Transcripts For CSPAN3 Robert 20240704

Largest health care player in the american system. A huge and growing federal entitlement. A little more than ten years, medicare will increase in enrollment, from 65 million to nearly 80 million enrollees. Total Program Spending will double. Today, roughly, one trillion dollars. Within ten years, it will be nearly two trillion dollars. At the same time, medicare is rapidly changing. Today roughly half of all Senior Citizens are enrolled in Medicare Advantage. A system of private coverage, which is the leading alternative to traditional medicare, and Medicare Advantage, a defined contribution system. What that means is what that means is the government makes a contribution on behalf of a beneficiary, plan. Given current trends, Medicare Advantage will soon be the dominant form of medicare coverage. The question before the house, and before the main nation, is a very big one. That is how do we provide high quality medical care to a huge and rapidly growing older population. At a cost that is affordable, not only to seniors, but also to american taxpayers. In our new book, modernizing medicare, from John Hopkins University press, a dozen of our colleagues in the Health Policy community have provided very specific answers to that question. Three of them are with us here today. Brian miller is a practicing physician. And assistant professor of medicine at John Hopkins University, and a fellow at the American Enterprise institute. John goodman is president of the goodman institute. Hes a Prominent Health care economist, and widely known throughout the United States as the father of Health Savings account. Doug holtzeakin is president of American Action forum, and former director of public budget office. Now with the debt limit facing the country, you can expect to see him on your National Television shows, dealing with the debt limit, and all the other problems that are connected with it. Without ladies and gentlemen, i would like i guess to come up and join us. And we will have a discussion about medicare. Brian, im going to start us off with question for you. Right now, as you know, millions of Senior Citizens are voting with their feet. And enrolling in private medicare it vantage points. Which is a defined benefit program of Medicare Advantage. As opposed to traditional medicare, which is a defined benefit program. You deal with this in chapter six of the book that has been published by Hopkins University press. What are the inherent tradeoffs facing seniors when they have to make a decision about whether to enroll in traditional medicare, or Medicare Advantage . First of all, bob thank you for having us. Medicare today really is a different program. Its traditional medicare, and Medicare Advantage. When you are in the employer market, you pick your Health Benefits. You sign up for health plan. And their Self Insured Health plan, or youre purchasing a planned product. When you end up in the medicare marketplace, things are little different. So you turn 65, you get a, less or something, you sign up for traditional medicare, you get your hospital benefit also physician benefits. You also have to pick a Prescription Drug plan. It traditional Medicare Program has now catastrophic out of pocket limits. Youve made three choices. The alternative of course is taking Medicare Advantage. Where you have one choice, you get traditional coverage. You get supplemental coverage, meta gap coverage. Youre also, 90 of plans include a Prescription Drug plan. You also get Supplemental Benefits potential vision in hearing problems. Think about, or if youre 65 years old, and entering medicare, and you have three or five chronic conditions. Youre on a fixed income, you have a limited number of assets, you dont have an incident you can spend all you want to. So making one choice, and getting an integrated, comprehensive Health Benefit practice bridge, package, it sounds like a bunch of inaudible . For the consumer, its a choice of financial protection, they dont have to make as many choices. And the tradeoff of course, you like theres always a catch, theres always a cost. And the cost of the beneficiary is that they have a network. They cant see every doctor. But if youve been in, you know, youre working for 30 years. You have Health Insurance through your employer. You have Health Insurance through the exchange, you have a network. You cant see every single doctor. That tradeoff for todays retirees is not so scary. And then also, theres usually some utilization review and some Access Control that goes with that. Its a tradeoff. Beneficiary says im gonna get more benefit, more financial protection. I can have some limitations on how use that. So its better benefits, more convenient. Pressure benefits, more convenient, and frankly, easier to choose. Because youre making one choice instead of three choices. The other evidence is that when somebody is with so many plans, its basically more affordable. It is more affordable to the beneficiary. Because if you had to purchase traditional medicare, and pay premiums for that, and used to take drug plan premiums, could luck being 70, 80 years old, and trying to get physicians dental or hearing coverage in the private market. You can get it in the private market. You get a three Medicare Advantage plan. John, in 2003 republicans in congress enacted the medicare modernization act, which created here a system of competing private plans as unaltered of to traditional medicare. Two years later, congress, with the support of president obama enacted the Affordable Care act. Called obamacare. Obamacare created a system of private planned competition, and state based health care traditions. On paper, they look similar. They seem similar. You make the argument that fact theyre different, and Medicare Advantage works much better