the 2019 House bill would have increased overall Part A and Part B benefit spending in fiscal year 2029 by 6.4% relative to the agency’s May 2019 baseline projections. The estimates presented in this analysis imply that the House proposal would have increased per enrollee spending in MA by somewhat more than it increased per enrollee spending in traditional Medicare, so this estimate is consistent with an increase in per enrollee spending in traditional Medicare of around 6%.

[4] Unlike almost all of the other estimates presented in this analysis, this estimate would not scale in proportion to the size of the new dental, hearing, and vision benefit. The offset would generally be larger in the case of a smaller dental, hearing, and vision benefit and smaller in the case of a larger benefit.

[5] In principle, plans might also use some of this additional revenue to make the basic benefit more attractive, like by adopting broader networks or looser utilization controls. Duggan, Starc, and Vabson find little evidence, however, that higher payments to MA plans lead to greater health care utilization by MA enrollees or higher quality of care, suggesting that any efforts along these lines may have little effect on patients.

[6] A recent Wakely analysis commissioned by AHIP, a health insurance industry trade group, concludes that excluding the new benefits from MA benchmarks would cause a large decline in rebate payments. AHIP has used this analysis to argue that excluding the costs of the new benefit from MA benchmarks would require plans to make large cuts to the supplemental benefits they currently offer, whereas my estimates suggest that plans would need to make at most small cuts to other supplemental benefits under this policy.

My conclusions differ for three main reasons. First, the Wakely analysis examines a policy under which the cost of the new benefits would be excluded from the MA benchmarks and MA plans would be required to finance the new benefits entirely out of rebates, whereas I examine a policy under which MA plans could include the new benefits in their bids. Second, Wakely assumes that benchmark changes would have no effect on plan bids, which runs contrary to the empirical evidence discussed in the main text and likely leads them to overstate the decline in rebate payments. Third, Wakely solely examines changes in total rebate payments, without accounting for the fact that rebate dollars currently devoted to dental, hearing, and vision coverage could now be used to fund other supplemental benefits. By contrast, I focus on the change in rebate payments available to fund benefits other than dental, hearing, and vision coverage; this is the more relevant metric for understanding how various policy changes would affect plans’ ability to continue offering the supplemental benefits they offer today.

[7] I note that a small portion of these private health plans are not MA plans, but rather other types of private plans that are paid differently. However, data from the Centers for Medicare and Medicaid Services indicate that MA plans accounted for more than 97% of all Medicare private plan enrollment as of August 2021.

[8] This percentage is slightly lower than the 25% quoted in the prior paragraph because, as discussed in the section on MA benchmarks, the increase in payments to MA plans would exceed the amount that MA plans spent on the new dental, hearing, and vision benefits (when spending on the new benefits is included in MA benchmark calculations). Correspondingly, the amounts that would be added to the Part B premium calculation would be smaller than the total change in benefit costs due to the new benefit.

About the Author Matthew Fiedler Fellow – Economic Studies, USC-Brookings Schaeffer Initiative for Health Policy Matthew Fiedler is a fellow with the USC-Brookings Schaeffer Initiative for Health Policy. His research examines a range of topics in health care economics and health care policy. Prior to joining the Brookings Institution in January 2017, Fiedler served as Chief Economist of the Council of Economic Advisers, where he oversaw the Council’s work on health care policy, including implementation of the Affordable Care Act’s health insurance expansions and health care delivery system reforms. Fiedler holds a Ph.D. in economics from Harvard University and a B.A. in mathematics and economics from Swarthmore College. Watch Matthew Fiedler’s testimony before the Senate Finance Committee (begins at 00:50)

Disclosures: The Brookings Institution is financed through the support of a diverse array of foundations, corporations, governments, individuals, as well as an endowment. A list of donors can be found in our annual reports published online here. The findings, interpretations, and conclusions in this report are solely those of its author(s) and are not influenced by any donation.

      

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