The Huge Advantage and Real Value of Medicare for All (The 20 Percent Solution)
May 1, 2020
We need a mechanism to get money to care sites that have been damaged by the things they have needed to do to respond to COVID-19.
We also need to figure out how we will provide health care coverage and care to our people going forward as a nation.
COVID-19 has done significant financial damage to sites of care in this country, and we need a way of saving our health care infrastructure now, protecting jobs over time in the care industry, and doing it in a way that will actually give us better care when we have our solution in place.
A very large percentage of American hospitals will fall into financial failure over the next several months and a number of our medical groups will fail very quickly as well if we don’t do the right things now to create financial stability and an ongoing cash flow for that industry.
Many physician groups are going down very negative paths to significant financial damage. Some medical groups and practices will be irreparably damaged by the COVID-related expenses and by the disruptions of care that they have needed to do to survive the disaster as caregivers.
We need a cash flow for care now and we need an approach to buying coverage and care now that will improve the quality and effectiveness of our care delivery as part of the process of saving it financially.
We need an approach to buying care that can give security to all Americans about both the availability of care and the cost of care both immediately and into the future — and that will help alleviate some of the COVID damage and keep the key parts of our health care delivery system intact and functioning.
We have tools available to us to do that work that we know can achieve those goals because they work now.
We can achieve both of those goals by creating a 20 percent payroll tax on all employment that is about what we pay now in most work sites for care costs and by using that payroll tax money to buy health care coverage for every American who is not on Medicaid through the Medicare Advantage program that we already use very successfully for large numbers of Medicare beneficiaries.
We would achieve universal coverage and we can fund it entirely with full financial security with a very affordable 20 percent payroll tax that is very close to the amounts spent in most work sites now to buy insured care.
Individual Americans will pay no more than 10 percent of their income to buy much better coverage than most people have now and to guarantee issuance of that coverage on the date that we choose to make it effective.
Some people believe we should try to achieve that same goal of covering everyone and creating a new cash flow for care that involves extending our standard Medicare program to all Americans.
That would actually be harder to do at multiple levels.
That extension of standard Medicare to everyone would take an entirely new infrastructure that we do not have now at this moment to make Medicare available to everyone. Our government actually does not directly administer standard Medicare today. They hire Medicare intermediaries to do that work now. We could expand that intermediary part of the program, but it would be hard to do it quickly enough to meet the needs of the failing hospitals and medical practices.
That approach would have us continue the highly dysfunctional approach of buying every item of care by the piece–and the payment levels currently embedded in our Medicare program would be much lower for each piece of care than the levels most providers are being paid now.
Medicare Advantage has negotiated payment rates with care providers now and extensive care networks that could be extended very quickly as needed to fill gaps needed for our newly insured Americans to receive their care.
Medicare Advantage could be extended by fiat and it could be done immediately because all of the pieces are in place now. It is a better program than standard Medicare at multiple levels because it has had to meet consumer needs and expectations to survive and grow.
Medicare Advantage has much better benefits, better care coordination, better quality controls, higher levels of performance accountability, and it gives us a much better and more immediate cash flow model for implementing and delivering continuously improving models of care than traditional Medicare.
The Medicare Advantage program exists now. We can expand it very quickly with relatively few things that need to be changed to make that happen. And we know that it tends to perform at a high and improving level for the people who have that coverage today.
We don’t need to invent anything new to achieve those goals. Medicare Advantage is already one of the two ways people can get Medicare coverage today.
The key point to understand is that Medicare Advantage has a very different cash flow from standard Medicare. Medicare Advantage uses Medicare money to buy care by the month — and not by the piece — for each person who is enrolled in the program.
The government pays each Medicare Advantage plan a fixed amount of money each month for each person who joins each plan.
Medicare knows with absolute certainty how much each Medicare Advantage enrollee will cost each year because Medicare pays the plans by the month for each beneficiary, and they set that monthly payment each year.
We could expand that program and we could extend it to our non-seniors and then use it to buy care in a package price by the month for all insured Americans who are not on Medicaid. We could fund those payments for Medicare Advantage Coverage from a new dedicated payroll tax instead of the current Medicare funding approach. We could have all employed people in America automatically eligible for enrollment in Medicare Advantage plans, and we could have those plans each paid by the month for each enrollee.
That approach would combine with our Medicaid program for our lower-income people to give us fully funded universal coverage for our entire country on January one — if we choose to go down that path and use that funding source and that set of programs on that date to do that work for us.
A payroll tax on all workers can generate enough money to make that all happen. We know the numbers.
We now spend $1.3 trillion a year as a nation to buy insured care. We spend $3.7 trillion on total care as a country — and the amount of money we get now from all of our private insurance payments to pay for care for insured people is $1.3 trillion. We could replace that money with the new Medicare Advantage cash flow by doing a payroll tax and then by paying the plans that same amount of money for insured care that we spend now for that care.
We know how much that payroll tax would need to be to pay for the Medicare Advantage coverage for everyone because we use a payroll tax now for Social Security. We now gather almost exactly $1 trillion a year as a nation to pay for Social Security benefits for everyone from an identical payroll tax charged to each employed person in the country.
The Social Security tax today is set at 12.2 percent of each paycheck. We could use the same universal eligibility standards for all employed people that we use for Social Security and we could collect enough money to insure everyone in this country who is not on Medicaid with a 20 percent payroll tax on every paycheck.
That 20 percent payroll tax would be less than most work sites who buy care are spending now on their current health coverage. That isn’t a painful amount of money. It would only add a 10 percent or less charge to each employees’ expenses — and that 10 percent is less than very large numbers of people spend now for health care and for much less desirable health insurance programs.
It would be functionally easy to collect that needed pool of money, because we have all of the collection tools in place now, and we would just need to adjust the number for the collection calculation.
That money is enough to pay for all insured care this year in our country. It is paid currently to a wide range of self-insured plans, insurance companies and trust funds, but we can change that channel and pay it instead for each employed American to the Medicare Advantage plans who will be offered through every site of employment and then selected by each person getting insurance.
Medicare Advantage plans often have employer relationships now because they offer retirement plans for employers in some settings and because they also have multiple lines of coverage and often offer the standard insurance programs to the employers as plan administrators in some sites and as full insurers in others.
If we expand the Medicare Advantage system to cover everyone, we would need the plans to be paid their piece of that total cash flow just like they currently accept their allocated piece of the total Medicare cash flow — with the amount paid for each enrolled person each month varying by gender, age, and geographic location for each beneficiary.
That distribution formula for that new pool of money would be easy to generate — because a very functional version of that distribution and payment approach is already used and accepted today by the Medicare Advantage Plans to cover their Senior members. Because that money would be spread out on an actuarially appropriate and fair basis across all insured people, we could create universal coverage for all Americans immediately and we would do it in a way that pays for continuously improving care because care improvement and quality improvement are already is part of the Medicare Advantage purchasing model.
We should move quickly to put this program in place. We need a source of money immediately to help COVID damaged care sites have a financial future. A payroll tax that generates the money needed to do that work can be done quickly and it would impose less of a burden on many employers than other significant and costly responses to the COVID crisis have already imposed.
A key factor relevant to the COVID crisis and this Medicare Advantage approach is that the money can be used immediately to get needed money to caregivers in this country that have been badly damaged by the COVID-19 crisis by guaranteeing coverage to every American and by making sure that all patients for all of the care sites have both coverage and care from January one on.
That organized purchasing approach can also make sure that we get value in return for the money we spend to achieve that goal, because there are extensive performance and quality requirements now for Medicare Advantage plans and we can do an even better job of defining those performance levels as we expand that program to insure everyone who is not on Medicaid.
We need Medicaid to continue and to meet the care needs of our lowest income people. Medicaid should be required to create data links with the Medicare Advantage plans and care sites to guarantee the full communication of care data for each patient and to help with team care and patient focused care in all settings.
This is the right time to make a significant change in how we buy care that gives us needed money to help those sites and to improve care.
It we do not put a functional national cash flow in place very quickly to buy care, many care sites will be irreparably damaged and the recovery for caregivers in many settings will be slow and grim if it happens at all.
We need a cash flow very quickly to care sites that can help us recover from the COVID crisis financial disaster for care. We need to be very honest with ourselves about how big that problem is. Many health care providers are in major financial difficulty now and will collapse without help. Many of the care organizations that are strong enough to survive have uncertain financial futures, and many of those many care organizations do not know how they will be paid and how they will stay financially alive into next year as the COVID issues continue. They would be very well served as planners and as business operational people if they knew that we will have a dependable cash flow for purchasing care into next year and years beyond that.
We need to give Medicare Advantage the job of both insuring everyone and also making sure that the care sites are paid for their patients and for their care for this crisis in both cash flow and coverage.
The opportunity we face gives us an extremely important potential benefit for the country if we do this right.
We can create a dependable cash flow into our national care delivery with that 20 percent payroll tax, and we can improve care in the process by using our Medicare Advantage program to cover everyone in the country and by having very clear requirements at multiple levels for how that money will be spend.
That 20 percent tax is about what employed people expect to pay now for their coverage. For care sites that pay more than 20 percent now, we can lock in their current pay levels and hold it in place until the 20 percent tax equals their payment level. That freezes all cost increases in health care for those employers and employees for some period of time — and that should be beneficial and attractive to those sites.
The employee per paycheck costs will be less than the 10 percent number in a significant number of sites immediately. Based on that approach.
Other sites who don’t pay that amount for care and coverage now will pay more — but the 20 percent tax on each paycheck is a small price to pay to help our health care infrastructure survive the COVID disaster and it is a very affordable number because many employers pay more now.
The impact on employers who do not pay any amount now will be only 10 percent of their paycheck. Many COVID expenses exceed that level now — and those employers will be able to offer very good health care benefits to their employees for that 10 percent. It is much lower for the employers with very low-income employees than any of the old traditional insurance premiums would have been as a percentage of the paycheck for employers, and the benefits will be much higher.
Using Medicare Advantage as our functional national care coverage response to the COVID crisis can give us universal coverage as a country immediately with a very good level of benefits, and can do it in a way that creates a highly functional, immediate and adequate flow of cash to our basic sites of care.
We need the money.
The cash flow that can be created for all of health care in America by having Medicare Advantage cover everyone who is not now on Medicaid or standard Medicare now can both shore up the deeply damaged health care infrastructure across our country and do it in a way that makes much better use of our health care dollars than the current highly dysfunctional perversely funded extremely complex non-system that we use now to buy both coverage and care for our country.
The COVID crisis has caused us to do a number of dramatic and expensive things to save lives and deliver care during the scope of the crisis. The COVID damage is getting worse for health care sites — and some experts predict the most hospitals will end up insolvent as a result of the expenses they are incurring and as a result of the loss of cash flow from patients they are currently turning away.
We should and probably will make grants of various kinds to those hospitals now to help them survive. We are now spending trillions of dollars in bail out moneys to get various people and organizations through the crisis. Health care will need some of those grants.
We will need to include recovery grants to multi-Grants can’t go on forever, but we do need the right grants now to get us into the future of having those care sites survive.
We can’t solve those issues with loans.
Loans are much less useful for solving those issues for health care sites. Creating loan programs of various kinds for care sites is better than no program but it is highly problematic, because loans usually need to be repaid. That approach might get us through the crisis but it would extend the financial pain and crisis into the future rather than making it disappear.
We need to do better than grants and loans. We need to create a dependable and permanent cash flow for care that will get us through this crisis and then help us move into the future and both stabilize and improve care.
If we decide, instead of just using Federal dollars to do various kinds of grants to care sites, to collect money through a payroll tax on all employees and then have everyone in the country with coverage on January one, and if we require the Medicare Advantage plans to both provide crisis coverage to those patients and have adequate care systems in place where ever they provide care, the hospitals and care sites will be able to count on a future of being paid for the patients they will serve.
That assurance of being paid in the future creates a very different financial and operational planning context and reality for those sites of care. That particular payment approach isn’t perfect, but it is far better than not being paid for those patients next year and it is far better than having to rely entirely on a piecework and completely undependable payment model for future care.
This approach will significantly reduce the drama of responding to our COVID crisis response and will give us a stable and functioning system of coverage and care that can cover everyone immediately on January one if we decide to use it.
The most useful piece of information relative to this proposal is that we can build that entire approach and that dedicated cash flow for care with functional tools for both revenue collection and coverage that we are using now, and we can do it very quickly.
We can achieve basic care site stability and coverage goals immediately — because the basic Medicare Advantage program is already in place and performs well and can be modified easily to do that work.
As a payment model, using a payroll tax instead of charging insurance premium, and having everyone enrolled with full coverage on January One has the ability to channel money immediately to the care system in a dependable and highly functional way — and it also has the ability to create clear and explicit expectations with the caregivers and the health plans for how the money is being used.
The need for a new cash flow for health care in this country is clear.
Care sites all over the country have been badly damaged by the COVID crisis. They have been doing layoffs, reducing access for many patients, and trying to set up new revenue flows of various kinds that they can’t count on to either help them recover or to reopen to serve the patients we want them all to serve.
The care sites do not know now if the pre-COVID mixture of insurance companies, self-insured employers, and direct payments from employed people will somehow re-emerge to pay them for care in the future. Health care organization planners and leaders are in an quandary today. The overall cash flow future for care is unknown now and highly problematic at best.
The crisis has shown us clearly that our old approach to buying care was both flawed and vulnerable. We should decide to take advantage of this opportunity to make some changes now in the ways we buy care as a county, because our old approach is broken, very unpopular with many Americans, and there is a growing sense that we obviously should do better for both coverage and care in the future.
It is very clear that key components of that old process and approach have been significantly damaged by our chosen functional and financial responses to the COVID-19 crisis. Care sites will be filing for bankruptcy and going through significant structural and financial pain if we don’t put in place an alternative model for buying care very quickly and use it for everyone relevant to the process soon.
We are still deeply immersed in the COVID crisis. We have not solved key pieces of that problem today. We are still figuring out important things about COVID care — and we will clearly have to find a way to go to get to the point where the crisis is over and where we can unravel everything that needs to be unraveled without COVID impairing our activities.
That does not mean that we should wait until all aspect of the crisis are over before putting in place the things we need to do to steer us to where we want health care to go.
We would not be well served as a country if we just waited until that unraveling happens across the country and then tried to figure out after the fact how to save as much of the badly damaged system as we can. Waiting until the entire mess has happened and has done major damage and then trying to fix it in situational ways with unlinked tools is the wrong approach to use to figure out the solution and response to that horrible mess that we will clearly be in.
We should plan that next stage for post COVID care now and we should decide on the future approach now because it is absolutely clear that when we get to the end of the COVID crisis, care organizations across the country will be badly damaged and might not be salvageable. Many sites will find themselves in dire financial straits and the health care financing and delivery infrastructure in every setting will need both repair and significant support and the long-term impact of that damage will be even worse if we don’t have an approach ready to go and prepared to do that work immediately.
We should all be very honest with ourselves about one major point.
Saving the old approach is impossible.
Saving it and rebuilding it as it existed would not be a good idea, because it was obviously not an optimal approach for either buying or delivering care.
We can see pretty clearly at this point in time that the old system cannot function to get us to the future we need for American health care, because too many parts and pieces are broken — and because the old system had a number of deep flaws that were largely invisible before the crisis but are painfully visible now.
Health care could and should be on the cusp of a golden age for care delivery. That is an extremely important point for us to understand.
Medical science is at a peak in both understanding and in the ability to improve care — and care support tools are also being enhanced every day at multiple levels. Technology could give us a wonderful next generation of care if we choose to have that be the future we want to have for care.
We need to build on a wonderful care improvement opportunity and we should choose to make continuously improving and excellent care available to all Americans as our new model of care.
We need to use a financing approach for care now that will let us take full advantage of that new set of care linkage and care improvement tools and not find ourselves receiving less than adequate care from a world of damaged, disorganized and impaired care systems and care sites that are generally delivering less than optimal care and fighting hard to survive financially and structurally rather than fighting to improve care.
Medicare Advantage can do that work because it is a way of purchasing care that allows us to specify that care delivery actually use those tools and use them to create team care, patient centered care, and continuously improving approaches to care — in a context that provides universal coverage for care.
We actually have the opportunity to do some very good things for both coverage and care that we should take advantage of.
The Medicare Advantage program already has care improvement incentives in place and has performed in its best sites in very impressive ways.
We could go to universal coverage very quickly and well by creating a payroll tax that we collect from every paycheck — at about the level that we spend now per paycheck to buy insured care — and then simply make that money available in a purchasing pool that allows all people who are not on Medicaid to choose coverage from a Medicare Advantage plan for their care.
Using a payroll deduction from each paycheck and then having employees choosing between competing health plans for their coverage and care is actually how most European countries buy both coverage and care today. As we look at our own potential options and ways of creating coverage for everyone, we should look at what some other relevant countries have done and are now doing to achieve that goal for themselves and we should understand their approach and learn from their successes in the process.
Most Americans today have completely wrong beliefs about what most European countries have done to achieve those goals for themselves. Our thinking about ways of achieving universal coverage as a nation has been skewed in unfortunate ways by the extreme inaccuracy of our knowledge on that point about those countries. Most people who talk about universal coverage in our country seem to believe that everyone in Europe uses the Canadian single payer system to buy care.
That is very wrong.
No one in Europe uses the Canadian single payer system to buy care.
People in Switzerland, Germany, The Netherlands and Belgium all pay part of their paycheck to buy care and then they choose from their own local competing private Medicare Advantage like health plans for the actual delivery of care.
Medicare Advantage plans are the actual model that most of Europe uses today for both coverage and care.
There is not one single person in Switzerland who has a government single payer health coverage or government insured care. Every Swiss resident chooses a health plan from a roster of independent and competing health plans and then each Swiss resident gets care directly from that health plan.
Those plans in each of those countries compete fiercely for the customer — and that competition between the plans keeps the entire process and program focused on the patient and on the customer and not on any government agency, bureaucracy or infrastructure of any kind.
The Swiss health plans run television ads trying to recruit customers.
The model works. The people in those countries get very good care from those plans.
The Swiss and Dutch and Germans all have much faster access to same day care and primary care than Americans — with multiple studies showing that to be true. They also have higher use of hospital days than we do by a significant margin as well as having excellent specialty care services at multiple levels that they celebrate in those settings.
People from those European settings are both amused and sometimes a little bit insulted that Americans believe they achieve their universal coverage by rationing care or by denying their people access to care. That absolutely is not how they achieve better costs of care or higher levels of care performance in those countries.
They do have much higher percentages of doctors in the primary care specialties than we do and they tend to pay for the education of the doctors who go into primary care to make that happen.
The key point for us to understand about those countries is that they actually each use an entirely equivalent Medicare Advantage for All competing health plan approach to buy and deliver care in each country today and that competing health plan approach works well in each of those settings.