than Health Insurance exchanges. Can you explain why that is true . Theyre very similar on paper. And very different in practice. And thats why 50 of seniors are in Medicare Advantage plan. And over in Obamacare Exchanges the nonsubsidize part of that market it was going away. Because no one was buying until congress came along and added subsidies, even for people making a lot a year. Medicare advantage is the only place in our Health Care System where if a doctor discovers that a patient has a change in medical condition, he can forward that information to the insurer, which in this case as medicare, and get a higher premium for his client. That is why, and Medicare Advantage, you have special need plans and specialize in diabetes, heart care, other illnesses. And want to attract people with these problems. Its the only place the Health Care System where this happens. There is no employer plan in this country that wants an employee with High Health Care costs. Theres no commercial ensure there once was. Nobody in the obamacare market,. And regular traditional medicare, there is 10,000 things that the medicare pays doctors to do. Not one of those 10,000 tasks houses, has its objective or state. But your job is to make the patient healthier. Or cure disease. Over in the Medicare Advantage plan by contrast, people lose, plans lose money. Make people healthier. This is former chairman and ceo of pfizer. Who says that regular medicare plan, 20 of diabetic patients get put all of those turning to amputations. This country spending 8 million a year on amputation over in the Medicare Advantage plan by contrast, even in the moderately successful ones, they have half whole half as many ulcers. And a third as many amputations. They do things that are probably not on the list of the 10,000 things that regular medicare pays for. So what prevents allstars, you make sure your patient has dry feet and dry socks. I dont think those are on the list of 10,000 things traditional medicare pays for. Blindness is another problem with older diabetics. Again, we have much higher rates than it cost hundred thousand dollars a year by the o 30000 a year for the blindness. Congestive heart failure. Again, we have a significant difference in outcomes in Medicare Advantage and traditional medicare. So so these plans act differently than regular their financial incentives are different. How so says the death rate for dual patients with some conditions is 40 higher than it is in medicare what george has to say, and you read the articles that have been appearing in Health Affairs, you think were describing two different worlds. My only problem with he calls it fever service. And Medicare Advantage capital did. Some of our best Medicare Advantage plans pay fever service. The distinction is not how the doctors pay. The distinction is over here we have integrated coordinated care, with the objective of keeping people healthy. And over here is not integrated, not coordinated. And people actually make more money when patients get sicker and require more treatment. Thank you very much. In chapter, chapter 12 of your contribution with the book, you do cost estimates that show a comprehensive defined contribution referred to of premium support system, driven by Consumer Choice, and rather robust competition would result in major savings for both medicare statements and taxpayers. Your focus, your chapter focus was primarily on taxpayer and beneficiary savings. I think the question though would be, what is the need or desire to move into a premium support system. Or a comprehensive defined contribution system. The desire to reduce health care spending, is that the only reason for moving in that direction . Or creating a premium support system in medicare . Absolutely not. I focus on budget costs, and beneficiary pocket costs. laughter very good. The more important inaudible laughter [inaudible] and more important part of the story really is to take lessons that weve learned in other settings, Medicare Advantage being one of them. The power of having competing plans, deciding which Supplemental Benefits, what things in addition to the care will allow them to stay in better health. Include their outcomes. Look at the Medicare Program,. For we harness private negotiation between pharmaceuticals and plain sponsors. Its the singular robust competition. Let individuals take among those plants, pick what matches their needs best, and the outcome they prefer. And in that process, we get extremely high beneficiary satisfaction. 80 to 90 are extremely happy with where they are, if its way cheaper for them, in the taxpayer, then back in 2003,. Weve learned that we can infuse into the Health Care Programs of the federal government, they respect for individuals the values they think are important. In the robust competition at the private sector, in order to serve taxpayers i think respecting the values and enhancing competition are the important things in enough themselves. Way more important than the dollars saved on the federal budget. Although i will stipulate, we need to. I mean, fun fact that you should not use a cocktail parties, cars will have no friends, the Medicare Program by itself is responsible for one third of all federal debt. This is a program that has never been designed to be financially sustainable. It bleeds red ink every year. And we want to get that under control on the half of the president s future generation. This is a way to do that. Thats a very important point. Medicare, aside from the fact that it spend so much money, and as you point out, is contributing to the deficit of international debt. Medicare is. Governed by a very powerful regulatory regime. The medicare bureaucracy referred to it as the center for medicare and medicaid services, cns. Four years of course this bureaucracy sets prices in