The Conservative Principles Inherent in the Medicare Reform Legislation

(This article was written from information gleaned from a variety of sources, including the White House, the Senate GOP Policy Committee, the Sen. Majority Leader's website, the Amer. Assoc. of Health Plans., and from the author's experience in the health care industry.)

There has been much murmuring among conservatives over President Bush’s domestic policies, stemming mainly from spending initiatives. “Spending like a drunken sailor” is pretty much the way it’s been characterized.

Central to the discontent has been the passage by Congress, at the urging of the President, of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. Virtually all of the attention, and ire, of grassroots conservatives has been directed at the price tag of the bill – an estimated $395-500 billion over the next ten years. Yet hardly any attention has been given to the overall provisions of the bill, many of which are consistent with conservative principles, and which indeed were supported by many conservatives in Congress. Because many the provisions of the bill reflect conservative principles, it is very likely that the estimated price tag of the bill is overstated since a major goal of the reform legislation is to reduce the overall future costs of Medicare, and health care in general, as the provisions of the bill take hold.

While the prescription drug benefit for the fee-for-service side of Medicare has received virtually all the popular attention, other provisions of the reform legislation include:

-- enhancing the ability of Americans to pay for their own health needs through expanding the availability of Health Savings Accounts (HSAs);
-- new accounting measures which will enhance accuracy in monitoring the solvency of the overall Medicare program;
-- expanding lower-cost choices in medical coverage for senior Americans rather than placing all into the traditional (and more expensive) fee-for-service side of Medicare;
-- reducing the rising cost of prescription drugs across the board; and
-- cost-containment provisions including income thresholds for Medicare Part B premiums starting in 2007 (the higher the income of an individual or a couple, the less the federal subsidy, and the higher the premium paid for Medicare coverage), and an increase in the Medicare Part B deductible with future raises in the deductible indexed to inflation.

Prescription drug coverage -- Incorporating the efficiencies of the private sector

The provision of the Medicare reform bill attracting the most attention is the prescription drug benefit. The big reason for this is that the drug benefit is admittedly the most costly aspect of the bill. But it should be pointed out that even the large estimated cost associated with the drug benefit is simply that -- an estimate -- and an estimate that is based on, if you will, a "worst-case scenario." The actual cost of the drug benefit is not known, and may end up being much lower than the Congressional Budget Office has projected.

One aspect which could result in this benefit being not as expensive as anticipated is that it is not actually an entitlement in the traditional sense of government assistance programs. First, the drug benefit program is voluntary; while available to every Medicare beneficiary, not every beneficiary will accept the benefit. In actuality, it is not a traditional government-run program at all. The Medicare prescription drug benefit will be made available through private drug benefit insurance companies or health plans which will administer the benefit. The benefit will, literally, be run as a commercial benefit plan, not as a traditional government program.

Similar to any private sector benefit plan, the Medicare drug benefit will require a monthly premium paid by the beneficiary; it will requirement the payment of an annual deductible; and once the deductible is paid, the benefit program requires a "coinsurance" cost paid by the beneficiary -- a 25% cost-sharing up to $2,250 of drug expenses. Such cost-sharing provisions have proven effective in controlling the cost of health care coverage.

Because the drug benefit is voluntary, Medicare beneficiaries are not required to buy into it. Many Medicare beneficiaries already have some form of Medicare supplemental coverage which includes a drug benefit, so they will likely be disinclined to sign up for the new Medicare drug benefit. Also, an aspect of the Medicare reform bill is to introduce competition between the Medicare program and private sector plans. There may be drug coverage products in the commercial market which provide a better deal to Medicare beneficiaries than what the Medicare reform bill provides. Another aspect of the Medicare reform bill is the enhancement of the managed care side of Medicare. Many of the existing private health plan products offered as an alternative to the fee-for-service side of Medicare already contain a prescription drug benefit, hence, the cost of drugs is already being paid by Medicare for those enrolled in such plans, which means that for these beneficiaries there will be no increase experienced in paying for their drug coverage. And since these plans will be offering comprehensive or "full-service" medical benefits, including prescription drugs, the cost to the consumer of the health plan's drug benefit may actually be less than the cost of the benefit as designed by the Medicare reform bill.