So using Medicare Advantage plans to cover all insured Americans would not — as some political speeches have indicated — be completely different than Europe. It’s actually a long-standing approach for those countries, and it works well there.
This proposal does not propose we follow any path now in our country to be a clone or an echo of Switzerland. This proposal does believe that we should also use a dedicated payroll tax approach to fund care and then use our health plans to get that money out to our caregivers quickly because we have so much of our care system being deeply damaged by the COVID crisis and we need to figure out a cash flow mechanism that can get an absolutely dependable and adequate flow of cash to our sites of care and do it very quickly.
The payroll tax anchors the program. It creates a dependable cash flow that we can use to buy the right care.
The Swiss, Dutch, and Germans each also very intentionally use a separate payroll tax on each employee and employer as well because they also want the care dollars in their governmental budgets to be separate from the general revenue cash flow and expenditures for their countries — and the people in those countries want the money collected from each paycheck to buy care to only be spent on care.
We can learn from that model and do the same thing here. A 20 percent payroll tax for health care, split 10 percent each of employers and employees, will raise the money we need to do that cash flow, and having universal coverage that includes everyone so that no American does not have coverage on January one will mean that the care sites will not have any uninsured people who are needing care but who have no payment approach linked to them on that date.
This re-channels money we are spending now for insured care.
That 20 percent tax raises enough money to pay the same average amount that we spend now on health care for insured care, plus dropping the average deductible for care from $1,700 for $1,000 for each person and also extend coverage to another 25 million people who are uninsured today.
That approach will work to create and fund both universal coverage and better care here. It meets our most immediate need today to provide cash flow immediately into the care delivery infrastructure as soon as we can do that after we get past the time when the government will be writing huge COVID-related recovery checks to care sites to keep them alive.
This is a good time for us to make care both better and more affordable, and to create a dependable cash flow for our care infrastructure that we can control and they can use to improve care and that we can also use to prop up the COVID damaged care sites by giving them a dependable and sufficient future flow of cash into next year.
We should have very high expectations for ourselves as we spend this re-channeled steam of money on care.
As we are recovering from the massive financial disruption that is being done to the health care delivery system by COVID-19, we now have the opportunity to move very intentionally and competently to a financial model for care that will give all Americans guaranteed access to affordable and continuously improving patient focused care, and that will create a cash flow that will allow our care sites to survive financially in the face of those massive losses and to continuously improve and enhance the care they deliver into the foreseeable future.
Health care is and has been a wonderful industry. We should want it to thrive in our country. We definitely benefit in positive ways from having health care jobs in any setting.
Health care jobs are good jobs. Health care creates some of the very best jobs in America and distributes them extremely well. Local hospitals, local nursing homes, and other local care sites anchor the economies of some smaller cities and towns and larger and better resourced care organizations build extremely strong employment resources in many of our largest cities. We want health care jobs to continue to exist across the country and so it makes sense to create an absolutely dependable cash flow for care that will allow that to happen in the face of the COVID disaster. That approach will allow the flow of cash to continue in highly functional and dependable ways for use to buy care for years to come.
We want our care system to both survive and thrive — and we want care to improve rather than deteriorating as our care infrastructure fights to rebuild and to get its long-term approaches directed down the right paths for best care and structural survival.
Medicare Advantage can do that work to be a conduit for continuously improving care, if we design it well, and Medicare Advantage can do that work for us immediately because it is basically in place now for a large and growing number of our Medicare enrollees and we can just extend it by fiat and decree to do this work for all other Americans.
It has proven its ability to do a good job for people who have chosen it for care.
The COVID crisis has given us the opportunity to improve the way we buy care, and we should take the opportunity to do the same kinds of bold thinking that we have done to deal with the care challenges set of by that crisis.
We really do not have a choice at one level relative to now actually changing the way we buy care.
We actually have to change the way we buy care, because the old model cannot be resurrected at this point in in time and because we need a cash flow for care now that we can get out quickly and well to help damaged care sites everywhere.
We need to be very honest with ourselves about the fact that many areas of our health-related economy will be damaged by what we have done and what we will continue to do to respond to the COVID crisis. It would be a very good thing to minimize the negative impact and the destructive disruption on sites of care by solving for that problem now.
We should use a new and expanded Medicare Advantage cash flow to give care sites a financial future they can count on for their planning and future operations.
When care sites know that everyone who comes to them for care will have insurance coverage through Medicare Advantage plans or through Medicaid coverage on January one, that allows the people running all of those care sites to make informed decisions about their own future with a sense of security that the cash flow for care will be there into the future to be included in their thinking and plans.
As a nation, we can control costs and we can also improve care — by using the Medicare Advantage purchasing model to both buy and deliver care in ways that give the care sites strategic security for their planning processes and thinking and that allow long term care improvement processes and investments to be made and put into operation that can never exist when care sites cannot count on future steams of cash to pay for that work.
That 20 percent tax should be used to create a special, protected, ongoing cash flow for care — and it is big enough to collect enough money to buy coverage now for everyone and to set up a financial model that will significantly improve future care. We currently pay $1.3 trillion out for total insured care in America every year.
We don’t need to do complex economic analysis to figure out that these numbers can be the right ones to solve these problems. We know that we currently collect $1 trillion to pay for Social Security with the 12 percent payroll tax that we use there for that purpose today. A 20 percent health care payroll tax — split in various ways between the employer and employee at each work site — would generate more than enough money to capitate all of the Medicare Advantage plans to cover everyone in the country who is not on Medicaid or Medicare today and to improve the benefits offered to a new average deductible of $1,000 instead of the wide range of sometimes damaging and painful deductible levels that too many people have in their coverage today.
The plans would have more than enough money to provide that coverage to all insured people because that cash flow would exceed the total cost of insured care today, and because there is so much waste and inefficiency today in the care delivery system that we can make care better and less expensive at the same time if we can channel the cash flow for care in a way that lets us do that work.
We should also be able to fairly easily significantly reduce the onerous administrative burden on health care that some people estimate to be upwards of 30 percent of the cost of care in our country now by channeling care into payment approaches that are heavily computer supported and built into care team approaches instead of being linked into expensive and wasteful insurance bureaucracy infrastructure nightmares.
Universal coverage would be almost immediate.
The tax would begin January one and the coverage for everyone would begin immediately.
Everyone in the country could choose between Medicare Advantage plans to be insured for that care through a plan on January one, and we would finally achieve and fund universal coverage as a nation using that approach.
Those plans would need to be expanded in a number of settings — and we would also need to give all care sites a chance to both become Medicare Advantage plans and to contract with those plans. The key to the success of that financial model at every level is to pay a capitation amount to each plan for each covered person. We would pay those plans for those newly insured people just like we pay them now for Medicare enrollees — with a per member per month payment for each plan that comes from the pool of money collected by that payroll tax.
Using Medicare Advantage to do that work actually is a clear echo of the health plan dependent and employer linked path to universal coverage that is being used very successfully now by Switzerland, Germany, and The Netherlands. We should take comfort in using a model that has worked well in several European countries to create universal coverage and very high levels of care.
We would parallel their model with this approach and then we could add our own enhancements to the purchasing process for our plans that would make our version even better than the ones they use.
We need all Americans to know that this is a proven way of achieving universal coverage. Each of those countries in Europe now uses competing health plans to provide both coverage and care, and each pays the plans with a dedicated pool of money that is collected from a payroll tax on every paycheck.
A universal mandate to cover everyone is key to that process working in those countries.
They all mandate that every person in their country must buy coverage. They use universal mandates and payroll deductions to create universal coverage and they use competing health plans — that look just like Medicare Advantage plans in the United States — to actually deliver and channel the care.
The countries in Europe all link the employer very directly to the coverage process for employed people. They use mandated payroll deductions and their employees in each work site choose from competing health plans offered by the employers for their actual coverage and care. Health plans need to make both employers happy and patients happy to keep their enrollment levels healthy.
Chancellor Bismarck invented that model for Germany centuries ago because he wanted universal coverage for the German people but he did not want the government to actually deliver or pay for care. He invented what he called Sickness Funds and set up more than 400 sickness funds to compete with each other for German health care financing and delivery.
The plans started by Bismarck continue to compete with each other very much like the health plans in our country compete with each other in our Medicare Advantage program now.
Those countries each made the choice to use capitated health plans instead of using a Canadian like single fee schedule government run purchasing model for their universal coverage because they did not want government employees and government departments to be the source of either service or care for their citizens. They all want every single person in each country to be covered by good coverage that each consumer has chosen for themselves through the plan selection process.
They pay each plan a flat premium each month based on the people who join each plan.
Our Medicare Advantage Plans today are also paid a flat amount of money per month for every person enrolled in each plan. That pool of money was once calculated as being based on the average Medicare program costs for each area — broken into average payments per person using reasonable factors for the formulae. The amount varies by age, sex, and geographic location, and can now also be adjusted if the Plans have higher scores on the quality of care and service levels that are part of the program.
There is no link in the Medicare Advantage payment approach to fees or to pieces of care at any level. It is a fixed payment per member per month. The European plans also do not bill the government in any way for any pieces of care.
So this approach allows us to collect a payroll tax and then use it immediately in a systematic and intentional way to buy full scope care for our people instead of using the money to buy vast numbers of pieces of care that we would do if we just extended traditional Medicare to do that work.
The entire process can be put in place with very little effort at some key levels, and it could happen as quickly as we decide to make it happen.
We already have a payroll deduction system set up to fund Social Security. We can use that same approach to buy care for everyone who is not on Medicaid now.
We need to continue the Medicaid program and enhance it in several ways that align with the care improvement strategy that we will be using in our universal coverage approach for everyone else.
Medicaid needs to be a key part of our universal coverage strategy. Medicaid does important coverage and care delivery work for a major part of our population today — and we have been working hard over the past several years to make that program more effective and more extensive.
We need to maintain and even expand the best features of our current Medicaid process as part of our solution set for the country. Those programs have their cash flows in place in every setting today. They reach out to our lowest income Americans now with a very rich benefit set and an increasing level of care quality and service — and we can maintain and enhance that program at the same time that we use Medicare Advantage to cover everyone else.
Medicare Advantage needs to be enhanced in a couple of areas to do that work at optimal levels, but it is an existing program and it functionally true that we could simply use it by year end without having to invent anything new or build any new government or new private infrastructure or programs for care or for the financing of care.
That is an extremely important thing to recognize and appreciate as we look at next steps to respond to the COVID mess. We can build that solution set for getting desperately needed cash flow and cash flow security into the care delivery system with tools we have in place now — that work well now and can be improved to work better in the future if we decide to use them for those purposes at this moment in time.
If we do not create a new cash model now and use it effectively for funding care, we will have a massive disaster across major portions of our care delivery system. Shutdowns and layoffs are happening now in a vast number of care sites. The recovery process is extremely uncertain for those sites because no one knows who will be paying for care on January One and no one in health care can count on any cash unless we give them a model that will cause a flow of cash to happen.
Health plans and health insurers are facing their own levels of fragility, damage, risk and potential financial failure at this moment in time. That industry has pieces that will survive and it has pieces that will suffer immediate COVID damage and that could be hugely damaged by future COVID-related expenses.
We also do not know which of our health insurance plans and companies will survive the disaster. Many of the health plans, themselves, do not know who will be paying their premiums after the crisis is over, and don’t know how they will sustain viable risk pools with the risk pool damage that will be done both by the disease and by the premium increases that will be needed to help care sites recover from the disease.
Many experts are opining that the rate increases that the health insurance plans will need to pay for both crisis era losses and for the much higher fees that will need to be charged by hospitals and other care sites after the crisis could exceed 40 percent.
Insurance premium is always the average cost of care for each group of covered people.
It is a very basic and inherently inflexible cost model and formula. For each risk pool, add up the total cost of care and divide it by the number of covered people and that is the premium that is needed for each insurance pool to survive and to pay their claims.
Higher costs of care will create higher premiums for insurance.
If the average cost of care goes up at very high levels for insurance companies after the COVID crisis — and that is exactly what some expert people predict will happen–, then premiums will need to go up to that exact amount plus the cost of administration services for the payment process and each risk pool to survive.
Right now, insurance companies do not know who will be paying their premium on January one after the crisis is over. They do not know how many customers will survive as either payers or patients. They do not know who in this country who survives the disaster as a business will be able or willing to actually pay their premiums next year.
We also need a solution set for the health insurance companies that answers those challenges with a dependable flow of cash for both coverage and care.
Our old insurance premiums were already unaffordable for many people. The new much higher premiums that are created by the provider impacts from the COVID crisis will be even worse.
So a payroll deduction amount that generates a significant and adequate cash flow to buy care that is that is paid to the Medicare Advantage plans that are chosen by each patient can also create the cash flow needed for our health plans and our health insurers to offer ongoing coverage, and care to their customers.
The Medicare Advantage purchasing model eliminates the concern about which employers will continue to buy health coverage because the payroll tax will cause every employer to pay that money into the risk pool. We should use the standards we have now for Social Security to determine who pays the tax.
The insurance plans will have to meet the specifications of being a Medicare Advantage plan to be available to the new market, but that is a less onerous burden for many insurers than trying to persuade a bankrupt client that they should include health insurance premium costs as an ongoing business expense.
Most insurance companies in this county have linkages to Medicare Advantage plans now. The majority of Medicare Advantage membership today is already in plans owned by the insurance industry — so the country also has major portions of that component of this strategy in place today as well that will make using it easier than not using it.
That combination of facts can make for a relatively painless transition period into this version of universal coverage.
The vast majority of people should be able to maintain their care providers for that transition, because all of the major insurance companies that now handle the claims payments for the vast majority of self-insured American businesses today also run their own Medicare Advantage plans now and because their existing provider of care networks and contracts could be used to meet that goal relatively easily.
Almost all providers of care in America have contracts of some kind with the key payers and local health plans now, and requiring that those contracts be extended for these populations of covered people will make sure that the number of uninsured and financially damaged people going into those care sites and creating bad debt and financial losses for those sites for next year is minimal.
Smaller not for profit health plans also almost all run their own Medicare Advantage plans now, and some of those plans have had very high levels of success in some of those markets.
Using Medicare Advantage would keep most of the private health care delivery system with a cash flow needed to survive financially because all of their patients would be insured. Major hospital systems now tend to have contracts with Medicare Advantage plans because more than a third of our Seniors have chosen those plans now.
We need to both protect those relationships and we also need to give all existing care systems an easy slope into becoming MA plans themselves if they make that choice. We need to have an easy transition for major care systems in our communities both to be become Medicare Advantage plans and to negotiate with the relevant plans for their settings to serve their patients.
A foundational strength of the model is that plans are forced to compete with each other on multiple levels to win and keep the loyalty and satisfaction levels of their patients and members. Medicare Advantage for All is built around competing health plans who need to keep their customers happy to stay in business. Having the right networks of providers will be a key component in that competitive environment.
Medicare Advantage plans already have an extensive number of quality requirements that are already written into their specifications by our government as an informed buyer.
History in those areas needs to be recognized and understood. There were some historical performance challenges in some sites when those programs began. The very first Medicare Advantage plans in our country did not have those same explicit expectations and requirements for either quality or service, and some of the initial sites did not do a good job of meeting their member and patient needs.
We went through a sometimes-painful learning process as a nation with that program and that process that has gotten us to a much better place — and we need to make those quality and service expectations even more extensive and useful now as we extend the program to more people and use it to anchor future improvements in care.
The current level of performance expectations in place for Medicare Advantage Plans have clearly already led to better care in some settings.
Quality is actually rewarded by the payment model used today for that program. In the current payment model, the only way a Medicare Advantage Plan in any setting can get more money is by improving the quality of care and service in 60 measured performance categories and proving that the quality and service levels exist for their patients in those categories.
None of those Medicare Advantage quality standards or service expectations or performance measurements exist or are available for patients who only have standard Medicare coverage today.
The Government Can Control the Cost of Insured Care Each Year by Determining the Per-Capita Amount
The major pure financial advantage for our government created by using Medicare Advantage to cover all insured people in our country at this point in time is that that approach buys all care for those newly insured members as a package and it does not buy anything by the piece. Piecework is gone from the macro purchasing model when we use Medicare Advantage as the model for insurance. That package price that is paid to each plan each month is a fixed amount per member per month and the exact amount for each insured person is set by the age, sex, geographic location, and health status of each member.
That package payment approach with a monthly payment per person gives major cost control to the government as the single buyer for that care for very obvious, highly functional irrefutable and undebatable reasons.
The government gets to actually set that amount that is paid for each member each month each year — and that amount is then the amount that used to buy care for all insured people in that program that year.
Government has absolute control over that number. When we make it the national purchasing model, setting that number each year will probably be a matter of significant national priority and very high visibility every year as a public policy issue.
We will need to figure out if the Congress should set the number or if it should be part of the current Administration scope of power as we do with the current program.
In any case, it will be an extremely important number and we will need to know each year what decisions are being made about that number.
That approach creates much better planning processes for care delivery business functionality and care delivery design.
We might want to even make it a multiyear model after the first year. Care sites would be able to do their financial planning with even more security and competence if the government sets rolling three-year payment numbers, and then changes them in three-year increments rather than adjusting them yearly and after the fact.
People who run hospitals and other care systems and health plans can all do extremely effective reengineering and process improvement work if they know what the monthly payment amount increases will be for multiple future years with some level of security.
In any case, setting an annual monthly capitation increase or decrease number is already a very different approach than the standard Medicare coverage payment model. Standard Medicare buys all care by the piece, and has had no link to quality improvement as part of that payment process.
Our government has had very little control over traditional Medicare cost trends, and the goal setting efforts set up relative to those Medicare cost trends has failed every year for decades.
The differences between the two approaches are painfully clear today. The government now has extremely high control over Medicare Advantage cost trends because the government directly sets those numbers each year rather than discovering them after the fact from the expense levels, and the government has no control over Medicare costs and functionally learns what the standard Medicare costs are as the money is spent.
If everyone enrolls in Medicare Advantage plans, the government actually can now control the annual cost increase and can control the exact cost level for Medicare Advantage as a program every year as a nation by simply deciding how much the annual capitation formula used to pay providers should increase by, and then functionally using that number to buy care for the entire insured population for that entire year.
It is a very elegant, effective and powerful model for the purchase of care, because it is based on a per capita payment for each patient and because it does not buy any care by the piece.
Fraud is also significantly reduced when you buy total care and not pieces of care.
Traditional Medicare now has massive and painful fraud expenses. Horror stories abound about Medicare fraud. Those fraud levels in the Medicare program are based almost entirely on fake reporting of pieces of care and fake billing by caregivers about pieces of care and about false and fake inflation in the numbers and the volumes of pieces of care.
That fraud disappears for Medicare Advantage payments because the Medicare Advantage payments to the health plans don’t pay anything for the pieces of care and fraud has no way of happening at a per piece work and payment level for the government in that model.