over 3000 throughout the United States. Frankly doesnt do a really good job with that. But Medicare Advantage in the coming of Medicare Advantage invites basically to deuces a new dynamic into the system. And that has an effect on the medicare bureaucracy, so i was gonna ask you brian, as a medical professional dealing with Senior Citizens and so one, how does Medicare Advantage as a system, this competitive system of private plans change the role of cms in the lives of your patients, and Senior Citizens . Actually i want to respond to something doug said about beneficiaries. She had six doctors a bunch of meds that she, took a pretty smart old lady. Her medical advantage plan helped her get model vacations for the bathroom. They got her a chair live show she could go up and down her stairs. Two stories of her house, a basement, on a fixed income. She was on a decent plan. She was medicare eligible. I remember talking with her and she didnt have her teeth. She had to get her teeth pulled. She had president. Is after how she did that and she said oh, i picked the one plan that would let me do that, and i said okay, what about all your doctors . We have six doctors, all your doctors and your network. I picked a new cardiologist for this, year and next year, after i get my teeth fixed, again, i got switched back to my other m. A. Plant that has my old cardiologist in. It after she got her teeth fixed. So its like, the beneficiaries can be pretty crafty, pretty smart in a good way. Should be a vaulting billion dollar company. And that was fun for me to see as her physician. If we improve the plan finder and give beneficiaries better choices, like, we show them how they can shop for their comprehensive health plan. Really some of our colleagues they have written about. We can empower consumers to make those choices and drive beneficiary satisfaction. To your question about mma and how it changes the world, ems right now is very much focused on payment levels. The annual cycle, all these roles happen. One of the missed 1500 pages recently. All that favors people inside 1500 page and analyze it for the appropriate stakeholders. Then you have the usual cycle of medical specialty societies that show up around the time that are set. People go into the various buildings in the capital. This focuses on payment levels. You have all of these payment levels, whereas everyone from the former secretary we have to transition from volume to values. Because m. A. Is our comprehensive benefits package. That allows the potential for cms to stop focusing on writing 1500 paymentlevel roles. Instead, focus on capitation rates, focus on planned regulation and start to set Population Health goals. Which was what i think both parties actually want for the Medicare Program. Better value for the dollar. Senior, is very good. Can i express concern . Medicare benefit is successful. I dont think ems understands its a fundamentally different delivery service. So if youve got a plan with a quality standard, you are providing contributions. We talk about making both of those. Better wide they need to know what happened in the encounter . You only need that if youre doing fee for service. Theyre trying to micromanage dna plan in a way that people are trying to accomplish, which is to regulate the system and harness the competition to get better outcomes. I worry about the future of and, a much less getting to a more robust form. Right, good point, john goodman, in the private sector, and you are largely responsible for this in many ways. As a result of your work in Congress Many years ago, promoting relentlessly the idea of a self account so people could make money to take tax free contributions, to build up an account where they could use that money for routine medical services and protect themselves against Unforeseen Health consequences. We have millions of americans in employment based Health Insurance that half savings accounts, but we dont have them for Senior Citizens. Why cant Senior Citizens have a Health Savings account . Here is something that a lot of people dont understand. The Health Savings account for non seniors is the best savings account there is. Its better than 401 k . The reason it is better is because during your working years you can save. By the time you reach 65, you can use your Health Savings account to pay part b and part b. You cant do that with an i. R. A. , you cant do that with a 401k. Even if you are healthy, for all your working years, you probably will exhaust your account paying those premiums during your senior years. And ill never pay taxes on that money at all. So we allow seniors to get a Tax Deduction for deposits in their savings. Account and they turn around and pay their premium with it. That is the equivalent of letting them deduct their part b premiums. We are already giving so much to seniors so they are not in the mood to give another Tax Deduction to this group of people. Thats why seniors werent allowed to do. This theres this account, its not very expensive from a budgeting point of view. And it will allow a Tax Deduction for into posit. You have to put tax dollars in the account. It goes tax free, but in this, way we have an account that is not very expensive from a budgeting point of view, and it would allow thirdparty payers to put money in this account for the chronically ill. You might say to a diabetic, if you manage some of your care, will put money in the account for you. If stay way from the emergence. Room that money is for you. And maybe if youre not compliant, and you go to the emergence, room you will have the cost. Seniors need an account opponents of this concept of comprehensive predefined contribution as a way to finance medicare, often referred to as premium support, halved often demonized this as voucher rising medicare. Ive heard this over