Additionally, the very inclusion of a drug benefit to Medicare will reduce the cost of the program. For example, prior to this reform, Medicare paid for extended hospital stays for ulcer surgery at a cost of about $28,000 per patient. Yet Medicare would not pay for the drugs which eliminate the cause of most ulcers, drugs that cost about $500 a year. Now, drug coverage under Medicare will allow seniors to replace more expensive surgeries and hospitalizations with less expensive prescription medicine to treat their conditions.

In short, while the Medicare drug benefit is available to all beneficiaries (those in the fee-for-service side, as well as in the managed care side), and since the cost estimates are largely based on the assumption that most will take advantage of the new benefit, the price tag placed in the drug benefit may actually be on the high side since many beneficiaries already have a drug benefit, or commercial products may provide a better deal than what the bill's design provides.

The bill also contains provisions, unrelated to Medicare, which will lower the cost of all drugs -- benefiting not only Medicare beneficiaries and the program, but every consumer. The law injects competition into the Medicare marketplace, which will drive down the price of drugs. Private health plans have largely been successful in negotiating discounts with pharmaceutical manufacturers. Beneficiaries enrolled in a Medicare prescription drug program or a Medicare Advantage program will reap additional savings, since these plans will likely combine the attributes of a private insurance company and a pharmacy benefit manager (PBM). PBMs are designed, in part, to negotiate discounts with pharmacies and drug manufacturers on behalf of health plans.

In addition, to help American consumers of all ages, the new law provides incentives to encourage the use of generic name drugs, which are usually less expensive than brand-name drugs. The law also streamlines the bureaucratic process to bring generic drugs to the market faster.

One of the main cost-containment aspects of the Medicare reform bill is the creation of a new "Medicare Advantage" program to replace the "Medicare+Choice" program established by the Republican Congress in 1997.

"Medicare+Choice" (M+C) was the addition of a managed care side to the Medicare program, providing a cost-effective option to the more costly fee-for-service design of traditional Medicare. Medicare+Choice was intended to bring the efficiencies of the commercial managed care design into Medicare. However, the funding formula for M+C in relation to the traditional fee-for-service side established by the Clinton Administration never enabled M+C to prove its promise of cost containment. (Some have speculated that the Clinton Administration's disdain for the commercial managed care industry after it helped defeat "HillaryCare" in 1994 motivated it to choke the life out of M+C before it could prove it's worth; clearly, the Clinton Administration never intended to allow M+C to succeed.)

As a revamped managed care side of the program, Medicare Advantage will allow beneficiaries a wider range of health coverage products, including preferred provider organizations (PPO) and HMO options, opening up the Medicare program to commercial health coverage designs which have proven more cost-effective than traditional fee-for-service indemnity insurance products. These more cost-effective alternatives will enable both the beneficiary, and the government, to share in anticipated cost savings.

According to a recent survey conducted by the American Association of Health Plans of commercial plans intending to sell products to the Medicare market, Medicare-Advantage beneficiaries will see immediate improvement in their coverage over current Medicare coverage, at an overall cost savings to the Medicare program due to the managed care approach. For example:

-- Lower cost sharing: The management of coverage built into the Medicare Advantage program will allow plans to lower monthly premiums, in some cases dramatically. As an example, one health plan in New England will decrease its premiums by an average of 23% -- with beneficiaries saving as much as $67 per month compared to current out-of-pocket costs; there is also expected to be a reduction in the cost of co-pays and deductibles.
-- Enhanced benefits: In addition to prescription drugs, many plans will be able to provide benefits not found in the traditional Medicare design, such as preventive screenings (e.g., for prostate or breast cancer, diabetes, and cardiovascular disease) which will enable diseases to be found earlier enhancing the likelihood of cure and lowering the long-term costs of treatment, and disease management programs.
-- Increased enrollment: After five years of slow growth and declining availability of private plans available through the Medicare+Choice program, plans are now expecting to add -- not subtract -- beneficiaries in the program. That is a strong sign of confidence in the direction of Medicare reform, and will result in greater cost savings for the Medicare program overall as more beneficiaries opt for the Medicare Advantage program.
-- New Products: A number of companies which intend to market products through the Medicare Advantage program plan to also offer Health Savings Accounts, drug discount cards, and new Medigap packages in addition to the basic scope of benefits guaranteed to Medicare beneficiaries. The reform legislation passed by Congress enables modernization of the Medicare program through the joining of product innovations brought in by the private sector.
-- Coordination of benefits: An element of the commercial health care marketplace, this practice has resulted in slower increases in health coverage premiums than have been experienced in the standard indemnity market. It will not be an element of Medicare through the Medicare Advantage program.