We need the specification that are set by the government for the plans to require plans to have components like mandated computer connectivity with patients, complaint processes, and care delivery coordination.
Team care can and should be a requirement and an expectation for Medicare Advantage.
The sad and grim reality is that team care it does not exist at any level today for the vast majority of traditional Medicare patients and it also clearly does not exist for far too many COVID patients. That team care deficit will end when COVID are enrollees and the plans have their full data on each patient in their enrollment materials and care data.
The new technology and team care approaches being developed in the best care sites today include an important set of connectivity and patient focus capabilities, that we should decide to introduce into our care delivery system as we recover from the damage done to care delivery by COVID-19 by mandating that the plans perform those functions for patients.
Medicare Advantage gives us the ability to require, define, purchase and receive levels of team care, care coordination, care alignment, care linkages, and care improvement approaches that we will never be able to achieve or receive if we just extend the standard Medicare program to everyone in the country and continue to not purchase care in an intentional way as a country through that program.
It would be a very good thing if the good people who are pushing hard today for very good and well-intentioned reasons for an extension of standard Medicare program as the primary plan for creating universal coverage today as a nation would decide that it can be an even better thing to achieve universal coverage with a Medicare Advantage tool kit.
At a political level, the term Medicare for All has been a popular slogan in a number of settings for a number of good reasons. It would be a very good think if the people who are pushing hard now for us to use basic Medicare For All as an linear extension of the current program to cover everyone in the country to know why that Medicare For All standard approach is extremely well intentioned and very well meaning, but functionally. deeply and perversely flawed at a couple of important and very relevant levels.
Traditional Medicare Coverage Care Now is Purchased by The Piece
Traditional Medicare buys care by the piece.
Many other insurance payers do the same thing.
Piecework is one of the worst ways to buy care.
Standard Medicare pays for each piece of care and does it in a way that functionally rewards bad care outcomes, rewards care delivery screw-ups, and actually pays providers in the Medicare network more money when their patients are in bad health and when their health conditions and health status get worse.
Those flaws and payment realities are very real. Anyone who actually looks directly in the context of functional care delivery at what that standard fee for service payment approach to buying health care actually does to and for patients cannot deny that those flaws exist. Buying care only by the piece has been a major reason why we have so many people with chronic conditions as a country, and that piecework payment model has also prevented many of the patients who have chronic disease from having care teams helping them in important ways with their disease.
Instead of rewarding care teams for preventing heart crises, preventing strokes, and preventing and avoiding asthma attacks — standard Medicare and most traditional insurance plans pay massive amounts when each of those negative and damaging care-related crises happen — and standard Medicare and most traditional insurers either pay either nothing or almost nothing to caregivers for keeping those crises from happening.
Most of the screwups and many of the painful team care failures and deficiencies that are happening to us in the COVID care crisis spill out of that badly designed approach to care.
Health care is a business. It functions like a business in very important ways. Like every other business, it does very specifically exactly what it is paid to do.
Health care is paid more when people are diabetic, and is not paid much at all to keep people from getting diabetes. So Medicare, today, has extensive diabetes-related expenses and many people have significantly lower quality care for their overall diabetes care delivery than they would have with a better approach to buying care that paid for the right diabetic care and then mandated that the care for diabetic patients should be patient focused and team-based care.
Many important, valuable, and effective care delivery process enhancements and tools that are available to caregivers today are crippled, prevented or even forbidden by that piecework payment approach. In a world where people use connectivity models for many areas of our lives, we know that many patients would like e-Visits and e-Consults with their caregiver. Many patients would prefer electronic support for their care. Until very recently, Medicare did not pay for those electronic services and actually sometimes criminalized providers and said that they had committed billing fraud for filing a claim to be paid for those kinds of electronic support services.
By contrast, some of the Medicare Advantage plans today who are paid by the month for each patient rather than paid by the piece, do millions of e-visits with their patients now, and as many as 60 percent of the patients in some Medicare Advantage settings have chosen that much more convenient and immediate approach to receiving some of their care.
Those care sites with that Medicare Advantage cash flow have been offering high levels of electronic connectivity now to their patients because those plans are all paid by the month for each enrollee, instead of being paid by the piece for each piece of care, and those care sites do not need to require the patient to be in a face to face office visit encounter setting to be paid for each piece of care.
The COVID-19 crisis has now actually forced many fee for service-based care sites to invent their own levels of electronic connections in order to maintain patient contact in the face of the distancing requirements and contact prevention needs triggered by that virus. Some good systems are being built during the crisis. Patients tend to like them. Those care sites who now have that connectivity will have to figure out ways of continuing to offer those services electronically after the crisis is over — and that will require some changes in the way health care providers are paid to make that happen or the providers will be bankrupted by the reduction in revenue.
Those changes in payment for those services would be much easier to achieve quickly for the entire country if all patients were enrolled in Medicare Advantage Plans and if the plans were both allowed to deliver that level of care and maybe required to offer some levels of electronic patient focused connections as a condition of being in the program.
Medicare Advantage plans already have much more flexibility in being able to meet patient needs in a number of areas. We are on the cusp of a golden age for care connectivity tools that Medicare Advantage plans will be able to use freely and well.
We should be moving to an entirely new set of care tools that will make care better for many patients and that will not happen for too many patients in the settings where fee schedules define care if we simply extended the current Medicare Program to All and then use their rules for acceptable tools for care.
Medicare Advantage plans and care sites can use all of those new care tools now — and many Medicare Advantage plans do use those tools in many settings because those connectivity and team care tools make care both better and less expensive for those plans.
If we moved beyond Medicare for All, and if we actually put in place Medicare Advantage for All as universal coverage for everyone, we could have a golden age of care connectivity and care improvement for America, because the Medicare Advantage payment approaches both allow and encourage those levels of service to patients and because the functional ability of care systems and payers to do those kinds of connectivity functions improves daily.
We Need to Support Data Availability and FIHR for Patient Access Tools
Consumers today want and even need various kinds of personal computer apps to help with care. Thousands of those apps of various kinds are sold to consumers now. Fit Bit-like tracking and information tools of various kinds are extremely popular with many Americans today.
A significant problem for many of those tools now is that they are not linked currently to the actual care data of each patient. Algorithms and care coaching tools are incomplete for some very innovative vendors because they rely on too little data available only from those devices and they need more information about the patients they are trying to serve to build optimal consumer friendly tools.
We could take those consumer chosen tools to a much higher level of effectiveness that many consumers would love by requiring all of the Medicare Advantage plans to make the claims history and care history of their patients available electronically in accessible ways to those patients.
Most care sites now have electronic medical information, but that information is generally not linked between sites. Care data tends to be in electronic siloes that are just as dysfunctional as the old paper siloes that existed when all medical records were on paper. People trying to help with that issue have invented some electronic tools and one of the best tools to do that work is FIHR.
FIHR stands for Fast Healthcare Interoperability Resources.
FIHR makes the links between patients’ medical records and other uses easier to do and it allows for some very useful linkages between multiple electronic medical records that currently exist for far too many individual patients only on multiple sites of care.
That information is relevant to this approach and Medicare Advantage for All proposal and strategy because the new FIHR connectivity tool that has been built and can be used to link electronic medical records between care sites could be required for all Medicare Advantage Plans as a service for each patient. That patient specific FIHR data could enhance the effectiveness of many consumer purchased care support tools and it could give consumers another level of useful control over their care.
Standard Medicare coverage extended to everyone cannot ever achieve any of those connectivity goals or create those tools or data flows for their patients.
We have a major deficiency in team care for Medicare Patients today in most care settings.
If we had Medicare Advantage for All for all patients, and if we decide to write the right specifications for our expectations from the Medicare Advantage plans, then their care sites would work as a team to reduce the number of strokes, asthma attacks, and diabetic cases for their patients and we would save money as a country because people would actually need less care.
People going to standard fee-based Medicare providers today find it almost impossible to get any quality-based information about those care sites or about their care teams.
If we had Medicare Advantage for All in place and if we build the specifications for those purchases well, we can have extensive data reporting almost immediately on the quality of care and service levels, and we could insist that every patient be given full electronic access in real time to important data about their own personal care and their various sites of care
Medicare Advantage Plans provide many of those services and data flows now, to their members now — and that is one of the reasons that the loyalty levels for those members is so high. Medicare does not provide them because they don’t even exist and cannot be built in major parts of that fee-based payment system.
This approach is also much more affordable.
The traditional program Medicare For All financing models presented to Congress would have required us to raise trillions of dollars in new taxes to pay for those plans. The exact amount needed was subject to heated debate in couple of settings. That debate is avoided entirely for this proposal by simply using an existing a payroll tax to collect the needed money and setting the amount at a level we already spend in employed settings to buy care. Instead of increasing various taxes by trillions of dollars, this proposal re-channels existing spending approaches to insure everyone and buy better care.
A 20 percent payroll tax generates more than the $1.3 trillion we spend now on insured care. It also would not be a jarring burden for our people, because we already collect money from payrolls for most people for coverage and those are very similar amounts to the amounts routinely collected now. As a 10 percent charge to each employee, that is less than we see now for most people for care related expenses.
When we look at health care expenses for employers in this country today, we see an average cost to employers of $20,576 per family coverage and $7,188 for individual coverage.
We see that the average worker now contributes $60,145 of that amount each year. Average income for the country this year is $44,564.
So the current health care expense incurred by our employers and employees in many work sites actually already significantly exceeds that 20 percent in many settings. We can deal with that reality of having some sites pay more now by grandfathering in the current payment for health coverage in each work site that already exceeds that 20 percent level — to keep that money and that cash flow in health care without losing it at this point in time — and then have the employer contribution frozen in each site until the total number is lower than 20 percent of payroll for that site.
That will give all of those employment sites who pay more than 20 percent now a zero premium increase level for a number of years — in contrast to the increase levels that have gone up from 4 to 20 percent a year each year for health care coverage costs for the past two decades. And it will bring all other work sites up to the minimum 20 percent level on January one to create the total fund we need to buy coverage for everyone by using a monthly capitation approach.
This is a good time to make that decision to use a payroll deduction to buy coverage and care. Compared to all of the other highly dramatic COVID crisis damage expenses that employers have been seeing over this year, that 20 percent total number and 10 percent per employee direct number is relatively inexpensive — and it actually gives their employees in all work sites needed health care going forward. So that is not out of synch expense level in the context of the current crisis.
We can decide as a country at some future point if we want to make that 20 percent total number higher, but that should not be needed if we do this well because it generates a massive amount of money immediately.
To duplicate the current private spend we have now for health care for America, we actually need slightly less than 20 percent for that tax. Twenty percent will also allow the current average deductible of roughly $1,700 per person per year in most work sites to be dropped to $1,000.
That will be very popular because multiple surveys show that most Americans are not happy with the higher insurance deductibles they have now for their coverage.
We do know from multiple studies that the total amount of waste and inefficiency in the health care delivery non-system runs from 20 to 50 percent depending on the format and set of assumptions that are used to make the estimate.
So moving everyone to Medicare Advantage coverage by taking the total amount of money generated by that tax and spreading it on an actuarially appropriate basis to the plans that are chosen by the individual members with a formula that echoes the allocation model and approach used now by Medicare Advantage for the old Medicare coverage could be done very quickly — and it would create a situation where that guaranteed cash flow would be used by the plans and by the providers to pay for and deliver the care we need for the next year.
It would be a very good thing if we actually had coverage for everyone in the country. That particular achievement is long overdue. Every other western nation has achieved that goal — and they have all done it spending much less money than we spend for care.
Covering everyone is long overdue because we now spend $3.7 trillion a year as a nation on care — far more than any other country on the planet. It is actually a mark of our gross purchasing incompetence as a country that we spend all of that money on care and we still have 30 million people who don’t have any health insurance, and 20 million more who are at least partially underinsured.
Every other industrialized country pays much less than we do for care, and every other country gets better health outcomes and provides direct access to care for all of their people.
We Would Have Better Care than Every Country in the World
If we put Medicare Advantage for All in place for everyone in our country, we would not only cover everyone, we would do it with a care system that would very quickly be better than any other care system in the world. That is an important point for us to understand.
That will be a highly desirable achievement and it is actually very possible for us if we use this approach to buy care.
We often hear people say that we Americans have the best care in the world. That is not true today in a number of ways — but it would actually be true if we used Medicare Advantage to buy and deliver all of our care and then took the opportunity that other countries are not taking and will not take to actually use the available new tool kit improve care.
Currently, most western countries have better access to primary care than we do and most western countries have about the same levels of access to specialty care as we do.
Every other country has more access to most kinds of hospital care — and all of the western countries have both higher rates of hospital admissions and longer lengths of stay than we do in their hospitals today.
Our very best subspecialty care hospitals are the best in the world by a significant margin, and the very best of those hospitals are getting continuously better, but those elite care sites only see a tiny fraction of our patients, and our overall mortality rates for our care are worse than most western countries.
We actually have an opportunity right now to have the best overall care in the world because most of the other countries have decided for internal political reasons to oppose and actually to forbid having their caregivers connected with each other electronically. Linking electronic medical records is actually illegal and a crime in several European countries. That ban on connecting care data between caregivers will put them at a major disadvantage for the next generation of care support tools compared to what we Americans will be able to do with those tools.
If we use Medicare Advantage as our payment model and if we mandate electronic connectivity for our caregivers for each patient, we will have better care data, better care teamwork, and more creative use of patient friendly care tools than any other country on the planet other than Singapore. Singapore is doing some very good care enhancement work. We will be as good or better than Singapore and we will be far better than everyone else in the world in a very short time.
We have the opportunity at this point in our history as a country to use the best science and the best tools when we buy and sell care as a package and we will actually have the best care on the planet when we do that because a number of other countries are very intentionally not doing good things now with computer connectivity tools to improve care in those ways.
Those countries who are banning care data connectivity will probably reconsider or at least regret those decisions when they see how much better care is here in our country when we use all of those tools.
American creativity would flourish and blossom and we would be the world leader in every major category of care if we decided to buy our care with the right expectations and the right flow of cash and if we put the expectations in place that would support and reward creativity in those areas.
This is the right time for us to decide to make buying care well a core competency for us as a nation because we need to figure out how to get money to our care sites very quickly. We desperately need a new flow of cash into health care now because the COVID-19 disaster has financially destroyed many sites of care and impaired many others. Care sites everywhere do not have any confidence or peace of mind that they will have any dependable payers for their care next year — and that is a very legitimate concern because many payers are going to find themselves financially damaged and in need of massive premium increases that will make their coverage unaffordable.
We obviously do need a new cash flow for care and we need it now. We can either throw money in huge quantities in non-systematic ways into a badly damaged care system — or we could channel money intelligently and skillfully into buying better care and stabilize the health care economy. We can choose to use Medicare Advantage to set up funding approaches for caregiving that can give our care providers secure flows of money that they can use to build their financial future, and that they can also use in this time of crisis simply to stay financially afloat.
We actually could be on the cusp of a golden opportunity age for care if we get this right, and we will see care deteriorate in many important and damaging ways if we get it wrong. Care will deteriorate in many ways and in many sites if our caregivers are financially impaired and if our caregivers have survival as their key financial priority instead of care improvement.
Care systems that are not able to meet their payroll and who are doing caregiver layoffs of various kinds will have a hard time improving diagnostic skills and enhancing treatment plans. We could slip into some grim and significantly damaged years in many care sites, or we could decide to actually support and fund team care, connected care and continuously improving care by giving adequate cash flow to those care sites now.
Continuously improving care is the better choice. Medicare Advantage gives us those tools and the opportunity and context to do that work.
We will be very tempted right now to get it wrong.
Throwing massive amounts of money into the current chaos in care will be demanded by many people because many of the care sites will be desperate for cash and because the care sites in dire need will have many friends and supporters for those requests.
Let’s resist the temptation to simply partially replenish the failed system as our long-term solution, and instead choose to use Medicare Advantage as a national agenda for propping up care sites and improving care at the same time.
We have already made a number of brave and bold decisions as a society in response to that virus.
We have done brave and non-traditional things already at many levels. We need to maintain the momentum of implementing initiatives and we need to continue our collective support of that innovative decision-making process legitimacy into helping our care systems both recover financially and improve care by using that set of tools now and getting everyone on board with that decision and strategy.
The Missing Link in Care is a Competent Buyer
A combination of medical science, continuous improvement, accessible large-scale data bases, remote connectivity tools and monitors, and even selectively applied Artificial Intelligence, will give us better care at significant levels and that can happen very quickly. The Mayo Clinic, alone, has more than 200 artificial intelligence projects today that are making revolutionary improvements in care at multiple levels — and they are developing diagnostic, predictive and tracking mechanisms that include remote access data points for some of the projects and activities.
Care can become a lot better in our country — but that will not happen for most patients and most care sites because we are so siloed now and because the fee for service payment model that we use to buy almost all care does not allow that market or some key sets of care improvements to emerge in any effective way.
It is also true that large numbers of our care sites have been so badly damaged by their response to the COVID crisis that they have absolutely no resources to spend at this point in time on enhancing care and those caregivers and care sites do not have care improvement as a current priority or goal.
The caregivers today in most sites of care are trying very hard to survive. Not to improve performance or outcomes.
We can do both.
We can use the expanded Medicare Advantage cash flow to organize and reorganize the purchasing process and model for care and we can have care improve as part of the package.
If we decide to change our purchasing model for care and if we decide to very intentionally use Medicare Advantage in a carefully structured way to buy care for all of our people, we will spend less than we would than just using the Medicare for All approach, and we will have much better care.
We Need Medicaid to be a Key Part of the Package and Tool Kit
Medicare Advantage for All can cover our employed population. We also need to continue our current Medicare program — with some additional steerage toward the Medicare Advantage plans — and we need to strengthen and build our Medicaid program to also provide continuously improving care.
Medicaid needs to be a key component in our health care recovery package for the country.
We need more than just Medicare Advantage for All to achieve our goals. To cover everyone and do it well, we also need to include the next generation of Medicaid plans in our care financing strategy, and we need those plans to be involved in supporting care connectivity and care improvement as well.
In the spirit of Medicare for All as a universal program to cover everyone, we need an overall agenda to strengthen Medicaid, to buy Medicare coverage more effectively for our seniors, and then to extend Medicare Advantage coverage to every other person in the country and fund it with a dedicated flow of cash.
We need to continue to use Medicaid for the things that Medicaid does well now.
The ideal package for us going forward in a practical, achievable, and affordable way to achieve universal coverage and to also deliver better care should be to continue, supplement and improve our current Medicaid program, and then to buy care well for everyone else using the template given to us in our Medicare Advantage tool kit and structure.
Medicaid does some things very well today. We need to build on the best of those programs to deliver Medicaid well everywhere. We need to be very clear about our expectations for team care, best care, high quality care, and continuously improving care for Medicaid patients — and we need to create a cash flow to our caregivers that will give us the very best care, and we need to do it in a way that spends as much or less money than we are spending in total today for care.