and over again. Frankly, going all the way back to the 1990s, you, know with the borough thomas proposal and so on. How do you respond to that criticism . Well, one, it doesnt matter if you have a, voucher its what the veteran gets. You could be really, good vouchers are fine. But more the point, i think that at the time of the discussion, you know, 15, 20 years ago. The dominant Medicare Program was the traditional pay for service program. And the contribution auction looked radically different and unfamiliar and it was easy to scare seniors with vouchers, medicare and privatizing. It all of these things have worked everywhere else in the economy. So now, with Medicare Advantage, you have a subsidy from the government and private competition plans and get to pick the money you want. It is the most popular form of medicare. It will be more than half of the enrollees so next year, it doesnt look all that different. So people have already vowed to rise the medicare voluntarily. And happily. We are just trying to improve the quality of what they get for the decision to go into that kind of system. Hing i know, the thing that is remarkable about this, the Democratic National convention, i think it was a couple of conventions, there was a lady who got up and address the country and she said basically that the republicans were going to give Senior Citizens a certificate, a voucher, where they would have to go out and negotiate with a private Health Insurance company. That was the source of demagoguery. It was the idea that, you know, and ive always i remember, i got into a rather spirited debate with somebody in the media. And i asked, them i, said well, let me ask you this, does the federal employees get a voucher . And of course, the answer is no. And you know, this has been going on for a long time. I think the point of it was psychological. It really scares Senior Citizens that they would be left alone somehow. Basically yeah, i mean, this was the oldest thing in politics. Get there first, try to characterize your ideas as their idea is bad, and there is the war over that getting their initial characterization. Attempt to damage the brand deliberately. People still the terms trickle down economics, nobody has any idea what the talk about. Its just the word theyve chosen to signify. The most important part of the story that gets lost in the beginning, if youre sick, or you get more, if you need more care, to get quality outcomes, the system provides you with more resources. And thats far from fauci rising, it is just a certificate everyone gets. Its what we ought to be doing. And if i may, its interesting also that private medicare marketplace is in competition benefits information, which is not an oxymoron. Its a thing that you see on a commercial or in the movie, office space. Its a real thing. If you go back to the 19 80s, in private medicare plans, medicare fee for service didnt have a Prescription Drug benefits. Something like four fifths of private medicare plans did. Thats the 80s. When you had the bricks alphonse. So fast forward 2000, three past the mma, get the Prescription Drug benefit which is an option for a fee for Service Beneficiaries subsidized by the government delivered by the private marketplace, through competition. Thats a 17 year delay. If you remember, the recent debate we had over adding our progressive colleagues to dental vision and hearing, traditional medicare, where did that come . From that came from private Market Competition in the mma marketplace, where those benefits are already available. One of the things that this shows, is for the future of medicare, for beneficiaries, private Market Competition is something that will benefit them. Right. Let me ask you this. What do you think is the source of this intense opposition to this movement . I would like to ask all three of you. The idea of transforming medicare into a competitive market . What is the real guts of this opposition . In other words, what is the motivation at the end . It comes from the idea that self interest is a bad thing in health care. And if youve ever heard Bernie Sanders say there should be no profit motive anywhere in the health care, he really believes. That hes not the only one. And i think that is the biggest problem. They dont like markets, they dont like for profit businesses. I dont like nonprofits that act like for profits. I think thats it. It is also breaking down payments. We have a lot of payments, and you know, everybody in every health care stakeholder ive ever talked to us all for innovation and changes, as of this disruptive and doesnt mess with their payment silo. So thats a big source of opposition. I would say it is something different. It is fear and loss of control. So that annual payment cycle of fee for service, you know when that will come out. Here is a proposed rule, theres, comments there is the whole game with that. Theres hundreds of pages of comments with every possible stakeholder that has a financial stake in that. They are familiar with that. That is a centralized authority that they can go argue with. If we take that away, or create it as one of many options, which is much more likely and more practical, then they lose that power and the world, as they know it, has changed. And its very grim, its a rather dramatic change. The loss of control over the basically, what youre talking about, is a radical reduction in the army of lawyers, lawyers, and consultants. My generation oops, sorry, my generation will probably be able to afford a house in d. C. As millennials who endured to recessions. But i will say, the loss of control is not necessarily a bad thing. Because what it does is it puts control in the hands of beneficiaries. The whole point of the Medicare Program is to give Health Benefits for the beneficiaries. Not for corporations or doctors