The passage of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 will provide all Medicare beneficiaries with the option of a standardized prescription drug benefit, but the bill also contains provisions which move the Medicare program on a path of privatization, introducing competition into the system, and expanding the quality of benefits and care to beneficiaries while instituting new cost-containment methods. The estimated cost of the reforms -- primarily the drug benefit provision -- are admittedly hefty. But the conservative principles of competition, private sector administration of the drug benefit, innovation in administration of benefits, and cost-containment provisions, could very likely bring down the overall cost of the program, while bringing Medicare coverage up to the level and quality of private benefit plans, and into the 21st Century.

(This overview of the Medicare reform bill was produced, in part, from information from the following sources):

The cost estimates of the Medicare bill are of great concern, but are only part of the picture. What most people ingore are the built-in cost-containmnet aspects of the Medicare bill, elements which will greatly improve the efficiency of the program, and will likely put the entire program on a path toward privatization -- decidedly CONSERVATIVE principles. This is another one of those "Big Picture" perspectives that conservatives need to be taking in regard to President Bush and the Congressional Republicans.

That is the best article I have seen yet on the "Conservative" aspects of the Medicare bill. Thanks for gathering all this information together.

When my Senator Inhofe voted for the bill, I knew then that it contained "Conservative" parts or he would not have voted for the bill. This bill is going to keep rural hospitals in Oklahoma up and running!

If anyone wants on the Bush-Cheney '04 ping list, please freep mail me.

Those who are concerned about the cost of the Medicare drug benefit are really expressing the position that the federal government shouldn't be providing any health care coverage to seniors at all. That's a fair position. But let's be honest: no responsible conservative politician or office holder is going to make that case. Medicare is a reality. The debate was lost 40 years ago. Now the question is how to institute real cost-containment measures into the program, and how to move more beneficiaries into the commercial health care coverage market. The Medicare reform bill includes steps in this direction.

The debate was lost 40 years ago.

Exactly. It is not going to go away so you get the best bill you can get to reform the program. This gives seniors a choice -- if they don't want a choice, they are free not to choose another plan. Never could figure out what seniors were so upset about having a choice since they could keep their old plan.

My Mom, who is a senior, thinks the reason seniors didn't like it is because they wanted it all for nothing.

THANK YOU for pinging me to this.....this is great...here's one interesting excerpt:

"Additionally, the very inclusion of a drug benefit to Medicare will reduce the cost of the program. For example, prior to this reform, Medicare paid for extended hospital stays for ulcer surgery at a cost of about $28,000 per patient. Yet Medicare would not pay for the drugs which eliminate the cause of most ulcers, drugs that cost about $500 a year. Now, drug coverage under Medicare will allow seniors to replace more expensive surgeries and hospitalizations with less expensive prescription medicine to treat their conditions."

Thank you so much for taking the time to do a detailed explanation of this program. Having dealt with Medicare for my parents, I am well aware of the costs to the government involved by the bureaucracy and paperwork, and also the way in whicih the government pays for certain things (like cataract surgery) but neglects paying for things like preventative screening.

Your articile is much appreciated. Thanks!

Outstanding research and analysis of an hugely important subject. Thanks for helping to inform us.