We should be able to spend the amount we are spending now in total on care, and we should be able to use that money to cover every single American by becoming a much better purchaser of both coverage and care. If we become a highly competent purchaser of care, we should be able to use that money to put in place continuously improving processes of care that provide the best science, the best service, the best connectivity, and the best data for patients about their own care and about the science of care.
Solid recent research shows us that between 25 percent and 30 percent of our care dollars go for waste, inefficiency, poor care coordination, fraud, abuse, and administrative complexity. Much of that waste would all be controllable and reduced quickly if care is delivered in a Medicare Advantage cash flow system and model that is paid by the package and not by the piece for care.
We should not mourn the loss of that old model of buying care for our country, because it truly was flawed at multiple levels. The coverage and care coordination failures and the patient data base shortfalls that emerged in so many settings for the COVID patients proved at multiple levels how dysfunctional and inferior that old non-system was.
We Need Much Better Patient-Focused Care for Less Money
We have great inconsistencies and extensive inadequacies in the delivery of care and the inconsistencies are not based at any level on patient needs or wants.
We should look hard at the pre-COVID care system results.
We have too many strokes, too many diabetic complications, too many kidney failures, too many asthma crises, too many congestive heart failure crises, and far too many people with both preventable and badly treated chronic conditions and diseases who should all be getting better care when we are spending $3.6 trillion to pay for that care.
We do not use our possible care tools very well for most patients, and the way we buy care causes those failures to exist.
Today, we have badly connected care for far too many patients, and we have deep and dysfunctional data silos in care that far too often keep caregivers from having the information needed to provide care at the optimum time and place.
Horror stories we hear now constantly about badly coordinated care abound and those stories should all disappear when we stop paying only for pieces of care, and when we use Medicare Advantage processes and approaches to mandate use of care teams, care coordination, patient focused care, and shared data about care.
We need the American public and our public leaders to all clearly understand why the piecework purchase of care approach is a very poor purchasing model and we should have the public demanding continuously improving, patient centered care and teams of care.
Far too many people still believe that buying care by the piece is the right way to buy care because it is the way we have always done it.
The truth is that we actually now have thousands of billing codes for pieces of care — and those billing codes only pay for units of care, rather than results. Results are irrelevant to the prices paid now for each piece of care. Better health is also not incented or rewarded in any way by the standard piece work based financial cash flow that goes to our caregivers today.
We need to put overall payment processes and cash flow realities in place that reward better health, better outcomes, and better connectivity between caregivers. We need to trigger the creativity of our caregivers for both better care and better patient health, and do that with those goals in mind.
Patients love care teams when patients need care from more than one caregiver — and those teams do not exist at any functional level in far too many settings for far too many patients. The current fee-based payment model for pieces of care helps make that unfortunate reality true.
We need to go in the opposite direction. We need to incent, encourage, reward and even require team care where team care is needed, and we need our care teams to have the most current science, the most complete data, and the most responsive care approaches for our patients in an organized and accessible way for each caregiver and patient.
Medicare for All proposals that use the traditional fee-based payment model to buy care will not make that care improvement happen.
Standard Medicare has no way of creating those specifications for improving care in any way that has any high likelihood of success.
We need the people who are extremely well intentioned, good hearted, and strong advocates and proponents of the Medicare for All universal coverage proposals to know what would happen if we functionally actually used that tool to do that work of buying health care for all of us.
We can fix the existing holes in the standard Medicare benefit coverage by getting rid of the co-pays and the current benefit caps, but we can’t get higher quality and more connected care from that program as long as Medicare continues to buy its care at the most basic level for each patient entirely by the piece.
We need to make the decision to buy patient-focused care for all patients, rather than caregiver-focused care, and we need to use the best purchasing tools we have available to specify and define what we want, and then we need to set up a process and program to buy and deliver that better care.
Medicare Advantage has the basic tools in place that will let us achieve those goals if we use it as our template, channel, and process for buying care and if we also become better buyers for that particular tool kit.
We should not assume that the current version of Medicare Advantage is as good as it can get. We need to enhance that tool to have it achieve our higher goals because we are smarter now than we were when we began down that road as a nation and as a buyer.
We should also make sure that the needed caregivers in every setting have the opportunity to either become Medicare Advantage plans or to do arrangements with those plans that will meet the needs of patients in our communities.
If we use Medicare Advantage as the cash-flow tool for major portions of care and if we become very clear in the buying process about our expectations for team care, high quality care, care connectivity, and continuously improving models of care as part of that purchasing process, then the cash flow of care in Medicare Advantage can be fairly easily channeled down the paths of internal team care and quality improvement approaches to meet patient needs.
The functional truth is that many very basic improvements in care are actually relatively easy to do when we decide to pay our caregivers to do them and when we create a cash flow that pays for and rewards that performance.
About a third of the people on Medicare in this country have already voluntarily moved to the current version of the Medicare Advantage program. More than half have enrolled in some areas where there is long standing plan availability. Both loyalty and satisfaction levels for Medicare Advantage members are high for most plans and most settings, and quality levels are higher than care delivered in non-plan settings.
Medicare Advantage Is Not Paid for Pieces of Care
The primary reason why that strategy and tool kit works for the patients it serves and for the providers who provide care to them is that Medicare Advantage is not paid by the piece. Medicare Advantage plans are paid by the month for each patient to provide total packages of care.
It is very important for us all to understand that concept if we decide to go down that road. The payment model for Medicare Advantage is based on a monthly payment per patient. Not a fee payment of any kind.
The payment models and the financial incentives are very different for the two approaches. Getting paid a lump sum per patient creates high levels of very useful flexibility in key areas for providers of care.
The government gives each Medicare Advantage Plan a fixed amount each month for each enrollee, and the plans then use that money to provide the basic package of needed care for their enrollees.
Flexibility is created by that cash flow for both health plans and providers of care.
The plans can use that money in much more flexible ways than standard Medicare care sites to help their patients.
Medicare Advantage plans already have done things like cut the number of broken bones by half for their patients by creating individualized care plans for each high-risk patient, and by even placing nurses in the home of some patients to reduce the likelihood of falls.
That kind of approach to care can be a major benefit to seniors. Studies have shown that seniors who break bones are more than 25 percent more likely to die in the next four years than seniors of the same age who do not break bones. It is a very good thing at many levels when the number of broken bones for our senior patients is reduced.
Most of the steps involved in that set of team care supports that are given to those patients by Medicare Advantage caregivers to reduce the number of broken bones is completely rejected for payment by the standard Medicare Fee for Service fee schedule — and a care site could be accused of fraud for sending a bill to Medicare for the support given by a nurse to a patient in the patient’s home to reduce the number of broken bones.
There is no fraud when a Medicare Advantage care team provides those services — and that approach is better for both the patient and the caregivers, because the caregivers who are not limited by the Medicare fee schedule can figure out the right thing to do based on the needs of the patient, and then do it for the patient without being accused of a crime by Medicare.
We need a purchasing approach for care that does not criminalize care improvement and we need it very quickly because we are being damaged in a number of ways until we put a new model in place.
We will discover as we go into January of next year that large numbers of people will have lost their current health insurance, and the health care providers will be faced with providing care at serious levels to much larger numbers of uninsured people. If we decide to enroll every employed person in the country who is not on Medicaid in a Medicare Advantage plan, then all of those patients who will go to our hospitals will have underlying insurance immediately.
We can mandate coverage for emergency care and emergent conditions for all enrolled people immediately, and have the plans work out the payment arrangements with the care sites in the process. Most sites will have payment arrangements with payers now — and can use those. Other patients will go to sites with no current negotiated arrangements — and the plans will be able to use the existing Medicare fee schedule for those pieces of care as a default if they can’t work out a better arrangement. That will guarantee for the hospitals that they will not have any uninsured patients in January of next year.
We could make the payroll deduction for health care funding a social security like tax instead of a voluntary insurance deduction, and that would give us a process in place everywhere and immediately to collect what we need to pay for everyone’s care beginning in January of next year.
Most of Europe uses a Medicare Advantage like model for universal coverage that is funded by a payroll tax now. That money collected by that payroll tax is fiercely protected in each of those countries today — and it is used only to buy care — using health plans in each country for both the benefit plans and provider payment processes.
The health plans of Europe actually compete fiercely with one another. They run ads that look very much like American health plan ads. The competing health plans of Switzerland, Germany, and The Netherlands each know that they need to meet the needs and desires of their customers in order to survive as businesses in those settings.
Germany has over 100 competing health plans, and many of them are over 100 years old.
Germany invented the idea of using a payroll deduction at the site of employment to buy care from health plans. Each German gets to decide which plan will receive their monthly payment from the government to pay for their coverage and care and the plans work hard to maintain a sense of consumer loyalty over time because their survival is based on consumers making those choices.
They have some actuarial adjustments that they use in those countries when people change health plans that reflect at least the age and gender of the enrollee, but those countries do not create any barriers to consumers deciding to change plans.
Each of the three major European countries that uses that model funds it with a designated a 15 percent payroll tax — split evenly in each country between the employee and employer. That is not enough money for us to achieve the same goal — but it is relatively close to the number that can work here.
A 20 percent payroll tax charged to each employee and employer in our country could give us a cash pool on January One that would be sufficient to set up universal coverage here.
That would put a 10 percent burden on each employer that does not exist now for the companies that do not offer any coverage now — but 10 percent is far lower than the cost of insurance premium would have been if those companies had tried to cover their employees in the past with standard health insurance plans. So companies will have a new employment expense — but it will be at an affordable level and far lower than some of the unintentional costs that have resulted for employers from the COVID response activities. We have a new normal for employers for all of those expenses, and 10 percent will seem like a very reasonable expense for many.
For employees who did not have health insurance through their employment before, 10 percent is an extremely good price for having a good level of benefits and access to a robust system of care for themselves and members of their families. The average cost of out of pocket expenses for uninsured Americans tends to be much higher than that number now. It can be described very legitimately as a very good benefit to receive — and the actual dollar impact is lowest for the lowest paid workers because it is a percentage and not a fixed and higher insurance premium.
To collect the tax, we should use the same income caps per person for the health care tax we use now for the Social Security tax — or the new tax with no caps would become the most progressive tax in the country by a significant margin.
Capping the revenue at $136,000 per paycheck is still actually functionally progressive because more money would be collected from the people at the top of that pay level than from the bottom to pay the tax.
We need a cash flow for care. We can achieve that cash flow by creating that tax and then turning it into an insurance purchasing pool and paying it out in capitation levels to create universal coverage. We can pay it out to competing Medicare Advantage plans on a per capita monthly basis, based on the age and sex of those who join each plan, using the same kinds of actuarial adjustments we use now to apportion the current Medicare Advantage payment approach.
We are very fortunate as a nation to have the key tools and processes that we need to use to make this process work already in place and working well.
Building new programs and building new infrastructure in any community settings can be difficult. Having to build new things to make this happen is not a problem with this approach because we could actually create, fund and implement universal coverage in our country almost instantaneously using pieces and processes we already use. That slightly modified use of our current approaches and tools will reduce both our implementation risks and our set up costs significantly.
We already collect money from payrolls for Social Security from every working person, so that cash collection infrastructure and process already exists.
The Medicare Advantage program also already exists. We would want to improve that program in several key ways, but those improvements and expectations are all easy to do.
The Medicare Advantage plans now receive a monthly payment from Medicare for their current senior patients based on the age, sex, and geography of each enrollee — and that same kind of calculation can simply be done for the new sets of enrollees to cover everyone and be easy to administer and implement.
We would cover everyone in the country without increasing the total amount we are spending now on care if we used Medicare Advantage for everyone not on Medicaid, and then also kept Medicaid in place for our lowest income Americans.
Medicaid should and would continue to cover all of the Medicaid enrollee. Medicaid does some important things well now. We should continue to use the richer Medicaid benefit package that we use for Medicaid now for low-income people. We can cover everyone else in the country with the Medicare Advantage competitive consumer centered choice model where health plans compete with each other for patients, and where patients have the fully informed choice of care teams and health plans, and then leave the current sets of Medicaid plans in place for our low-income Americans.
That would be a much better use of our care dollars.
We can go very quickly from wasting money on badly coordinated and poorly linked care with almost no quality monitoring or service level tracking, to having care teams focused on meeting patient needs and using the right tools to meet those needs without being banned and penalized relative to the use of those tools by the Medicare fee-based payment rules.
We can use that approach of buying care through the Plans to go from being a very weak and inept purchaser of inconsistent and often incomplete care as a nation, to being a highly skilled and very intentional buyer for health care services using those health plans as our mechanism and our vehicle for delivering complete and continuously-improving care.
This approach allows us to collectively decide exactly what we want from our care delivery and our caregivers for both service and quality and then set up purchasing mechanisms that will deliver those expectations to us and will reward and incent caregivers for meeting our collective and individual needs.
Universal coverage is both possible and very affordable if we go down that path. The payroll tax of 20 percent is very close to the approach and cash flow used by large numbers of American employers today. The average employer in America currently has an annual health care expense of $20,576 per employee. Employees pay, on average, $6,015 of that expense.
We should grandfather in the current exact payment level for any employer sites that now pay more than 20 percent until their payment equals or equals 20 percent. That will be a long-term cost break for many employers because their premium increases will end when we use that approach and their future expenses will increase at the rate that their other employee expenses increase.
Employers who now pay less than 20 percent will end up working out with their employees what the percentage payment should be. Again — grandfathering in the current employer contribution can create stability in that process for an interim time.
Everyone employed in the U.S. would be eligible for that Medicare Advantage coverage on January one. Every employer should pay that 20 percent deduction from each paycheck into the fund, collecting enough money in the aggregate to create a funding pool that is adequate to pay for coverage for everyone using that approach.
People with multiple employers would have each employer as a source of that money.
The proportionate split between employer and employee of the 20 percent payroll tax payment could be worked out separately at each place of employment. Most employers already have a significant direct expense for their health care benefits, so whatever approach is being used now to pay that amount could be used initially to figure out payment of the 20 percent tax for each setting.
Payments would need to be tax-deductible expenses for the employer, as well as non-taxed income for the employee — regardless of the contribution percentages used in each setting.
The flexibility of the payroll process to handle that payroll tax number already exists in most settings. We have a very long history of using payroll deductions to buy health insurance. Setting up the first year of that process as we move to this approach would be an adjustment, but the truth is that we have a very long history of using payroll deductions based on insurance premiums to pay for care, and we have seen those deductions drastically increase from year to year.
Companies have had decades of experience reacting to annual health insurance premium increases, and employers have had major annual changes in those expenses for decades without disruptions to the survival of their businesses and with minimal disruption to employment.
That same ability that we have shown in the past to be flexible for past health insurance premium increases gives us some comfort that this new set of payroll deduction numbers for health care expenses will be absorbable in flexible ways by both employers and employees, and that we will simply incorporate those payroll deduction numbers into the run rate of business expenses fairly quickly and well.
The historic volatility that we have seen for both employer and employee health care costs would disappear with this new funding approach because the 20 percent would be locked as an expense at the same level each year.
This approach works for all levels of employees and offers several advantages for the lowest income employees. Arithmetic is relevant in making that judgment that this approach is good for both lower-income employees and their employers. For the lowest income employees, insurance-based health care expenses have been a higher percentage of their paycheck than those same expenses are for higher paid employees. That will change with this approach — and that will make it easier for employers of low-income workers to pay health care expenses, because there will be more certainty about what those care expense numbers will be, and the health insurance premium number will not be a higher percentage of a low-income worker paycheck.
This approach helps significantly with the challenges and problems for a growing number of workers who now have multiple employers who are currently refusing to offer health benefits.
This approach will collect money from each employer and then pool it for the employee so they have coverage regardless of how many employers they have.
This approach also gives us a steady stream of funding from part-time employment — and it gives each part-time employee security about having health coverage that is tied to their employment but independent of their work site.
Part-time employees will easily be covered through this approach. The process would need to set up rules for how much part-time employees would need to pay to get the amount needed for the coverage.
People who only have a minimal income and who fall below a standard based on hours worked should be able to pay the difference between their full-time 20 percent number and the average per capita payment made to health plans in their coverage area from the government purchasing pool.
The risk pool created by having all employed people paying into the pool can be sufficient to cover all employed people because it is a risk pool fund and not an insurance premium-based funding model and it can be extended by definition to extend payment for everyone with at least half-time employment.
People who are entirely unemployed in January will be Medicaid eligible in their local states. We will want to get as many people employed as we can, because employment is the driving source of the money that creates this funding approach.
The very lowest-income workers in some states will remain on Medicaid — and we need to do a very good job of setting up Medicaid enrollment processes to serve that set of people. All employed people with basic incomes will pay the payroll tax and they will all be in the newly focused Medicare Advantage plan enrollments on January 1.
Health plans of all sizes participate in Medicare Advantage program for seniors today, so the likelihood of consumers being able to select their current plan under this approach would be extremely high. It is hard to imagine many settings where that would not be true.
That aspect of the transition would be almost painless for both consumers and plans.
We will be using basic insurance risk pooling principles, so we do not need the partially employed to have a payment target set on their own age and gender. We can create an adequate pool of cash from partially employed people by having those people pay the difference between the amount raised through their payroll deductions and that area’s average monthly payment amount.
Our very lowest income workers should continue to be on Medicaid. We should make sure that all of our low-income individuals are on that program, which would ensure they have the necessary coverage and appropriate levels of care as well. Our state exchanges can help channel and support that process.
The Medicaid programs have improved significantly and have become more patient focused over the years. We should expect that those plans would begin to all meet the same basic kinds of connectivity and reporting standards that we will put in place for the new Medicare Advantage Plans.
Veterans Administration programs should be expected to meet those same kinds of data connectivity standards. We should have all of the VA care sites and systems using the new FIHR electronic medical record connection tools for all of their patients. Use of FIHR will give those care sites the ability to link in useful and meaningful ways with the rest of the care system even before the VA finishes its transition to its own new electronic medical records system.
The Basic Benefit Package Should Be a $1,000 Deductible
The basic benefit package that should be extended to all Americans and purchased by the fund for everyone except the people who would have richer benefits because they are already on Medicare Advantage for Seniors or on Medicaid would be a $1,000 deductible plan.
That benefit package is slightly better than the average $1,700 deductible that is being used this year in American work sites, so most people converting to that new universal coverage will have a benefit improvement. Most people will be able to continue to use their current health plan to administer that richer benefit because most of the organizations that administer health coverage for self-insured employers today also now have Medicare Advantage plans or capacity.
We need to allow individual employers and work sites to offer richer benefits and additional services to their employees that could include health support or other types and levels of benefits. Plans could also compete with one another by offering richer benefits, as they do now in the existing Medicare Advantage program.
Dental benefits should continue to be an optional coverage enhancement in each work setting. Various kinds of long-term care insurance could be offered at the employer level in settings where that makes sense as part of the benefit package for the employer.