or bureaucrats at cms, or lobbyists, its for the beneficiaries. So if we start to work on these changes slowly over time, its actually good for the population. Right. Its interesting you mention that because our colleague at eisen hire always used to refer to medicare is the providercentric system. Its not a patientcentric system. Its a providercentric system. All the activity in the house and senate is trying to figure it how to read jigger the payment formula to get the right formula for them, usually at the expense of their colleagues who are performing perhaps a different specialty. I want to follow up with you, brian, on something that has preoccupied that is the whole question of fiscal responsibility. You know, a number of us were watching the debate on the debt limit, and the debate on spending and so on. We were looking at what seems like crazy spending within the congressional madhouse. You know, i know im showing my age, but the idea of annual trillion dollar deficits. It is stunning, really, its incredible. We are developing as doug pointed out, we are looking at a situation where were having we are accumulating a very large and dangerous debt. Your friends, doug, at the cbo talk about the potential of his goal crisis, which i dont think americans really understand the gravity of this. I dont know how far away we are from, it but in the case of Medicare Advantage, just zeroing back to the Medicare Advantage program. Brian, kind of following up with what doug raised, the framework, the way the Medicare Advantage is structured, the way it is programmatically organized. How do you see that contributing to the promotion of long term fiscal sanity . Yeah, so sanity and Health Care Policy would be a nice change. Its something we dont get very often. The Medicare Advantage program, we need benchmark reform. That is something that dog has been intimately involved in, knows about it in great detail. That aside just so people understand. That is a reformed that refers to the basis upon which the federal government makes a contribution to the different plants. Right so that is something that needs to be addressed. I think the policy committee will eventually address. It but Medicare Advantage of ours is like putting your house on a budget. We have the mortgage that we pay, the grocery bill, et cetera. There is an amount that we spend every month, theres an amount that we spend every year. Medicare advantage is structured the same way. It is risk adjusted capitation. It is risk adjusted for health, status, it is paid per member per month. Per beneficiary per month. That is a good framework for budgeting. We can debate about what the appropriate competition rates are. We can debate about what the appropriate risk adjustment methodology. Is we should have those debates and everyone is having those debates right now in Medicare Advantage. It can be quite exhausting emotionally. Article after article about medicaid advantage risk adjustment. That will get sorted. That but the general principles of having a Population Based budget for that Medicare Program is something that could allow us to potentially budget for medicare for maybe doug, you have more information on that . Two things on, that i think thats the single most important thing we can do for medicare from a fiscal perspective. To have a budget. At the moment, everyone has an openended draw on the treasury, and if the providers, the device manufacturers, the pharmaceutical manufacturers, the beneficiaries, all realize that there was a finite amount of money available to do good things, they would behave differently, so getting them on a budget by some mechanism is incredibly desirable from a fiscal point of view. I will point out there is a lot of agreeing on this across the aisle, i dont think they quite realize it. On the left you hear a lot of talk about how we have to create bundles, we need to hit, bundle and the bundle, a set of services, there is a ay quality outcome. That is putting that set of services on a budget and asking for quality outcome, on the right you have Medicare Advantage, it is one big bundle, its quality metric, its this contribution, thats, it theres an agreement about how to do this, this one is more comprehensive. Neither is perfect, theres a great deal of improvement that i think would come from better quality metrics. The most important quality metric is a consumer willing to buy your service. We dont have that anywhere. So that is the advantage of doing. This but theres not that much disagreement. Its just the scale. It is the scale. Yeah. Right, well, thats remarkable. You think theres actually a bipartisan way when i didnt say that. Oh, you didnt. I think those, hope at the level of policy design, there is an agreement about some of the incentive affects and thats what you see going on. At the level of selling reforms and getting legislation through congress, theres a lot of work to do. I would add that seniors are choosing for us. Because Medicare Advantage Market Penetration in the Medicare Program at large has increased by one absolute percentage point every year for the past decade. Recently it surpassed 50 . The Kaiser Family Foundation Just came out with their report, which is 50 now. Which is quite remarkable. Whats even more remarkable is that our friends who write the Medicare Trustees report, every year, theyve always underestimated the growth of Medicare Advantage, which i always thought was interesting. John, i have a question, that i want to ask you about your provocative proposals and your book, modernizing medicare, most people think that when you sign up for insurance you should sign up once a year, and thats it. And basically, the argument is, of, course we want markets to build. We want some stability in the market. If you have an enrollment season, people make the