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1、CHAPTer3CharIesP.B1ahous.PhDPursuingMedicareReformintheContextofaFinancingCrisisMedicarefacesa1oomingfinancingcrisis,whichhason1ygrownmoreurgentduetotheeconomicdamagewroughtbytheCOVID-19pandemic.Federa11awmakerswi11havenochoicebuttoactsoontoshoreupMedicare,sso1vency,whetherbys1owingthegrowthofprogra
2、mcosts,raisinge1igibi1ityages,increasingtaxes,oracombinationofa11three.A11decisionsaboutthefuturedesignandscopeofMedicarewi11bemadeinthecontextofthisoverridingfinancia1cha11enge.Evenbeforethepandemichit,Medicarewasheadingintotroub1e.MediCareshospita1insurance(HI)programtheonepartOfMedicarethatcanexp
3、erienceadep1etionOfitsfinancia1resources-enteredca1endaryear2023withatrustfundba1ancesufficienton1ytofund1essthansevenmonths,worthofbenefitpayments.1Thismeantthatitsnear-termfinancia1stabi1itydepended1arge1yonwhetherincomingpayro11taxrevenueswou1dbenear1ysufficientbythemse1vestofundoutgoingbenefitpa
4、yments.TheMedicaretrustees,reportre1easedinJune2023projectedthatthisde1icateba1ancingactwou1dbesustainedon1yunti12028,atwhichpointthehospita1insuranceprogramwou1dbecomeinso1vent.Inso1vency,inthiscontext,meansthattheHItrustfundwi11notbeab1etoprovidea11ofthepromisedhospita1benefitsattheprojected1eve1o
5、fdedicatedfinancingundercurrent1aw.ImpendingMedicareHIinso1vencyisasizab1eenoughprob1embyitse1f,butitactua11yrepresents1essthanha1fofthe1argerMedicarefinancingcha11enge.ThegreaterpartofMedicare,whichcoversphysiciansendees,prescriptiondrugs,anda11otherbenefitsroutedthroughitssupp1ementary1medica1insu
6、rance(SMI)trustfund,facesanevenmoreseverecostgrowthprob1em.MedicareSMIisstatutori1yconstructedsothattechnica11yitcannotbecomeinso1vent;premiumassessmentsonSMIbeneficiaries,andcontributionsoffedera1genera1revenues,areautomatica11yincreasedeachyearintheamountsnecessarrtofundbenefitpayments.However,the
7、absenceofinso1vencywithinSMIdoesn,tmeanthatit1acksfinancingstrains.Itsimp1ymeansthatthepainofitsuncontro11edcostgrowthisfe1tindifferentwaysbydifferentpeop1e(e.g.,PremiUm-Payingbeneficiariesandfedera1taxpayers).TherisingcostsofMedicareSMIcou1dwe11beconsideredthemostdauntingMedicare-re1atedcha11engefa
8、cing1awmakers,greatereventhanMedicareHsimpendinginso1vency.ThetrusteeshadestimatedthatMedicareSMIwou1drequire$377bi11ioningenera1revenuefundingin2023a1one.2Thisdrawongenera1governmentrevenuesexistsaboveandbeyonda11otherMedicarefinancingsources,inc1udingthepayro11taxesco11ectedforMedicareH1,andpremiu
9、mspaidbyandonbeha1fofMedicarebeneficiaries.Goingforward,thesepressuresonthefedera1budgetwi11on1yintensify(asi11ustratedinfig.3.1).MedicareSMIcostsaregrowingsorapid1ythatby2035theyareprojectedtoabsorbashareofUSgrossdomesticproduct(GDP)thatismorethan50percent1argerthantheydotoday.3Thiscostgrowthwi11a1
10、sodrainthepocketbooksofMedicare,sagedbeneficiariesbyreducingtheeffectivepurchasingpoweroftheirmonth1ySocia1Securitychecks.Undercurrent1aw,averageMedicarePartBandPartDpremiumsareprojectedtosoarfrom13percentoftheaverageSocia1Securitybenefittodayto19percentbytheendofthetrustees,75-yearva1uationwindow.4
11、Figure3.1.MedicareCostsandRevenueSourcesasaPercentageofGrossDomesticProduct.ProjectedMedicareob1igationswi11swampthefedera1budget.Source：BoardsofTrusteesoftheFedera1Hospita1InsuranceandFedera1Supp1ementaryMedica1InsuranceTrustFunds,2023Annua1ReportoftheBoardsofTrustees(Washington,DC:CentersforMedica
12、reandMedicaidServices,Apri122,2023),figure1.1,.govfi1csdocumcnt2023-mcdicarc-tnistccs-rcport.pdf(prcpandcmicprojections).Soberingthoughthesenumbersare,theyref1ectare1ative1yoptimistictakeonMedicare,sfuture.Specifica11y,theyassumethatcertainambitiouscost-containmentprovisionsofthe2010Affordab1eCareAc
13、t(ACA)aresuccessfu1andremaininforce.TheACAinstatedgradua1reductionsinMedicareproviderpaymentgrowth,whichsubtractrough1y1percenteachyearfromannua1paymentupdates.5Thecompoundingeffectsoftheseannua1adjustmentswi11widenana1ready1argedifferentia1betweenMedicareandprivateinsurancepaymentrates.Forexamp1e,M
14、edicarepaymentratesforinpatienthospita1carearecurrent1yon1yabout60percentofwhattheyareunderprivateinsurance.TheO；ficeoftheActuaryattheCentersf(rMedicareandMedicaidSerViCeS(CMS),theagencythatadministerstheprogram,projectsthatduetotheACA,Medicarepaymentratesforinpatienthospita1carewi11eventua11ydec1in
15、etorough1y40percentofwhatprivateinsurancepaysonaverage.6NooneknowstheconsequencesofsuchavastdivergencebetweenfutureMedicareandprivatepaymentrates,asituationthatsubjectsprogramparticipantstotremendousuncertainty.Forexamp1e,Medi-care,sactuarieshaveexpressedconcernthatpushingMedicareproviderpaymentrate
16、ssofarbe1owprivateinsurancerateswhichwou1da1sobewe11be1owproviders,reportedcostsofoperationcou1dresu1tin“accessandqua1ity-ORCAreissuesforMedicarebeneficiaries.,7Thisinturncou1ddrivemountingpo1itica1pressuretoeventua11yrepea1theseprovisionsoftheACA.Ifthathappens,Medicarecostswi11beevenhigherthancurrentprojectionsshow,acce1eratingHIinso1vencyandrequiringsti11greatersacrificesfrombeneficiariesandtaxpayers.Fortunate1y,fromtheperspectiveofMedica
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