The key to making this approach work to create universal coverage will be to use the basic pool of money we will be collecting to function as a much better purchaser of care than the purchasing power and steerage that same amount created when it flowed down 1,000 channels to the providers of care.
In order to make the change as a nation from paying through more than 1,000 channels for our care to a more structured and focused purchasing model that uses Medicare Advantage to buy care for most Americans, we will need people to clearly see why that approach is a good idea and why everyone should be supporting us in moving to that approach.
We need to start by explaining to everyone in the country how care will be and should be better with this approach.
When we are spending $3.7 trillion each year as a nation on care, we can and should be on the cusp of a golden age for health care delivery, but we need all Americans to recognize that that golden age will not happen if we continue to buy care by the piece and the harsh market reality is that we need to mandate that we receive those services and benefits and set up a way to pay for them or they simply will not happen for most Americans.
The reality is that medical science has never been better, and the technology of health care diagnosis and health care delivery is continuously improving and we should extend the benefits of those improvements to all Americans.
We can now use computers and the best science to create patient-focused care delivery with care teams working together effectively, efficiently, and in truly patient-centered approaches to give us all both the best health and the best care that we deserve to have when we spend $3 trillion on care.
We are not benefiting from care being as good as it could and should be now, because we do not pay in any way now for those improvements to happen. Care does what it is paid to do, and it is paid to do things today in unconnected pieces that are not focused on patient needs in any meaningful way.
We are in a situation today where the science of care is inconsistently applied, and where far too many patients are damaged by care delivery mistakes and incomplete and badly connected resources.
We have too many infections, too many medical errors, and far too many patients with serious medical problems who have to create their own information sharing connectivity links with their various caregivers. We have very poor and highly inconsistent information sharing tools in place for both our caregivers and our patients today.
At a time and in a situation where patient care should be better and more affordable than it has ever been, we have patients who avoid needed care because they can’t afford it, and we have patients with complications and serious and damaging medical difficulties that should and could have been prevented or avoided, if only their care systems and care givers had made better care a priority or a capability in those areas.
Experts agree that we have huge opportunities to bring down the cost of care by improving patient health and significantly reducing the wasteful administrative costs that we have imposed on our care delivery settings. That is all very possible to do — but it will not happen as long as we keep buying care by the piece, and as long as our caregivers have no tools for improvement, and then actually face financial injury when they do improve care.
We Buy Care Badly in Five Ways
To appreciate the advantages of moving to an approach where we buy care as package and not just in pieces, it will be very useful if we all understood that the health care delivery system in this country is actually paid now in a primitive, dysfunctional, and too often dangerous piecework anchored cash-flow approach that creates significant adverse consequences for far too many patients.
We need people to understand that it is extremely limiting and often dysfunctional to buy care almost entirely by the piece in this country. We pay for pieces of care rather than for care processes or care outcomes, and that is not good for patients or our care programs.
There are actually more than 10,000 billing codes for pieces of care — and there is not one single billing code for a better outcome or for a cure.
Every industry produces what it is paid for producing. We buy care only by the piece, so the care delivery infrastructure is built around producing and selling pieces of care, and our care delivery infrastructure is not built around patients or around any kinds of care packages that help improve the delivery or outcomes of care.
The unfortunate, but undisputed and grim and painful reality is that the cash flow of care in our country actually benefits from bad care outcomes, because bad outcomes tend to create more pieces of care.
The cash flow and the business model of care that we use in this country today are also, very perversely, far too often rewarded financially by complications of care.
In fact, the piecework based financial mechanisms we use to buy care generally penalize our caregivers who figure out more efficient processes for the delivery of care, and who implement those improvements in care for their patients.
The core flaws in the current payment model are crippling. We want care to get better, and we want care tools and care connectivity to improve, which will not happen in any effective or consistent way until we change the way we buy care.
We can wish that was not true, but wishful thinking will not make care better. Good hearts, good luck, and good intentions will not get us to consistent and continuously improving better care.
The only way we will get to the outcomes we want is if we understand each of those flaws and deficiencies in the way we pay for care, and then make the clear and intentional choice to use a purchasing approach for care that lets us overcome all five flaws in the current model.
We need to start that change process by understanding the basic deficiencies inherent in the way we now buy care.
Volume incentives are the first and often most visible deficiency that results from buying care by the piece.
Deficiency 1: Volume Incentives
When we buy care only by the piece, and when we pay fees for each piece — we directly encourage, incent, and reward piecework volume, but we do not pay for or reward quality, or effectiveness, or care outcomes. So we get expensive and sometimes inappropriate volume in a number of areas of care that are driven heavily by that set of incentives, and not by the patient need for those services.
Deficiency 2: Perverse Care Outcome Incentives
Our purchase model for care actually benefits from bad patient health. That perverse and unintended link between bad health and provider cash flow is clear and direct. Cash flow for care is higher when patients are sicker and cash flow for our caregivers increases when patients have more health problems.
Deficiency 3: Adverse Event Incentives
Our care purchase model actually benefits directly for many care providers from adverse care outcomes and from care delivery mistakes with our patients. Providers often make more money when patients have complications and infections, and there are no direct financial incentives for caregivers to either correct or avoid mistakes.
Imagine the incentives and the thought processes in the automobile industry that would exist if the manufacturers of our cars made more money when their cars crashed. Ethics and basic human decency would keep those companies from designing cars to crash, but the best minds in the automobile industry might not be focused on reducing or preventing crashes.
Deficiency 4: Negates and Undermines Price-Related Market Force Influences
The specific piecework payment approach and process that we use to buy care appears to use market forces, but it actually does not trigger relevant and effective market forces because the process we use to buy care disguises and hides the actual fees for each piece of care from the patients.
The highly dysfunctional reality and the obviously damaging and expensive economic consequence of that approach is that price increases by individual providers generally face no market pressure, and our unit fees for each piece of care are now two or three times higher than the fees in other industrialized countries for the same procedures, because there are no countervailing market impacts or penalties that affect patient purchasing decisions when prices increase.
Deficiency 5: Piecework Payments Cripple, Hinder, and Perversely Penalize Re-engineering Processes
Because we pay for care by the piece and not by the package, our caregivers are financially penalized when they reorganize care to make it more efficient and more effective. Providers avoid improving care in any ways that that will reduce their payment stream because no businesses in any industry will intentionally penalize itself financially.
The people who run all of the major care systems in America can explain clearly the frustration of not being able to re-engineer care in a number of areas because of the financial penalties and the direct and immediate damage to their cash flow that can result from doing anything to impede the basic current flow of fees.
We tend not to understand or appreciate how big a flaw that set of realities about economically hindering re-engineering by caregivers is for care. That destruction of process improvement as a tool for care is actually the biggest single danger and the most damaging consequence of paying for care entirely by the piece. Not using re-engineering processes to improve care is the primary damage factor, and the most dysfunctional and perverse outcome for care delivery in this country created by the way we buy care.
All other industries make re-engineering their basic processes a foundational strategy and the well-run companies in other industries make process improvement and re-engineering a highly valued organizational strength and capability.
Health care does not do that.
In a world and time where all other industries constantly re-engineer their processes, make process improvement skills a top management priority, and work hard to build and enhance key tools and implement core process improvement strategies for their organizations — because their organizations are more likely to succeed financially when they do that process-related work well — health care is actually hurt financially by most care engineering approaches that make processes work better, so health care avoids using many of the basic process-design tools that make other industries stronger and more effective.
Those are crippling flaws in our payment model.
We see a tiny fraction of the care improvements that are possible to create now, because our business model does not incent or reward the creation of those improvements. We will be able to live with the new Medicare Advantage capitation numbers and payments because that approach will reward doing those improvements in all of those areas.
It is possible to reduce the number of asthma crises in children by half or more — but we pay our caregivers a lot of money in many settings when those attacks happen, and in general we pay nothing for preventing the attack.
A patient who has a stroke can generate hundreds of thousands of dollars in care expenses that all become part of the $3 trillion we spend each year on care — and our care system is not rewarded in any way for doing basic things that could cut the incidence of stroke by half or more.
More than 70 percent of the health care costs in America come from chronic conditions. Many people know and cite that number — but almost nothing has been done to take advantage of the opportunity that number creates for us. There are important and effective things we can do to both reduce the number of chronic conditions and to avoid the complications and physical damage that those conditions cause to large numbers of our people. We could reduce the percentages of chronic condition suffering patients by half or more by focusing the right care and the right health agendas on all of our high-risk patients.
We know that to be true, but we do not reflect that reality in any way by the fee for service payment and fee schedule defined approach we use to buy care today. When our providers are paid entirely by the service, we do not reward our caregivers in any way for keeping people from having those conditions or from minimizing their negative impact.
We need to recognize that reality. That’s why we need to use Medicare Advantage to buy care on a capitated per member per month basis.
We should now collectively refuse to allow that old fee for service piecework approach to continue to define our future delivery of care, because we can’t afford to be spending all of that money on chronic care, and because our patients do not deserve to be impaired, damaged, or have their lives shortened by those conditions.
We should take advantage of this opportunity to now use the Medicare Advantage tool kit to significantly improve the level of chronic care condition prevention and actual chronic care delivery approaches by paying for care by the month and not by the piece for each insured person.
We can make prevention an expectation and a core competency for our care teams if we simply build that performance into our Medicare Advantage purchasing specifications and then track how well that process works going forward.
The Potential to Improve Care has Never Been Greater, but Is Not Being Realized
This should be a golden age for patient care.
That is an important reality for us to recognize.
Tools that can improve care are being created every day. Computer science and computer connectivity has never been better for every industry in the country. People and businesses in most industries and areas of the economy are now connected at multiple levels.
Except in health care.
We should be honest with ourselves and painfully aware that health care in our country lives in an electronic connectivity ineptness wilderness. No one is connected to anyone else for most elements of care. We have vast and growing amounts of data about patients in care sites, but that information lives in electronic and paper silos. It is isolated (not connected).
We don’t have the technology in place in our care sites to have the information that exists for each patient flow in any effective way to each caregiver to support patient care. Care delivery is an information-based process and science, but the U.S. generally does a horrible job of getting major pieces of needed information about their patients to our caregivers in a useful and timely way.
There are a few notable and easy-to-see care team exceptions to those massive care delivery flaws, and those care systems that are exceptions now to those dysfunctional realities prove and demonstrate every day that all of our best computer connectivity aspirations for health care are possible — but those flaws and dysfunctional realities exist for most patients and care settings in America today, and care is both more expensive and less adequate because those flaws exist.
We need to increase our expectations of what we deserve for what we are spending. We can have our Medicare Advantage plans do that work because we can specify that we want that work to be done.
We deserve better care.
We should never forget or fail to understand that we now spend well over $3.5 trillion a year on care — equaling 18 percent of our total GDP — and we waste large portions of that money because we have far more congestive heart failures, far more strokes, far more asthma attacks, and far more cases of diabetic complications than we would if we had patient-focused care for every patient, and if we used the best science and the best connectivity tools for all Americans.
Our death rates from cancer vary by multiples of two or three — depending on the care sites we use — and our patients today do not have the data-flow needed to figure out which cancer team to use when cancer is the reality that they personally face.
We also have, by far, the highest level of administrative cost burden for our caregivers of any country in the world, and we have not done basic things with our administrative systems that are needed to make most of those fundamentally unnecessary and extremely wasteful expenses disappear.
Some estimates are that more than a third of the total health care dollars in a high percentage of care settings is spent on administration expenses, and the reality is that a very high percentage of those expenses in those settings tend to be directly related to the complex processes we use for government programs and for private fee-based health plans and administrators to pay for each piece of care in each setting.
Having more than 10,000 billing codes for the purchase of care is part of that problem, and massive regulations about care delivery are another. Medicare, alone, has over 100,000 pages of provider care delivery regulations, and every insurance company also sets up its own regulatory requirements for the billing processes that will trigger fee payments.
Providers must comply with each of those process requirements from all of those payers to get their money, so we have care sites that spend far too many resources in the administratively expensive pursuit of that cash, and we are spending significant amounts of care dollars on high cost and wasteful activities that have nothing to do with care.
We need continuously improving care with great patient-focused care data connectivity, and we need programs in place that very directly improve the health for the people of our country. We also need to mandate computerized information flow for payment processes that make it easy for care sites to get their money after delivering care.
Simply Extending Standard Medicare to Everyone Will Not Fix Those Deficiencies or Achieve Those Key Goals
We need the significant number of very well-meaning people who want to extend Medicare to everyone to understand and accept the functional reality that standard Medicare does not buy care well because it buys everything by the piece and that is a very bad way to buy care.
We need to figure out how to use that positive political and intellectual energy that exists to support that Medicare for All program that is now aimed almost exclusively at creating a very real form of universal coverage with that approach to change their thinking a bit and have both universal coverage and better care as their dual goals and then have those people understand that we can actually achieve both of goals in the very best ways by simply extending Medicare Advantage to everyone.
There are some new well-intentioned and appropriately-focused pilot programs within Medicare intended to improve care coordination and delivery, but those pilots and new payment approaches have had relatively disappointing impact in most sites, and the reality is that basic current Medicare payment functionality not only hinders many aspects of innovation — but actually criminalizes some care redesign approaches that can significantly improve patient care.
Medicare has very strict rules embedded in their 100,000 pages of regulations about the roles of caregivers relative to what they can do and what they can charge for. Those Medicare billing rules for their basic sets of benefits were built by actuaries and accountants, and the equivalent insurance company fee schedules and payment rules that parallel and echo the Medicare approaches were also often built by actuaries and administrative staff from traditional legacy care delivery approach payment lists. The reality is that those fee schedules and those billing rules for all those payers were not built by people directly involved with the functional design or delivery of care.
Every economic system gets what it pays for. Bakeries produce bread because people buy bread. George Bernard Shaw eloquently pointed out those incentive issues for caregivers over a century ago in the wonderful and witty preface to “The Doctors Dilemma.”
People who are not in the business of delivering care have a hard time understanding or even believing how much impact the Fee Schedule that is blessed by the Medicare actuaries and administrative staff has today to functionally dictate and define care delivery In America. Medicare patients and Medicare caregivers are both subjected to the tyranny of the Medicare fee schedule — and care that is not included on that list is not delivered in most sites.
Medicare actually has more than 110,000 pages of provider regulations, and the Medicare administrators take their regulations and regulatory enforcement roles very seriously.
The billing rules for Canadian Medicare payments for both doctors and hospitals have been written to be simple and clear and inexpensive and they can be carried on a laminated pocket protector. By contrast, the thousands of pages of billing rules for U.S. Medicare require a microchip. Entire floors of highly trained Medicare billing clerks exist today in some major caregiver settings, and they exist in part because we have intentionally criminalized some sections of that process.
Medicare in our country even has a reward system that can pay patients cash if they successfully report their physician or their hospital for submitting a fraudulent bill. The goal of creating that patient reward process for providing our Medicare administrators with information about incorrect billing instances at care sites is admirable at one level, but it can create significant unintended consequences for both patients and caregivers at several other levels.
Covering everyone in the country with Medicare Advantage can very quickly eliminate all of those problems, because the Medicare Advantage plans are paid a lump sum each month for each enrollee, and they are not paid a separate fee for each piece of care.
When the plan is paid a lump sum for each enrollee for each month, the plan and its care teams have the solid and direct incentive to avoid, prevent, and eliminate care crises and complications for patients, rather than actually and directly profit from them.
Plans that are paid a flat monthly payment per patient have the clear and direct incentive to prevent the onset and the complications of diabetes. Plans that are paid monthly have the incentive to help people maintain healthy hearts, and they have a very strong and direct incentive to keep patients from heart failure crises and trauma — because that trauma is unpleasant, frightening, and very expensive when it happens.
Instead of just paying for vast streams of individual and often unlinked care pieces through standard Medicare, using Medicare Advantage plans allows us to change our approach for buying care to one that is anchored on care purchasing models that encourage, enable, and reward the best and most effective care, and that support both well connected and continuously improving care.
We all need to understand, finally, why continuous improvement is a major and almost ideological management commitment and strategy in most other industries and it is rarely used in health care settings. We need to change that reality and we need use specifications built into the purchasing model for the Medicare Advantage plans to make continuous improvement a goal and expectation for the way we buy care.
Health care also does a terrible job of using connectivity tools today.
People who see they can use computer connectivity to make purchases and easily both see and share relevant and useful information in every other area of their lives are increasingly unhappy about the total failure of most elements of care delivery to offer similar capabilities, electronically supported levels of service, and functionality for care.
That lack of connectivity damages many people who have multiple medical conditions.
Horror stories abound about people with multiple medical conditions who need to invent their own care information connectivity tools.
The COVID crisis has given us tens of millions of additional horror stories about how hard it is to coordinate care in our current non-system approach to data and care.
COVID has been a proof point for our need to fix that entire set of tool kits for care.
People who have their own serious medical conditions and comorbidities even when there is no pandemic who go through the misery and frustration of trying to share their own relevant medical information between multiple caregivers almost always find themselves in a setting where they have almost no relevant information about their own care costs or care option. The people who need care from multiple care givers and find that the caregivers do not have the capability of sharing their care data tend to be unhappy, frustrated, and often even angry about that situation and that reality.
On the other side of that continuum, we know that the largest Medicare Advantage plan in the country today was the first major care site in America to standardize and distribute COVID tests and they got those very important tests to their 50,000 physicians months before they were available for other care settings.
That kind of outcome should be an expectation for our care delivery. We need to mandate that Medicare Advantage plans create team-care data-sharing between caregivers and patients, patient-focused care plans, and care support. All of that is possible to do, but it is not happening for far too many patients in too many settings because Medicare and some insurers do not pay for those services and penalize some when they are done.
Some Well Meaning Programs Have Taken Us Part Way Down the Road to Accountable Care
The flaws that are inherent in buying care by the piece have been increasingly evident to the people who run our governmental programs, and there have been a number of very well-meaning efforts to change that purchasing model for some pieces and parts of care.
The government has been taking some steps in that direction with some attempts to buy what has often been labelled, Value Based Care.
A number of advocates have recommended over the past several years that the government move away from buying everything by the piece and buy at least some things by packages rather than pieces, and some attempts have been made to make that happen.
The Idea of Buying Care by the Package has Growing Support
The idea of buying care by the package has had a lot of support from many health care policy makers and from a number of care providers. People in health policy settings have been criticizing and even attacking the piecework purchasing model for years, and some have been experimenting with various ways of buying packages of care.
Some creative work is being done in that area in a number of settings. That work has been very good and educational work to do, and it is good that we have done it. It has turned out to be far more difficult than people had hoped it would be.
Many sites have started down that road to selling packages of care as part of that agenda, and we now have enough experience with those incomplete and flawed attempts to change the purchasing model in the past couple of years to recognize the harsh but clear reality that going part-way to the new care cash flow model is not enough for that particular set of problems and issues for most care settings.