decisions. They and roll, they get their coverage, and thats it until the next season. We do we have been doing that in private Health Insurance for forever. We do it in huge federal employee Health Benefits programs. We do it in Medicare Advantage. You, however, john, want to change that. You want to have a situation where people can make a decision to enroll in a different plan when they think they should enroll indifferent plans. I imagine that some of our friends in the Insurance Companies would be very nervous about this proposal. But why, i would like to hear your argument, i think other people, and anybody listening to this program, especially on youtube and around the country, they might like to hear why you think there ought to be a continuous open enrollment . We well, not quite continuous, by close to it. We have a strange asymmetry here. If you are chronically ill, whether youre in the obamacare exchange, or Medicare Advantage, you are going to look at the networks of different plans, you can choose from many different. Once you are going to choose plans based on what doctors we but basically, after youve made your, choice youre stuck for the next 12. Months the Insurance Company, on the other, hand is not stuck. And after youve made your choice, after the ultimate Enrollment Period ends, they can change their network and this has happened, and there are tragic consequences of this happening where people are denied access to cancel specialists, if they thought they were gonna have access to them. So you are, right the Insurance Industry says, well we had continuous open enrollment. It would be disruptive. The continuous open enrollment, i dont remember a lot of disrupted miss. What i propose is that you are going to be stuck with a plan you choose, unless youre Health Condition changes. If you have a new Health Condition, a heart, condition for, example you should be able to go immediately to the special needs heart place. And several separately, to the diabetic, plan so. On change in Health Condition. Change in the network that you had access to. Especially if there was a doctor treating, you and help doctors no longer in the network. That ought to be a condition for switching plans. And so, lets call it partial continuous row meant. I think that would benefit everybody. Right, let me ask you, this how do you respond to folks in the Insurance Industry and elsewhere who might say, well john, that sounds great but you are really promoting adverse selection in the system. We will have more instability in the market as a result of that in that will jeopardize the viability of a lot of plans if we actually had that kind of a system. How do you respond . That i think the asymmetries unfair. The Insurance Company can change its network to at the drop of a hat, but the patient cant make switches. I think with senator wyden, announcing his staff found that for several Medicare Advantage, plans their networks were gross networks. Doctors that they claim were in the network werent really there. To me, thats ground for allowing to unreleased to switch to another plan. So we need to make it possible for people to switch plans, especially when their health is at stake. Not because they just happen to change their minds on when, but for some Serious Health care reason. There ought to be a way to do this. Remember, the whole idea behind Medicare Advantage is you have risk adjusted premiums, and when your Health Condition changes, you your plan is entitled to a different premium, probably a higher premium. And that is why this works, and it works so well. Thats why we have the special needs plans. All right, let me follow up on this a little bit. There is a special Enrollment Period, for example, so for Medicare Advantage you have sixweek period, then you have a few more months when you can make a change. But beyond, that you really cant change plans until the next Enrollment Period. But my point was it sounds like what youre proposing is just for things that happened to you, we have special Enrollment Periods generously to allow people to switch. Yes, but it needs to be it needs to be close to continuous a role meant. [inaudible] it would be, its when the events happen. Then you get four weeks to go sign up for a new plan. Yes. Health condition change, Provider Network change, they lie to you about the network. All those. Things what the insurers are afraid of is discretionary medical care that you are hopping around to have that paid for, and then leave. And that is. All [laughter] im trying to agree with you. Its not like me. All right. Remember, were talking about somebody who used to Tell Congress what to do. Oh no. And they exchange, [laughter] terrible example in virginia, a couple had a daughter with rare cancer and this one clinic, the only clinic in Northern Virginia the dealt with this cancer. And they chose the plan, and after they open enrollment closed, that plan kicked the clinic out of the network, and by the, way in the if you go out of the network, the plan is nothing, almost everywhere. This family was really miss treated. Yeah,. And thats where i think its wrong. Let me ask you this, though, were talking about continuous enrollment. And it brings up another question. Its not another area, which is somewhat controversial with regards to Medicare Advantage. And that is the way in which we have a risk adjustment operation. A risk adjustment system of Medicare Advantage. Some of the arguments that are being made, especially by some of our friends in Health Affairs. Is that the risk adjustment is so flawed that it basically is such a fundamental flaw in the system it is basically an argument against the system. Risk adjustment is a complicated area, but it is an important area for Medicare Advantage and Medicare Advantage Going Forward. Dogs, you have thoughts