The following bona fide CONSERVATIVE aspects of Medicare reform cannot be emphasized enough:

enhancing the ability of Americans to pay for their own health needs through expanding the availability of Health Savings Accounts (HSAs);
new accounting measures which will enhance accuracy in monitoring the solvency of the overall Medicare program;
expanding lower-cost choices in medical coverage for senior Americans rather than placing all into the traditional (and more expensive) fee-for-service side of Medicare;
reducing the rising cost of prescription drugs across the board; and
cost-containment provisions including income thresholds for Medicare Part B premiums starting in 2007 (the higher the income of an individual or a couple, the less the federal subsidy, and the higher the premium paid for Medicare coverage), and an increase in the Medicare Part B deductible with future raises in the deductible indexed to inflation.

Here's the difference between Democrats and Republicans: Democrats talk about "health care reform," but never do anything because if they actually *solved* problems, they'd lose an issue they can bring up every two years. Republicans actually make the effort to institute real reforms. They are not going to sponsor a bill to eliminate Medicare. What they have done is passed a bill which includes reforms that are conservative in principle, including cost-containment measures, encouraging greater efficiencies, including more of the private sector into providing coverage for beneficiaries, and putting the program on a path toward privatization.

To simply argue that the price of the drug benefit is too high is, frankly, a lazy argument. The entire bill should be considered, and the provisions that are conservative in principle should be supported.

I've acknowledged the cost concern in the article. But I'm also appealing to people to show some integrity and consider other aspects of the bill which will begin to reign-in the overall costs of the program.

To bang on the price tag and say "this is the only issue that matters" is short-sighted. The price tag is a concern, but consider the other issues which may mitigate that price tag.

Think the same may apply to diabetic care?

To reiterate from the post:

"Enhanced benefits: In addition to prescription drugs, many plans will be able to provide benefits not found in the traditional Medicare design, such as preventive screenings (e.g., for prostate or breast cancer, diabetes, and cardiovascular disease) which will enable diseases to be found earlier enhancing the likelihood of cure and lowering the long-term costs of treatment, and disease management programs."

This is excellent. You will never hear me complaining about George Bush's Medicare Bill. As an employer, I was hit with the excessive cost for insurance coverage for employees over 50. It is really easy to see why older workers are let go -- their health premiums raise the cost of the whole pool. I know that it is illegal to let people go because of their age, but in reality it happens all of the time.

Because of the recession, I made the choice to kick my husband and myself off of our own company insurance and move to Medicare. We each purchased a Medicare supplement, so we are 100% covered. Since even a minor illness with one or two days treatment as an outpatient can cost $12,000 and up these days, this was an absolute necessity.

The only problem is that we cannot purchase drug coverage. Since both of us are on Lipitor and blood pressure meds (as are all of our friends our age) we are finding the cost expensive. The idea of ever needing any additional medicine is truly frightening as our income declines. Blood pressure meds and meds to lower cholesterol are truly helping the aging population. Use of these drugs is preventative and saves the Government money in the long run because they prevent strokes, etc, that would cost a whole lot more money to treat. It is foolish to risk the more expensive treatment by not helping with the less expensive solution.

I appreciate your position.

Do you REALLY believe in your heart that the federal government will ever reduce the amount spent on MEDICARE?

I don't. Now not only will medicare spending continue to increase every year, the entitlement has been augmented.

All of those items you mentioned are terrific, could they have been done without adding a bunch more spending?

I suspect that it's very possible.

My apologies for swiping your screen name but,

That's my 2 cents......

I applaud you for going through the tireless work of putting this all together, backed with your keen awareness of this issue!

For that, I am going to retrieve my pinger/paperweight from my computer desk and ping fellow FReepers toward this thread!

*ping*

The only thing that will drive down the cost of healthcare, including prescription drugs, will if the consumer directly pays for more of the services or products directly.

Having the government pay for the cost of prescription drugs is the surest way to increase the cost of prescription drugs. A third-party paying for products and services is the problen, a problem that gets worse thanks to this socialist plan.

If there was a true interest in reducing the cost of prescription drugs, seniors would be given greater access to buy drugs on the free market from countries like Canada and Mexico.

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