The care sites that are trying to deal with their asthma patients down two tracks that encourages care patterns that significantly reduces the number of emergency room admissions for all asthma patients find themselves with major revenue shortfalls by reducing those admissions for their standard fee-based patients and simply having damaged cash flow in their emergency rooms and inpatient beds as a result. Those care sites know they are doing the right thing by reducing the crisis admissions for all of those patients, but their chief financial officers can find themselves in panic mode trying to make up the lost fee for service revenue from those patients.
Chief financial officers at hospitals have well defined sets of projections and expectations for those emergency room visits and admissions, and having them simply disappear because their care team improved care makes the CFO job much more difficult.
Emergency room visits at some hospitals range from hundreds of dollars in fees to upwards of $10,000 per admission and having those patients disappearing from the cash flow of the hospital can make the SFO workload more difficult for those settings.
Medicare has been experimenting with a number of very well-intentioned alternative payment programs that are working hard to buy various kinds of care packages and to reward providers for making care better in organized, team-based ways. Accountable Care Organizations — or ACOs — have been experimenting in some settings with those approaches.
Medicare has recently been supporting both care sites and teams in setting up a number of very well intentioned and directionally correct Accountable Care Organizations whose goal is to do a better job coordinating and delivering care for the subset of their patients included in the ACO designation. There have been a number of experiments in creating payment approaches for those care sites.
That work has been very difficult to do in a mixed payment approach in many sites because the ACO processes can create cash flow problems for the other patients in those sites.
Some very well-intentioned care sites in our country now are semi-paralyzed and are doing unintentionally wasteful and frustrating things because we have gone part-way down the path to buying some care by the package in their care sites instead of buying it all by the piece, but we have only gone far enough down that road in many sites to make the situation they face in delivering care more difficult and complicated, instead of making it better.
Today, too many care sites are either purely incented by volumes, or now have a mixed, confusing, and sometimes contradictory set of incentives that keep them from being as good as they could be in accomplishing either set of care strategies.
We need to clean up that mess and make the right set of incentives, care support tools, and care information flows available to all caregivers so that each site can focus on patient-centered and continuously-improving care.
Most of the current ACO models and sites in the country that deal with the insured population and not just with Medicare patients will be made irrelevant and moot by having those same people enrolled in the Medicare Advantage plan for each carrier.
That could benefit the ACOs. Those divergent financial incentives that make care improvement so hard and impossible in many sites will melt away when the overall payment model becomes more clearly pre-paid for patient care. And the process enhancements and tool kit that they have built to make care better in their new ACOs will be very useful and will probably get significant use in a number of Medicare Advantage settings. So many of those efforts will not be wasted.
We should have a clear and open public debate over the course of the next couple of years about what the new purchasing expectations for health care teams should be and actually are now.
We can now require patient-focused team care with extensive reporting requirements for multiple levels of both quality and service if we go down that path and we can then also have everyone making their free choice of plan for their plan of enrollment. We need the plans to compete with each other in highly visible and accountable ways — and we need consumers to be able to make the same kinds of choices about plans that consumers make about other products in our markets, today.
Market forces tend to be absent from most health care decision making today. Most people today do not get to choose between caregivers or care sites with any level of data about their performance.
If we create a consumer-focused marketplace where consumers have great transparency about the performance of their possible choices for enrollment — and if the plans and care sites all have very clear expectations and requirements about what they will be delivering to the patients, then plans will compete for patients and care decisions can be both local and patient specific in a well-structured and easy to use way.
We Can Spend the Same Amount We Spend Now and Improve Care
We are very fortunate that the payroll deduction percentage that would give us sufficient money to create that pool that will pay for the monthly capitation payments for all insured Americans is a reasonable number that runs very close to the payroll deduction percentage most employers use now for funding health care coverage.
We only need a 20 percent payroll tax to give us that pool of money, and it can be collected in a payroll deduction process that would look and feel very much like the process most companies now use to pay for health coverage for their employees.
Medicare Advantage plans who meet the criteria set up by our single buyer for plan capabilities and financial stability would be made available in each market and in every employment site to everyone who is not on Medicaid or in a private employer self-insured pool.
To maintain market flexibility and encourage funding creativity, we should allow large self-insured companies who choose to cover all of their employees, but do not want to use the payroll-tax-created funding pool, to continue to offer self-insured health benefits to their employees.
We also need to allow all of the union trust funds for care that exist now to either use their own network for the delivery of care or to join in the Medicare Advantage market model and either use the standard payment amount or do their own direct deals with those plans.
Each trust fund would be able to make their own decisions on those issues.
For the workers that are not actually employed by a single employer, but who do work with one or more employers for their income, the 20 percent should be charged as part of each and every contract and the funding pool for those workers should be set up to make the lowest income workers Medicaid eligible and the higher paid workers part of the Medicare Advantage purchasing pool.
That payroll deduction funding process and benefit delivery approach for both union trust funds and self-insured employers have been included as anchors of offering coverage to Americans for nearly a century, and we should allow those unions and companies to continue down that path so long as they meet the basic standards of benefit levels for their insured people.
Most self-insured companies will probably convert to the payroll-tax-funded pool, but some will not, and their employees will still be a legitimate part of the universal-coverage agenda and strategy for America, because their employees will have coverage.
That transition might be very easy in many settings because there is already a major overlap for those payment approaches and care delivery networks. Most self-insured employers hire someone to administer their programs. Most of the administrators of the purely self-insured plans in our country who do that work today for those self-insured buyers also already participate in one or more markets as Medicare Advantage plans.
So those administrators will also probably find this approach relatively easy to work with as we go forward as a nation to pay for care for everyone.
Cap Total Costs by Capping the Monthly Amount Spent
This will make us a single buyer as a country for most insured care, rather than a single payer like Canada, or a completely unorganized and unintentional multiplicity of buyers model like the one we use now.
Most states actually already do function as single buyers now for their local Medicaid programs. Each state used to run its own program and pay its own claims for pieces of care. Relatively few states still run and operate their own single payer Medicaid plans as agencies of the government. Almost all states now hire plans of various kinds to actually create provider networks and to provide care to their Medicaid beneficiaries.
They find that approach both improves the quality of care and gives them significant control as states over some of the key costs of care.
Extending that same single buyer approach to purchasing health insurance for all other Americans can obviously give us much better control over the total costs of care that we will expend as a country because it uses an easily controllable annual payment amount for the Medicare Advantage plans that we can determine as a nation each year.
The $1.1 trillion will be more than sufficient to create that cash flow because there is so much waste and bad care today in the health care cash flow now because of the piecework approach we use, that the plans paid a guaranteed monthly amount per enrollee will be able to provide both higher benefits and universal coverage using that amount.
Setting the care expense to 20 percent of our total income for at least several years could also potentially be used to bring down the total percentage of the GDP we spend on care as a nation without doing any damage to any care sites or risk pools for the insurance or delivery of care.
It could functionally give us the ability to decide as a nation what we want our GDP percentage spent on care to be and we could simply make it happen with the numbers we choose for our per member per month payment levels instead of having the care delivery world create our health care GDP and impose it on us.
We actually could choose over time to move to a target like 17 percent or less of the GDP as our total health care expense by moderating the increase in the total amount we spend on care in a way that would not cripple care delivery businesses in any way.
We actually do want our care delivery businesses to thrive. Care delivery creates great jobs and our care sites anchor many local communities. We want to maintain the right sets of care jobs — and we want to make sure that we use our care resources in the ways that offer the most benefit and value to our citizens and to the patients.
We can do that because there are so many inefficiencies in care today and there is so much badly spent money in health care delivery now that we will be able to save billions of dollars relatively easily once the cash flow of care makes those kinds of changes safe for care systems to do.
There is a significant amount of very low hanging fruit that we can harvest relatively easily when we buy both care and coverage through Advantage Plans.
There is so much money in health care now and there is so much money wasted on bad health, bad care outcomes, weak interventions, weak and ineffective population health agendas, and sheer administrative cost inefficiency and bureaucratic waste that the care systems that will work with the plans will have a relatively easy time achieving those cost goals as soon as they are free from the financial schizophrenia of having to trigger and generate volumes of fees, and having to do it all with a crippling administrative cost burden.
We need the Medicare Advantage plans to make care re-engineering a priority, and we need plans to partner with caregivers to design and achieve those goals. We need creativity to flourish in the context of the new cash flow, and we need the plans committed to sharing best practices and support tools freely and widely for all of those agendas.
We need plans to work in the context of patient centered medical homes and electronic connectivity with patients to make care better and less costly. Medical homes can do great work for patients — and we need to create specifications for the care plans that require the existence of medical homes or their equivalent functionality for our patients.
We know that the Medicare Advantage plans can achieve those kinds of goals because many of those care improvements are happening now in a number of Medicare Advantage care sites and the plans who use those tools well prosper as a result.
Medicare Advantage Plans Have Richer Benefits and Better Care
Medicare Advantage Plans in their current form already provide several levels of care quality and care delivery service-level reporting that do not exist for standard Medicare enrollees.
The Medicare Advantage Plans have nearly 60 measures of quality and service available now through the standardized and mandated NCQA reporting processes — and that quality oversight program already has an easy template to use for adding additional measures that consumers and patients might decide to want when we extend that program to everyone.
We need to build a rich and robust set of reporting and consumer feedback tools for each of the Medicare Advantage plans and care sites that echo the best kinds of tools used now in other parts of the economy by consumers, and we need to have that newer and richer set of information flow become the expectations of all patients in this country relative to their care.
Blended Programs or Two Better Tracks than We Have Now?
Some people who advocate taking our country into universal coverage propose that we should blend Medicare and Medicaid into a single program and run them together as part of that strategy.
Running them as one program at some point might have some advantages relative to long-term efficiency and program clarity, but the reality today is that going through the vast array of changes that would be necessary to make that blending happen in each of the states and for each of the care sites would add years of complexity, delay and administrative expense and activity for relatively small gain, and the total positive impact would probably not be worth the effort required.
Also, there are a number of reasons why it makes sense to run the Medicaid programs as their own agendas.
One reason to keep them separate at this point in time is that we currently have plans in place in every state for future Medicaid funding, and it will be much easier for us to get to universal coverage and pay for it if we can assume that the planned Medicaid funding will simply continue forward in each of the states.
The two programs have very different benefit packages — and that is a good thing to have for several relevant reasons. Medicaid currently has very rich and complete benefits with almost no cost sharing for patients because the Medicaid beneficiaries are very low-income, and it is important not to have financial barriers to care for low-income Medicaid patients.
The new Medicare Advantage program that we use for non-seniors — should have a $1,000 deductible plan as the standard benefit package but allow various employer sites and union trust funds to decrease that deductible amount if that is the approach they prefer to go down. We should not allow anyone to have a higher deductible than that, but lower levels should be allowed based on local decisions.
Having an actual deductible can make sense at several levels for our enrollees, because it can create an important sense that care is not free, and because that deductible expense can be channeled as a way of encouraging some levels of caregiver competition if we build the right data flows for patient choices into the care package.
Most deductible plans offered by insurance companies do not actually trigger real and functional provider price competition today because the insured people with the deductibles tend not to have any needed information about care prices for various care providers in making their care decisions. That lack of information about the actual relevant unit prices for each piece of care should be changed as part of the Medicare Advantage benefit design support requirements for those plans.
The thousand-dollar deductible plan needs to be administered in a way that facilitates patient choice of caregivers for the care that is received before the deductible is met.
Medicaid also has very good reasons for needing programs that deal with social support issues that are less relevant to most of the higher-income people who will have Medicare Advantage new levels of coverage.
Births need to be a Medicaid program area of great competence. Over half of the births in America this year will be to Medicaid Mothers.
We need to do a very good job of both setting up the most effective prenatal programs, and setting up the very best programs for encouraging early brain development support for all families in the weeks, months, and years immediately after birth.
The Medicaid programs in many states have been working hard to get better at team care and to build and implement proactive approaches to care delivery, and we need to build on all of those programs going forward and share them with one another as part of learning for the country on those issues.
The goal of this proposal is universal coverage.
As we look at overall funding for our universal coverage strategy, we can basically assume that the funding for those currently eligible for Medicare will also stay on the track it is on now, and that we will make Medicare Advantage available to those covered by that program using the payroll tax as the source of money for the capitation payments.
We Need a Funding Source for Covering Everyone Not Currently on Medicare or Medicaid
We would not be unique in making that decision to fund universal coverage using a payroll deduction as the primary source of money.
Canada and Great Britain use a different model. They both use general revenue taxes to buy care.
But most other countries use a payroll tax and they each tie their national health care funding to pay checks. Being employed is encouraged in all of those countries — and encouraging people to be employed is probably a good thing to do for multiple levels of economic security and stability in each country.
They all use a payroll deduction for the purchase of care and they all require the employer to match the employee contribution at a 50-50 match.
They all continue to link health coverage and basic funding for coverage for each person to their employers, and they generally have the employer either deciding which health plans will be offered or are at least involved in that decision.
The people who say in health policy debates in our country that Europe has completely excluded and eliminated the link between employment and health coverage for workers are wrong for most of those countries.
They actually mandate and enforce that link, and they want people to be employed as part of their culture of who they are in each of those settings.
So it is true that most countries in Europe use a payroll deduction approach to fund care and they have a payroll deduction from each employee that is usually matched by an equal deduction from the employer to buy health plans from a selection that tends to be centered in some ways on each employer.
Fifteen percent of each paycheck is about what they tend to use in each of those countries to create that pool of money. That is not enough money for us to achieve our goals — but it is relatively close to the amount we need. We will need 20 percent of each paycheck to achieve that same goal here. But it would work just like the tax they use in Europe, to create the cash pool that we use to buy care.
They split that contribution 50-50 between employers and employees in each of those countries. We should probably use that 50-50 split as our default template here for the initial offering of our plan, but we should also allow each work site to come up with any split that works for the site.
Unionized sites might have a very different employer contribution number at particular sites. In non-union settings, employers who are wanting to recruit people might use a higher percentage to entice workers to join and then keep them as loyal employees over time.
We should probably allow those payment split options to happen. But we should begin with the template of an even split and impose that on the process in each site until we hear differently from the site.
There are actually several good reasons for us to go down that same payroll deduction path to build our own single buyer care payment fund as a country.
We already use that same exact model to collect money from everyone who is employed to fund our Social Security program. People in our country know that model now and like it for Social Security.
We don’t need to build anything new or invent any kind of tax infrastructure to collect that money. We already have a very workable and well-functioning process and program in place to collect that Social Security fund money from each paycheck and we can extend it easily to collect money for health care.
We know how that process works and we know how much money it raises. The Social Security tax we use now charges 6.2 percent to the worker, and the employer then matches that amount.
Collecting 12.4 percent in total from every paycheck now creates an annual pool of $1 trillion in revenue that is used for Social Security.
We can fund the $1.3 trillion we need to buy insured care with slightly better benefits and we can increase the number of people covered to create universal coverage by using just that 20 percent tax.
We don’t need a perfect number for the initial tax percentage level that is driven by detailed actuarial calculations if we have a “good enough” number that will give us enough money to pay the basic level of capitation for all the people who have employment in our work places and who therefore will be entitled to have coverage.
When we started the Medicare Advantage plan originally, the initial capitation number for the plans was arbitrarily set at 95 percent of the Average Area Per Capita cost for Medicare at that point in time. The plans were challenged to beat the Medicare cost number by having that percentage lower than 100 percent of those costs.
This approach resembles that by setting the capitation number at 100 percent of the national average cost for insured care in America — and improving the benefits and extending the coverage to more people with the difference between the $1.3 trillion and the total amount collected by the 20 percent tax.
We can set that new payment level up just like we do with the massive Medicare Advantage capitation cash flow that we have in place now and we can build a new formulae that adjusts by the right actuarial computations for age, gender, and geographic location to give us a good enough cash flow to make the program work.
We will have a massive positive impact on our health care economy by using that approach and by having the numbers that we use to be functionally “good enough” to work
That number will become the new normal cash flow for American healthcare. There will be a shakeout period on costs over a couple of years, but there is so much inefficiency and waste and bad care results happening now, that that 20 percent tax cash flow number will be more than sufficient over time to buy and pay for care and to reward our care sites and our health plans for delivering really good care in the future.
We know that we can deliver better care over time by doing the right things for patients in each setting. We can manage to have half as many asthma attacks and have as many CHF crisis and half as many diabetic amputations and half as many pressure ulcers in our care sites with basic care improvements that are easy to do when you are not paid only by the piece for each piece of care.
That amount of money requited to pay that tax should not be disruptive as a cash flow issue for either our workers or our work sites.
A 10 percent impact on workers will be a small price to pay to get full coverage — and it is well within the typical amounts charged by employers to employees for the past several decades for covering workers in America.
That is a relatively pain free transition to universal coverage.
If we assume even basic low-hanging fruit harvesting from care improvement for our patients, and if we assume very basic low-hanging fruit harvesting from the 30 percent or more of the care dollars we spend now on wasteful and unnecessary administrative expenses, then we should be able to extend a $1,000 deductible plan to everyone, and extend this coverage to the 30 million who do not have coverage now, and we should be able to pay for it all with the $1.3 trillion that could be paid out in per capita amounts to the health plans — if we simply collect a 20 percent tax from every paycheck.
Too many people in our country today have painfully high deductible plans. In some cases, those high deductibles are almost the functional equivalent of being uninsured.
That is a real problem for millions of people today that this plan would end immediately.
We can offer much better benefits than extremely high deductibles as a component of universal coverage that should be very popular with many people.
To significantly improve patient buying power in the context of the basic thousand-dollar deductible, we should definitely and effectively give patients much more information about the costs of relevant care. We should put very explicit requirements in place for the plans, requiring each plan to give all patients electronically available information about costs and prices for each piece of care paid before the deductible is met.
Market forces do not work well in health care now in America now relative to deductible benefit plans, because most consumers with deductible insurance plans do not have any available actual pricing information about each piece of care.
That process deficit is easy to fix when we become a more competent purchaser of care by requiring the plans to make that information available. Providing pricing information to patients should be an expectation and a requirement for each health plan and it will drive providers of care to make decisions about their pricing levels that they do not now make when all prices are hidden.
We would offer better benefits, guaranteed coverage, and better information to use in making care decisions immediately as these plans go into effect.
We also would have a dependable cash flow immediately to help COVID damaged care sites recover and plan for their futures.
The politics of getting Congress aligned with any funding approach for covering us all have probably changed in a major way very recently as the result of the COVID crisis.
We now have a clear sense of how badly organized care delivery is in their country and how completely inadequate our data-sharing tools are now for our patients. We also know that car sites need some security about being paid for patient care next year.
So creating universal coverage suddenly feels like the answer to a real problem rather than just being an ideological or political topic of inter group angst and debate.