about how to improve the risk adjustment system . Well, i think the most important thing would be to stop developing the risk measures on the surface population, and apply them to Medicare Advantage. The risk adjustment in mma on the ema population, and risk adjustment is different than forecasting the particular procedures of patients coming. In people start going down that road, and then they are in and mindset. Theres a characteristic of an individual we preexisting conditions, whatever, take those characteristics. And then you do that and you Pay Attention to whats going on inside the care bubble. You, ask what is the outcome in terms of cost of care for a particular level of quality. Before and, after and then you do that. Matt its just method does that. And then stop tinkering with all of those things in between. They are over tinkering because they have a service mentality. What is happening in the Health Affairs article, it are preparing the Medicare Advantage plan. The problem is that the Medicare Advantage doctors know that they will get more money if they have more medical problems. There is pressure to be very careful about documenting the condition. There is no extra payment for doctors being careful to get everything done on paper about the patient. The recent article is that the implication was that these people are finding a lot of problems and making things up. I think it is the other way around. I think that they are its in their informational interest. I dont think they are making up those problems. The best plans keep you healthy. The prediabetics prediabetic. You dont wait until the foot needs to be amputated. These plans are not all equally good. If i have one overall improvement that needs to be made in Medicare Advantage, it needs to be more competitive. There are plans needs to b there that often lose. They often go out of business because they are not doing what they should do. The best plans, if you have diabetes, make insulin free. The visit to the endocrinologists free. Its free because they pay. They keep the patient out of the hospital and you make money. The more competitive we make this market, the better it is going to be. I was practicing i can definitely say i agree with you, john. In traditional medicare, you dont have the incentive to code all of those diagnoses. I know you dont have that. I have my iphone in my pocket. There is an app on it which tells me if my diagnosis coating in the hospital isnt the hospital is harassing me. I added diagnoses codes. I can tell you it is a huge business, right . Doctors ignore that. They ignore the mentorship or minding or oversight and ignore the phone. I would say fee for service is probably underfunded. What we see in the Health Affairs articles is we see confusion between up coating and coating intensely. Coating for something that is not usually there, coating intensity is what we are all talking about. We find agnostic that are there but have not been accounted for or are specifying more complications or adding clinical specificity. Adding clinical specificity is good for clinical communications. That is dependent on the market regulator and the program divide. If plans are finding more diseases or coating more diseases, its more accurate than the complications thereof. Its dependent on policymakers to give plans incentives to do something with that information. Im not really angry at health plans necessarily finding more diagnoses or finding more specificity. We can and should have a debate about what degree of that is accurate and what degree is not. If they are finding more specificity, we should give them an incentive to use the information to help the beneficiary. Rather than eliminate the incentive to code appropriately. It seems that when we are Going Forward we have a lot of work to do in terms of the crafting of some reforms for Medicare Advantage. I am right about that, is that correct . This is going to be some serious heavy lifting. Is that right . I think so. Let me ask you this, do you think that there is, could there be a bipartisan interest in reforming Medicare Advantage . What do you think . Is there a possibility to thats an interesting question. You have to understand the democratic mind. They dont like Medicare Advantage because it is a for profit firm. They really like medicaid. Im not sure they realize the most medicaid patients are being taken care of by for profit managed care appropriately. But if we could get over that, yes, of course the two parties could come together. A lot of this is common sense. I think there is less just look at the map. A lot of the constituents are in they are in the concentrated urban areas. People are easier to serve in that way. Absolutely. Look at the minorities, absolutely. I think inaudible you are right about the medicaid market, 72 of medicaid managed care. The irony of not liking medicare being 50. 2 Medicare Advantage sort of makes when we talk about premiums and whatever we want to call it, the f a h b, weve talked about it many times. That is the premium program, 150 of the weighted average. Thats correct. The apa exchanges are also a premium subsidy. Whats wrong with thinking about how we can be more fiscally responsible for medicare and create a better platform so that future generations or my generation have access to medicare benefits . Speaking of generations, i want to go back to doug for a moment. This is an important question. It is a simple question. I think we have already answered it in a way but i would like dog to perhaps expand on this a little bit. The whole point of moving to a comprehensive and divine contribution system of premium support is to harness the power of Consumer Choice to basically enable people to make the choices that are best for them and at the same time drive efficiency in the Health Care System. Here