Creating the New Reality is Easy Once We Start
Health care, itself, is ready and even eager to respond to that opportunity and to that badly needed crisis support cash flow.
Much of health care management and organizational planning was in a state of limbo before the COVID crisis, waiting for the next financing reality for the industry to become real — and the ability of the people who run care sites to adjust in creative and productive ways to the new payment approach and opportunity will be fairly high and immediate because they ae very ready for a better approach.
We have very intelligent people working hard in those organizations on those sets of issues now who are very frustrated. The ACO dilemmas have frustrated a number of care sites.
It is not an easy job to run the finances of a care delivery site in this country today — and many people who are managing the financial functions of our care sites will find this Medicare Advantage created cash flow approach to be more positive and easier than their current cash management job.
Selling this approach to the public should have a couple of significant points that need to be explained clearly to gain support.
Universal coverage will be a strong selling point for some people.
A clear majority of people have said in a number of fairly recent polls that they are in favor of Medicare For All when it has been proposed in survey form as a way of covering everyone.
The idea of using a program they like and trust and extending it to everyone has been well received.
The challenge here for this Medicare Advantage for All proposal would be to persuade the people with that level of support for universal coverage that this approach very clearly and strongly meets that set of needs.
People will also like it at this point in our history because it gives their COVID damaged care sites immediate and ongoing support, and people like when their care sites survive.
Overall, most people want affordable care. This proposal meets that need very strongly. The premium replacement of the payroll tax makes it affordable at every paycheck. Most Americans have significant health care expenses that will disappear when this program is in place.
It meets their current affordability needs and improves their current benefit levels at ways that should be popular with consumers.
Many Americans are angry with their current insurance deductible plans. This proposal will eliminate that anger.
The $1,000 deductible benefit package would be significantly better than the benefits that most people have today. Most Americans with private insurance have deductible levels that exceed that level now. Telling everyone that they will now only have a $1,000 deductible would be understood and appreciated as a richer set of benefits for most Americans.
We need to have some flexibility on benefits by employer, but that flexibility has to be limited to making benefits better and not making them worse or somehow decreasing them.
We will see a better market for some pieces of care.
If caregivers in an area know that their price for an office visit for a sick child will be visible to each patient, then caregivers will factor fee levels into their financial strategies, and price competition between caregivers will result fairly quickly in a number of settings.
Some caregivers currently charging $200 for an office visit, for example, might decide to reconsider, and offer a $150 visit — or even a $100 visit to generate patient volume.
That price-related competition does not exist now for those pieces of care because prices currently do not steer care for those services. Competition will exist when price information anchors care purchasing for some services.
Electronic Care Will Blossom and Flourish
People love using their computers and connectivity tools to support their care. This will facilitate that at a very high level and that should be extremely popular once people realize what it is.
An important area of service and care that will generate additional volume and trigger significant and important care delivery innovation will relate to electronic visits and the electronic delivery of care. Consumers want electronically connected care. Sixty percent or more choose it now when it is available.
Medicare does not allow that connection to happen.
Standard Medicare and most private plans avoid paying for electronic visits today, even though many patients prefer them to the logistical challenges of face-to-face provider visits, because Medicare and most payers fear electronic volumes in a fee-based payment model are too easy for providers to increase, which will simply trigger additional fees.
Patients would appreciate the choice of both prices and virtual care sites. A patient with a $1,000 deductible benefit plan might prefer to use a $30 electronic visit for that piece of care instead of triggering a $200 face-to-face visit with their provider of care.
When care systems are paid for the total package of care, there are very high levels of electronic encounters messages, connections, and linkages because they are used by the provider to improve care outcomes, and they are much more convenient for the patients.
The COVID crisis has actually put that topic in the forefront of American care delivery today — because many care sites are now creating electronic connections to avoid losing contact with the patients they serve.
This approach will make those processes work at even higher levels.
Anyone selling this proposal should strongly describe how much better the electronic connectivity tools will be for both care data and care delivery when that information is required as a condition of service for Medicare Advantage plans. Consumers will find that set of enhancements to be highly desirable and attractive.
We should also figure out how to continue to do some specialized plan choices for people next year.
There are now several specialized Medicare Advantage Plans for people with chronic illnesses or who are institutionalized. Those plans already focus even more intently on creating the right benefits and care incentives for groups with high medical needs. We need to figure out whether to continue those plans or include them in the overall package. When those plans are paid for overall care, they have done some very creative and very effective things to deliver that care.
The people who regulate licenses in each state will continue to have a role in setting the standards that fit their needs for determining who is allowed to sell what in each setting. Those regulators should support and facilitate extensive creativity and continuous improvements in the delivery of care, and should require that plans report regularly on their progress.
The government should not design and mandate the actual connectivity pieces for care sites, but the information flow from the health plans should be required to be very clear about the types and levels of connections that exist for their patients.
The best sites will continuously improve, but explicit connection rules imposed by government agencies can cripple positive change. Relevant regulators should mandate connectivity, and then get reports from the care sites and plans that explain what the current versions of that creativity are.
As a buyer, the purchasing pool should expect the plans to meet high standards for quality, service, information sharing, team care, and patient support. Complete patient information available to both the care team and the patient should be an expectation for every plan. Purchasing by the package gives us the opportunity set requirements for both care information and care information sharing by caregivers that create more patient focused care deliver.
The current Medicare Advantage plans already have extensive reporting about their care linkages and care quality, which does not exist for standard Medicare patients with those exact same conditions. We need to build on those reporting requirements, expand them, and create very user-friendly electronic feedback mechanisms from patients, similar to those that exist in other industries today.
Health care provides those levels of feedback badly today, and it will be important to set up good processes in the future that are best practices in those areas because care delivery is so important to us.
Care will also improve in a wide range of areas — and we know that to be true because we have seen it happen for plans today when they are free from the tyranny of the Medicare fee schedule. Each plan can expand benefits by using more effective care team approaches for their patients, and not be limited by the actuary created traditional Medicare fee schedule rules and definitions in the process.
Some plans have significantly reduced the number of broken bones in their patients by using nurses to do both support and coaching, and by using home preparation and enhancement approaches that make homes safer for seniors.
Medicare Advantage plans can actually expand services in ways that enhance care delivery because they are not paid by the fee, and because they are not limited to the rule set of the standard Medicare fee schedule in putting together caregiver support teams or care delivery approaches.
That creates a very different and very patient centered financial model. Medicare Advantage plans have strong and direct financial incentives to work to reduce the level of diabetic complications for their patients because, unlike fee-based Medicare sites and approaches, the plans are not rewarded financially for care failures and for care-related complications for diabetic patients. The clear financial incentive for the Medicare Advantage care teams and care networks is to help patients be healthy enough to avoid physical failures and to reduce care complications.
We Need Extensive and Continuously Improving Quality Reporting
That care for Medicare Advantage members and plans takes place now in a context of extensive quality measurement. NCQA reporting processes and systems currently track care inside the Medicare Advantage plans for diabetes, stroke, heart failure, and for fifty other care measures.
That is the same NCQA reporting, credentialing, and tracking model used today by the largest private employers for providing quality oversight to their own health plan purchases — and it is very different from standard Medicare program patient care where those levels of care quality and care service level tracking do not exist.
We need to get continuously better at quality measurement and consumer feedback, and all of that is much more likely to succeed in a single buyer world where plans are accountable for total care than they are likely to succeed in a piecework payment world when each caregiver is a silo, and no one is responsible for any part of aligning or improving care.
We Can and Should Create Financial Incentives to Improve Care and Make it More Affordable
Cutting asthma crises in half is good, but the financial reality is that when a hospital is paid well for each crisis, and is not paid at all for preventing them — and when hospitals need their revenue from each piece of care every day in order to pay their staff — the number of prevention programs for those crises that are created are not high.
However, when hospitals have a clear incentive to reduce crises — proactivity flourishes with improving and more affordable care happening fairly quickly in those care sites.
That means, structurally, that it makes sense in terms of incentives to have someone or some organization in the stream of cash going to a set of patients who benefits financially from making care better — and it is also true that the relevant party does not need to be either the physician or the hospital. It can be a care team or some organization that is a key part of the cash flow and has the ability and incentive to help the care team in each setting do the right thing for their patients.
We Need Incentives at the Right Level
Incentives should exist for every patient — but they do not need to exist for each patient at the physician level. Many of the best care settings in this country have their entire medical team only on salary, and those care organizations very intentionally divorce their individual physicians from anything relative to either actuarial risk or care procedure based financial incentives. Those care sites all tend to have very high quality of care ratings.
We need care teams and overall care organizations to be at risk — not individual doctors at risk — and we need organizations with the right skill sets and resources to be supporting the organization and reorganization of care in each setting with those incentives in place at the macro level.
That is why channeling the funding stream to the care teams in the context of a Medicare Advantage approach that clearly restricts inappropriate or challenging financial arrangements can both improve and bring down the total cost of care without having individual caregivers facing conflicted incentives and dueling compensation realities.
Each Medicare Advantage plan needs to build a care network that meets patient needs and has all the parts and pieces needed to provide and continuously improve care. We need both accountability and creativity as part of the process, and we need enough visibility, relative to what the care teams and health plans are doing, so that they can learn from each other and continuously improve.
Health care actually does create great jobs and is very good for local economies, and we will earn significantly more value from those care dollars if we put patient-focused and continuously-improving care models in place through our purchasing approach and incentives.
If the U.S. is Ready, We Could Convert Everyone Relatively Rapidly to Universal Coverage with MA and Do It Well
Care would improve immediately.
Electronic patient connectivity would blossom. Caregivers and patients both appreciate the high levels of electronic connectivity that are possible but now outlawed by the Medicare fee schedules. Patient contacts could be built around patient needs instead of the need to trigger a patient encounter fee.
More than a third of direct face-to-face provider contacts in many care sites could be done electronically in ways that patients and caregivers prefer when both the fee schedule limitations of the payers, and the cash flow needs of the care sites are no longer keeping those electronic contacts from happening.
Care teams can form and begin to function immediately. The information flow needed to support their work will exist because when people enroll in a plan, the plan automatically sets up data processes for each enrollee, and can be used to support care, instead of simply triggering a claims payment.
At this point in time, it is a matter of political will — not functional capabilities — for making that conversion. The functions needed to go down this path and to fund it all exist. We need to decide whether we collectively want to use them.
Medicare, Medicaid, Large Employers, and Catastrophic Coverage for a Lonely Few
To minimize market disruption and reduce political resistance to the new agenda, we should encourage and allow large private employers to continue to self-fund their health benefits for their employees.
Their employees already have coverage and we want that to continue. We don’t want to lose either the creativity or the cash flow that can come from the self-funded employers who would continue to sponsor plans. Those plans have the potential to help improve care, and they already cover millions of Americans today. We don’t need to end those plans to make this strategy work, so we should allow them to continue to operate as long as their benefits are not lower than a $1,000 deductible.
We also want the labor union trust funds that have been set up to provide health care for their workers to be able to work with the Medicare Advantage Plans and even Medicaid programs in each market. If those plans decide to continue to function separately, and if their union members want them to continue to operate, they can be certified as Medicare Advantage Plans for cash flow purposes, and can receive that same money from the insurance trust fund amount for their members.
Keeping Medicaid in the picture as a key component part of the solution set makes sense at multiple levels. Medicaid already covers millions of Americans who really need that coverage. The current Medicaid benefit package is much richer than the thousand-dollar deductible that will be used by most other Americans, and the Medicaid providers are already in the communities with Medicaid beneficiaries.
Medicaid has been increasingly effective as both a purchaser and provider of care, and we need to link the best aspects of what those new Medicaid plans do with our care improvement agenda and processes through the Medicare Advantage plans and tool kit.
We need to do more than just retain Medicaid. We actually need to expand our use of Medicaid in several important ways. We need all low-income people to have Medicaid coverage.
Medicaid is already a massive program and covers more than 25 percent of our population today. We would simply continue to use the Medicaid funding streams in place now for Medicaid for those patients — so that approach will not add anything to the cost of care.
Medicaid now covers more than half the births in America.
Medicaid also now covers more than 70 percent of our nursing home expenses.
Those are extremely important components of our health care delivery reality. We need to understand how important it will be to do those programs well, and we need to support that process.
The coverage of nursing home expenses by Medicaid today tells us that patients who trigger those expenses would be well served by having a care coordination link between our physicians, our hospitals, and our Medicaid eligible patients that can be built into the plan specifications.
There are a number of things we should do to strengthen the public health agendas for our Medicaid patients — and we can do that work more effectively if we require coordination between those programs and the new Medicare Advantage plan that we would be using to cover all Americans of all ages.
The Biggest Single Source of Cash for Care in America Would be Medicare Advantage
We need to link this plan to our payrolls and we need to encourage employment whenever we can encourage it. This approach would actually work well for people with multiple jobs. An increasing number of people work out of their home and do not have a link to employer-based health care and coverage today. This approach would reach into every home because it would be linked to every paycheck.
People who work part-time or who serve two or more employers would automatically have provisions and funding for coverage, because 15 percent of the payment from each employer would be accumulated automatically on their behalf.
Labor unions used similar funding accumulation approaches when they had multiple employers hiring their workers. That ability to blend pay from multiple employers was a major benefit of being a union employee. We could echo that multiple employer trust model for part-time and multiple employee in-home workers with this approach.
Part-time employers could use the availability of this coverage to compete for employees, and some could become favored employers with employee loyalty links by offering to pay a higher portion of the health payroll deduction for the people they employ. It would be good to have that option built into the payment model for employers of piecework work forces to create funding options that could work for making that process attractive to workers and employers.
The insurance exchanges that exist in the states now could continue to operate by accepting the payments from the insurance fund into their cash flow, and by including both the Medicare Advantage Plans and the Managed Medicaid plans into their networks. States could each decide how to utilize that resource.
The cash flow to everyone with coverage from the central health care fund could also be channeled into health plans through the state exchanges that continue to operate in some settings.
Some states have created and implemented robust exchanges with highly desirable features, and it could make sense for those plans to continue to function in the cash flow created by the Medicare Advantage payroll deduction.
We need to make it easy for providers of care to both participate in Medicare Advantage programs and to create and run their own Medicare Advantage plans where that approach makes the most sense for the local care system.
We have a long history of some Medicare Advantage plans becoming increasingly good at supporting caregivers in the delivery of care and setting up care teams, and that skillset and package of behaviors will be even more useful when everyone is enrolled in a plan with the expectations of receiving team care.
We Need to Protect Providers of Care in Transition
We need to make sure that we protect and support care providers during the period of transition.
As part of the initial extension approach, we will need to provide caregivers the opportunity to participate in the Medicare Advantage plans as well as form their own. Each state should work out its own processes and schedules for their current programs to implement this broader agenda and support local caregivers.
The goal in each state will be to have all providers either in one or more Medicare Advantage plan, or to have the providers functioning as part of the Medicaid and Children’s Health Program for their states.
That particular approach of creating local care system-based plans would support existing care teams and it will give local care giving institutions in various communities both the choice and the opportunity to form their own Medicare Advantage plans.
Low-interest money should be made available to care systems that choose to start and run their own plans.
The support process that would exist for caregivers who want to function in those capacities is a market that is already rich in vendors and funding sources. There will be no shortage of qualified and competent vendors, potential partners, and computer support organizations available to help those caregivers enter into that capacity or to create ACO like programs in various settings to work with the Medicare Advantage Plans.
The Medicare Advantage plan participation standards created by each state would expect those providers who create those capabilities to meet some basic financial safeguards and to create reasonable ways of coordinating their transition from their existing payer contracts in ways that would not impair current payment approaches for current plans in each setting that work now with those providers.
Moving all insured Americans to Medicare Advantage plans would give us the opportunity to channel the cash flow for health care into a context where caregivers would work as teams on behalf of their patients, and could make investments in those tool kits and capabilities knowing that those tools would be useful and valid over time for each setting.
Knowing that particular cash flow would define the future cash flow for care in each setting would create a care context where significant care data-flow connectivity could be put in place for every patient, and where care teams could build and use the support and tools needed for team care, because those tools would be sustainable over time in that economic reality. Those investments by care sites can be risky when the future cash flow for care is unclear and those investments can be extremely beneficial and very low risk when future cash flow expectations are clear for each care team.
Patients will benefit very quickly from having the new coverage and new payment approach, beginning immediately with better team care and better flow of information about their own care than we have now in most settings. The average patient today with co-morbidities averages more than five caregivers per patient — and the normal situation we face for each patient includes very weak or non-existent processes, and almost no tools for sharing information about a patient between those caregivers.
Caregivers today tend to function as information siloes with very little data sharing, even for the sickest patients. Enrolling patients in Medicare Advantage plans and Medicaid programs with extensive computer support tools and an automatic data channel for each patient will create automatic data flow that could be used by the caregivers to support fully informed care delivery.
Quality reporting will be strong and will continuously improve using that purchasing model for care.
That process has a good beginning now.
Medicare Advantage Plans are now required by law to have all the information for their patients, and to report on care quality and service levels in 60 reporting categories that have been defined and validated as legitimate measures and as accurate reporting processes.
Patient centered medical homes that have been created in recent years as part of the care improvement agenda have another two-dozen sets of information sharing and reporting requirements. The Medicare Advantage plans should be required to use those sets of tools.
All of those quality and service requirements will be far better for patients than the complete lack of information sharing requirements that exist for standard fee-based Medicare patients today.
Enrolling everyone in Plans would give us much needed access to care data and information for all patients. If all Americans were enrolled in Medicare Advantage Plans, with patient-focused data collection, we would have the ability to deal with issues of responding to possibly dangerous medical devices that might have been implanted in days instead of in months or years.
Likewise, if every American knows who their available care team members are, then data reporting on issues like hospital death rates and care team comparative survival rates for various types of cancer could be made easily available to patients. Initial data shows us that there can be significant differences in caregiver performance on issues like cancer survival rates — and those differences can be highly relevant to patients.
Today, we have no mechanisms for doing that kind of follow-up reporting — and it would be relatively easy to do using the kinds of data-bases that are inherently set up when everyone is enrolled in Medicare Advantage plans.
New Electronic Care Support Tools Will Have an Exploding Market and Higher Levels of Success
We should be able to use the new levels of data processing and even artificial intelligence to help support patient care — and that will not happen at any significant level as long as traditional Medicare controls the health care database and sets up barriers to both information sharing and team care. Medicare Advantage plans can be required to create full data access for each patient, and to supply that data in ways that both care givers and various support tools can use to help people with their health and care.
When that data about all pieces of care that is used by each patient becomes available for each patient, care will be better within care teams, and patients will have a wonderful opportunity to expand their own knowledge about their own care using a wide and expanding variety of care tool options.
We need a patient focused marketplace for care support information flows and care delivery processes. That will not happen until we mandate it as part of the purchase of care. It will not happen on its own. Someone needs to have that work as an assignment, or it will not exist.