is the issue. You hear it over and over again. We are talking about a population that is older, 65 or 75, 80, and so on. Is it really a sensible strategy for Older Americans to make these kinds of choices effectively . I raise this because if you really go all the way back to the New York Times back in the 1990s, the basic argument against moving in this direction was that the complexity of health care was so overwhelming that ordinary people could not actually make these decisions and that experts could only make these decisions. You have talked about this. Tell us what you think about that problem. We are not asking for a senior to get on a Desert Island and decide for themselves everything in their lives. We are asking them to make important choices with trusted advisers and panel members. They can talk to buyers and doctors. The idea that somehow in health care and health care alone you are by yourself making these really complicated decisions is just a red herring. Thats not the reality. We make complicated decisions a lot. We dont understand the technical aspects of them. How do they work . I dont know. You have Advisor Networks and technical experts on the things that are actually consumed in financial markets. We do that with product markets. You do this everywhere in the economy. Those same seniors are out making those same decisions. I am still not sure why my nine year old mother needs cooper but she has won. They are participating in inaudible the philosophy of respecting the ability to make choices and getting the help they need to make them. They have done it. They did not partake. Everyone says they will never be able to do this. Its too hard for seniors. It has worked very well. Perfectly, no, but very, very well. That is something we have to take seriously. John, you have seniors turn to you for health care plans. We have really muzzled these guys during a lot of years. The physician couldnt tell the patient if the patient was in unaccountable Care Organization which has some of the same financial advantages of the Medicare Advantage plans. Even under trump, there has been some deregulation. A doctor cant encourage his patient to join the Medicare Advantage plans that he is a member of. We need to on muzzle the doctors who have the most information about how they work. What will be good for patients they are treating . You have booking. Com for booking airfare, hotels. You cant even use airbnb. You could reserve a house. We make complex decisions all the time. We help others by providing appropriate information and creating in a constructive fashion. We can and should do that for medicare. We can improve the plan. The thoughts that i have on premiums, as part of premium supporters inaudible putting them on an equal playing field. They are upset about risk adjustment. Why dont we think about how we apply risk adjustment to all Market Participants including traditional medicare, yes. Right, why dont we apply star ratings are traditional medicare . None of this should be a handout or a subsidy across the plan. We need to treat the Market Participants and that viable public option and preserve that for the future. That is a conversation i dont think the policy community has had. Thats vitally important point b because we are all participating in complex sectors of the economy like retirement and Financial Planning and so on. Most of us have a expertise in those areas. We rely upon advocates. We rely upon families andexperte areas. Friends and so on in order to make these decisions. I am told by the economist, you guys, that there are market leaders in many cases where in other words you get ten to 12 of the entire demand side of the equation to actually determine the direction in which things go. It seems that in this case Medicare Advantage seems to be doing pretty well with regard to the rather massive increase in enrollment over the last several years. Ladies and gentlemen, i think we are coming to the end of our program. I would say this. Over the next ten years, we are going to spend a lot more on medicare than we do today simply because the sheer size of the senior population. With rapid medical technology, the cost of delivering medical care on a per capita basis is also going to increase. The issue is really not so much how much we spend, but the ultimate issue is, are we getting the best value for our medicare dollars . Are we getting Higher Quality care at an affordable cost . Higher quality care is, i would argue that Higher Quality of care is not a product of better quality Central Planning but our colleagues have made the point that competition in fact works. It is demonstrable. If you are interested in the details about choice competition, it can work and it can improve the medical program. Check out our new book, modernizing medicare, harnessing the power of personal choice and Market Competition from johns Hopkins University press. All good things come to an end. This is our program at its end. Please give our panelists a hand and thank you all very much for joining us. Thank you all for coming to the heritage foundation. Thank you. Let me take the liberty on behalf of the panel and everyone involved to think our panelists for their involvement. Congress returns from summer recess in september with a busy legislative floor schedule ahead. The house and senate are expected to take up federal spending bills funding to government through next year to prevent a government shutdown. Current government funding expires on september 30th. Lawmakers are also facing end of the month of deadlines to reauthorize faa and pandemic preparedness programs. The senate will continue working with president bidens judicial and executive nominations including for the federal reserve. Watch live coverage of the house on cspan, descended on cspan two, and a reminder