The patients should be able to use their own data in any set of care support tools or processes that they might want to use. This approach of mandating Medicare Advantage plans to make that data available will be a powerful enabler for those new markets.
A number of organizations are trying to create products intended to help patients make better health care and general health decisions. Millions are wearing health monitors of various kinds already.
The problem today is that there is no good way of using that separate stream of data from those new electronic monitors to fully support and inform patients, because the systems and vendors for those products do not have access to the full set of data about each patient that would make that data most useful.
That will change if everyone enrolls in a Medicare Advantage Plan, and if the patients are entitled to their own data from the plan’s electronic files.
We will see a golden age of patient support tools when that data flow about each patient becomes available and usable by each patient.
That set of available electronic data can only happen with high levels of success if someone builds that file for each patient — and that file will not be built until someone has the functional need at the patient level to collect and use that data.
Plans will have both that need and that capability as a condition of being allowed to function in that market.
Providers Will Invest in Care Improvement When the Rewards for Those Investments are Put in Place in the Flow of Cash
Our single most important goal in moving to that level of coverage will be to get the full benefit for our country of providers functioning in team focused care. The COVID crisis has shown us how few care sites do team care now. That will change.
We can also do better long-range planning for care sites.
Caregivers who either create their own Medicare Advantage plans or who know that their future payment cash flow will come from that Medicare Advantage linked source, can work with those plans to create a dependable revenue flow that will allow both better planning and the creation of various levels of systematic care improvement in ways that will never happen as long as we buy and sell care at the core level entirely by the piece.
Patient Centered Medical Homes for both primary care sites and medical specialists should be a required available payment approach and a delivery model option for the Medicare Advantage plans, and that should create an opportunity for private practice care sites and community clinics to join the Medicare Advantage cash flow.
This benefit funding approach can either replace the Health Care Exchanges over a few years, or we can use the Medicare Advantage approach as the next stage of development for the local health exchange marketplace. Individual states could and should make that choice in the context that works best for each state.
Medicaid Should be an Anchor Funding Mechanism for the New Health Care Marketplace
Medicaid should continue to be a major care-purchasing program for the government and should be expanded to cover more low-income Americans as a voluntary enrollment choice for those who buy their own coverage. We should allow low-income people who prefer the local Medicaid plans over their local Medicare Advantage plans the opportunity to enroll in either.
The monthly payment to the plan for the people making that decision would be based on the average costs of providing Medicaid care in that setting, and not on the Medicare Advantage care cost number for that area.
Medicaid is currently the most affordable care-purchasing tool for the government, and its fees are significantly lower than those paid by either Medicare or by our private insurers.
Medicaid has been doing increasingly effective and creative work in a number of states in both meeting patient needs and creating team care for both mothers and babies. The states that now buy care by the package for their Medicaid patients have seen an explosion in capability enhancements relative to both preventive and team care. Those programs are built around the populations they serve and have been increasingly patient focused in their care models.
We should keep the very best components of the current Medicaid program in place, and we should use that program and those capabilities to continue to meet the coverage needs of our lowest-income people.
We need to ensure those programs are achieving their quality of care and service level requirements, but that is an extension of our current practices rather than a new direction for that care.
We do need to make sure the Medicaid plans and programs coordinate data flow and relevant logistics with the Medicare Advantage plans, but that should be relatively easy when sharing information is a requirement. That will be particularly true for the nursing-home payment components of Medicaid coverage.
We Should Definitely Cover Everyone in America
Using a combination of employer-based plans and Medicare Advantage plans for our working and higher-income people and our employer groups — and utilizing our current Medicaid, CHIP, and community clinic approaches for our lowest-income people — can give us a path to universal coverage that we could implement without having to build any major new government programs or any significant infrastructure.
Those three core funding approaches and cash flow realities will not be in functional or economic conflict with one another. Both Medicare Advantage and prepaid Medicaid will encourage and support provider relationships that focus on prevention and team care. The employer self-insured plans in each setting can work in creative ways with local caregivers to figure out effective ways of delivering care.
The advantages of having organized and accountable team care with extensive quality reporting mechanisms in place to deliver care for our low-income people, compared to a pure fee for service reimbursement model that we have historically used where low-income people have to somehow find care givers who will take care of them, is increasingly obvious to anyone looking at the various ways we now deliver care to our low-income patients.
The use of Medicaid for most births in America also gives the care delivery teams an opportunity to educate every parent about the biological reality that talking and interacting with each child in the first months and years of life strengthens brains.
Brain science is developing in important directions that are extremely relevant to Medicaid patients. Now that the great child-research programs at Harvard, Columbia, The University of Washington, and Berkeley have established the importance of those interactions with children in those time frames, we need to get that information to every parent. More than 90 percent of Medicaid parents in one study did not know they could exercise and strengthen their child’s brain in those first months and years.
The brain of each child starts a purging and pruning process at age four, and the new science tells us that much of the work done with children from all groups after that point in time has much lower impact.
The Center for The Developing Child at Harvard and other great research programs at The University of Washington, Columbia, and the University of California all now know that science extensively and well, but that knowledge has been completely invisible to Medicaid parents and only marginally visible to others.
Learning gaps exist in our schools in far too many communities because we have not shared that information with families and parents. That represents a massive public health failure for us as a country.
We need our Medicaid caregivers to help each parent understand those opportunities or we will not close the learning gaps in our schools. Efforts to close those learning gaps at 15 years have consistently failed, because the pure biological science now tells us clearly we need to close them at 15 months.
Many of the same insurers who will participate in Medicare Advantage will also participate in Medicaid managed care, so opportunities for continuity of care and coverage both exist as people become eligible for different programs in those states, and the people who change eligibility in those settings don’t have to switch into entirely different systems.
Even if the plans are different from one another, however, when we have created the requirements for team care and mandated certain components of data flows about patients for both Medicare and Medicaid, the transfer of data focused on the patients can simply be made a requirement that plans must meet in both programs.
Minimally, we need an equivalent of the FIHR data base sharing tool for electronic medical records at different care sites to be available for sharing data on a patient specific level between care systems.
The VA system can be asked to use the same data transfer processes and protocols, and that can obviously make care coordination between the VA and other systems more patient friendly and effective.
The VA Hospitals and care sites have some care capabilities that are highly useful to their communities, and they should be able to continue to meet those needs so long as they adapt their reporting and care support information flow systems to interact with the rest of the care infrastructure. This approach would not interfere with the funding approaches for the VA care sites, but it could enhance some levels of VA care, because the same requirements set up for data flow about patients inside the Medicare Advantage plans could also be met by the VA systems.
The FIHR connectivity tool could also help create data sharing on a patient basis within the VA before they get their new electronic medical record fully installed.
Some Will Remain Uninsured
This approach should result in very few uninsured. But no matter how well we set up those processes, we will still have a small number of uninsured.
We need a path to the functional equivalency of coverage and a process to pay for at least catastrophic care for those who will remain without coverage. We need to make policy-level choices about how we deal with those care expenses.
We need to create a fourth cash flow for care that provides catastrophic coverage in designated care settings for the otherwise uninsured as a safety net and financial mechanism for keeping local hospitals from having major unreimbursed costs.
As a cash-flow issue, we should create a catastrophic care insurance pool for uninsured Americans by channeling one-tenth of 1 percent raised by the payroll tax into that fund, and we should extend that catastrophic coverage payment approach to anyone who does not have insurance by having those people receive care when it is needed from designated subsets of the local care system who have been selected to provide that care.
Those subsets of the care community that will provide care to those otherwise completely uninsured can be chosen by each community from the most logical and appropriate set of providers for each setting. Judgment by the local setting can determine what that system is in each location. States could tie that coverage and those local care delivery mechanisms to their Medicaid program, or purchase that catastrophic insurance from Medicare Advantage plans.
Or they could create an entirely new set of provider relationships just for that purpose.
Car insurance has one set of benefit components that protects the insured person’s own property and another set of components that provide protection to the other drivers who might be damaged in the event of a car accident. That second category of car coverage protects other people — not the person buying the insurance.
Our catastrophic health coverage would provide a somewhat similar role in keeping the caregivers who end up treating very ill and expensive uninsured people from having major financial losses as a result of that care. That combination of financing approaches will give our care providers the assurances they will need to redesign the delivery of care.
We Can Create Universal Coverage for America Without a Single-Payer System
We can cover everyone in America with better care than most people have now and do it spending less money than we spend now and with a guaranteed future cost level by making Medicare Advantage for All our strategy and approach for both coverage and care.
We need to function as a purchaser of care — not just a buyer of care.
The Medicare Advantage plans that will be paid a voucher-like amount each month for every patient will have both the incentive and the ability to deal with the key functional and structural components of the cost of care. This approach of having both the government and the market buy care by the package will allow plans to work directly with the caregivers to help bring down the unit costs of care.
It will also give plans the opportunity to compete with each other for patients in ways that will improve both products and service levels in ways that will not exist by simply deciding to expand standard Medicare and administer this expansion of coverage as an agency or as a government department, instead of as a marketplace for competing and accountable businesses.
We can cover everyone in the country without using a single-payer system by having the health care funding pool function as a buyer, not a payer.
We can achieve universal coverage without changing our payment approach to a Canada-like single-payer system.
We already know that to be true, because achieving universal coverage without using a single-payer system is actually what most countries in Europe do to achieve that goal. A Medicare Advantage-like market-based multi-payer approach is what most countries in Europe actually use now today to purchase care and coverage for their people.
European Countries are Single-Buyers — Not Single-Payers — And We Do Not Understand What They Are Actually Doing
We have extensive and heated debate in Washington DC about the fact that our health care expenses significantly exceed health care costs in every other country in the world — and we often try to solve our health care costs by using those other countries in sometimes heated debates as examples of either what we should do better in our country or what we should avoid doing here.
The effectiveness of our debates and thinking on those issues is badly damaged by the fact that we usually say important things that are inaccurate, misleading, and wrong in those discussions about those other countries.
We can’t learn from what they are doing if we completely get it wrong in our discussions of what they are doing.
It can, however, be very useful to our debate and to our thinking to actually know what is actually happening in Canada and in Europe relative to the cost and delivery of care.
We have a pretty good sense of what Canada does — because it is very close to us and they have a very definite single payer approach to both coverage and care.
We all need to know and understand that none of the European countries who all actually spend less than Canada spends per capita currently use a Canadian clone or even an echo of a Canadian style single-payer model to buy their care.
A number of people who have a strong ideological and sometimes political hostility and direct opposition to the role of health plans and health insurance companies in America — tend to claim with great clarity that health insurance companies are the primary reason that our health care costs are so much higher than Europe — and those people in our debates tend to very explicitly name and blame health plans and health insurance companies as being the primary reason for the cost difference between us and Europe and between us and Canada.
That could not be more wrong for Europe. The exact opposite is true because the truth is that most of the countries actually use Medicare Advantage like insurance companies and plans now.
It is an absolute fact that no country in Europe uses the Canadian single-payer model. Not one.
They actually do not use a single-payer system to buy care as their payment mechanism for coverage or care in any country.
The counties in Europe go down two very different paths to provide and buy care and neither path duplicates or replicates Canada.
The Scandinavian countries basically own their entire care systems. They have no payments of any kind in those countries for care, because there are no fees charged in those owned care sites for care. They don’t use a single-payer system in Sweden because the government owns the hospitals and hires the caregivers and there are no fees– so there is no one to pay.
The Scandinavian countries look very much like Kaiser Permanente care teams in our country. They are entirely vertically integrated and they actually purchase medical care from their caregivers by the month in salaries, instead of buying it by the piece in fees for each unit of care.
France has a mixed model with the government setting very low provider payment levels and roughly 90 percent of the people purchasing private health insurance for their networks and higher payment levels.
The other countries use Medicare Advantage like health plan choice insurance company linked models for coverage and care.
As we consider using that approach here, we should understand how it works there.
Europe has successfully achieved universal coverage, and every country in Europe spends a much smaller percent of its GDP on health care than we do, while providing coverage to every resident in every country without using the Canadian single-payer approach in any setting.
They use what are very Medicare Advantage-like competing health plans in all of those countries. People in each country choose between competing and privately owned and run health plans for their care.
They also tend to tie their health plan choices in each country to each employer. They run their own versions of exchanges and they require their people to select a plan from the list blessed by their employer. The governments in each of those countries take a payroll deduction from every employee every month and they each mandate that every single person in the country pick a health plan from the list of plans available in their geographic area.
Europe invented health plans. They had them long before they existed in the U.S.
Most countries in Europe actually have a long history of using competing health care plans, and they manage to cover everyone though those plans, with no government programs of any kind. Romney Care in Massachusetts looked a lot like the standard health plan exchange system of Switzerland, except for the much stronger mandate to buy coverage in Switzerland.
Chancellor Bismarck of Germany invented the approach more than 130 years ago. Bismarck was opposed to a socialist system of government and he also did not want the government to insure care — but he wanted all Germans to have access to affordable health care and he thought having access to care as a universal reality for all Germans would help create uniform support for the German nation and help build a sense of identity for his country.
To achieve that goal, Bismarck invented competing Sickness Insurance Funds. There were hundreds of those sickness funds in Germany at one point in time, and more than 100 of those private plans remain in business and compete with each other today.
Those sickness fund health plans and a small number of health insurance companies all enroll members in their insurance products, and those plans compete directly with each other for customers every day.
Mandates to be insured are essential for those programs to work.
The functional anchor to that market model that is allowing it to survive financially for more than a century is a mandate. Coverage is not optional in Germany. The Germans use the same mandate model for health coverage that we use in our country for social security. And, to a lesser degree, for our car insurance. Every German must join a sickness fund. Payroll deductions for each employee create the cash flow that purchases care from the funds in each country.
The percentage of each paycheck that is spent on health care has remained very consistently at 15 percent for a number of years, and that expense is split equally between employer and employee.
Switzerland and The Netherlands use that same approach. Neither country uses a single-payer approach. There is not one single person in either country today with government health insurance. Competing health plans compete with each other for enrollees in each of those countries. People and their employers each pay a portion of the premium.
Television ads in Switzerland trying to persuade people to enroll in Swiss health plans look very much like the ads we see on television for our health plan sales efforts in America.
That model works financially because each of those countries mandate that every citizen join a plan and they have no free riders who get coverage but don’t pay part of the premium.
They Have Faster Access to Most Care
Health plans in those European countries provide very complete coverage. They spend about half as much money per capita as we do. We need to understand that massive difference in cost as we go forward to build our own universal coverage strategy.
The cost difference in care between us and them is not created by rationing. Many people who are debating and discussing health care coverage and costs in America believe care in Europe costs less because it is rationed. That is not accurate.
They do not spend half as much on care in those countries because they are rationing care. That alleged care rationing approach by the countries of Europe is an extremely inaccurate but very powerful urban legend in our country, and the caregivers and competing health plans in those countries are sometimes offended by our public statements about their supposed care rationing.
They actually pay significantly less that we do for each piece of care. They don’t ration care. They get a better price for care.
Their patients actually have faster access to both primary medical care and basic hospital care than we do in our country, and their access to very good levels of specialty care in those countries is very similar to ours.
Many media articles in this country have pointed out with sorrow and envy that those countries actually achieve better health outcomes in some areas than we do. There are deep streams of evidence showing they have better health care outcomes for most diseases, and they tend to have lower levels of chronic health care complications.
That is partially true because they actually have significantly more primary care doctors than we do, and primary care in most settings does good work in preventing complications of diseases.
They all actually have higher levels of hospital use and much longer lengths of stay in their hospitals than we have in our country. People in our policy circles who say that Europe denies hospital care should look at actual hospital use, hospital bed numbers, and hospital capacity levels in those countries. They charge much less per day than we do, but they actually use many more hospital days than we use, both in total and by patient.
Using more days of hospital care for each patient in each of those nations is obviously not because they are rationing.
They pay for all of that care through competing health plans, and those countries absolutely do not use any government-run single-payer systems to buy care. There is not one person in Switzerland or in The Netherlands who has government administered single-payer coverage of any kind.
There is a high level of confusion in our country on that single-payer health plan point primarily because our closest and most visible neighbor with universal coverage — Canada — actually does use a single-payer health insurance system, and we simply tend to believe that Europe somehow clones and duplicates Canada.
Great Britain does have a form of single-payer care-purchasing approach because they functionally capitate each of their primary care doctors for their panels of patients, but they don’t charge or pay fees, and they also do not buy the overwhelming bulk of their care by the piece.
They simply prepay and capitate for most care in Great Britain using monthly per patient payments to the primary care doctors rather than piecework fees. They actually depend for their care delivery on a massive number of private practice primary care doctors who are each capitated monthly based on the number of patients who choose to be in their panel.
Those capitated primary care doctors in Great Britain work with government budgeted specialists and government hospitals when they need care that extends beyond basic primary medical care. Hospitals in Great Britain tend to be government owned, most specialists are on salary to the government, and the hospitals and government budget constraints put limits on how much money they spend on both hospitals and specialists.
The bulk of the horror stories we sometimes hear about treatment delays for specialty care under universal coverage and under the single-payer payment model come from those two settings. Canada and Great Britain.
Both Canada and Great Britain have had some care delay issues in some areas of care delivery where the single-payer, government-budget based approach to funding care has created limited access to some specialist resources.
Canada does have some care access issues for some areas. Their access to primary care is as good or better than ours, but they do put some limits on how much they spend on hospital operations and on some components of specialty care.
Canadian provinces set the hospital budgets for each hospital and there are strong anti-tax forces at work in some settings with some of the voters in Canada with ebbing and waning levels of political support that keep budgets lean for many of those hospital settings. They have very good hospital care in Canada — but when the hospital budget is lean for a given hospital because they have decided not to raise local taxes to buy more care, there can be delays for some care in some of those settings.
Europe does not have those kinds of care delays or problems.
As we look at our own health care financing options, and when we look at our own aspirations of universal coverage, we need to understand that those kinds of access problems to medical caregivers and limited access to hospitals do not exist in the countries of Europe that use competing health plans and private market competing caregivers instead of government insurance single-payer approaches to finance care. Each of those countries that use that competing health plan model literally and measurably actually has more extensive use of hospital care and primary care than we do.
They spend less money on care in each of those countries because they do a better job of creating access to primary care, and because they pay significantly less than we do for each piece of care. All the countries in Europe and Canada pay less than we do for each piece of care, and their total cost of care is lower as a result.
The arithmetic is clear. We have significantly less hospital care per capita than the European countries, but they charge much less for each day in the hospital so their total hospital costs are lower.
Prices for Units of Care Create the Major Differences in Care Costs
All of those countries spend significantly less than we spend for each piece of care for all areas of our health care economy other than Medicaid. A coronary bypass surgery that costs roughly $10,000 in Europe, costs anywhere from $30,000 to $100,000 in our country.
The most visible and most important exception in our country to that practice of paying much more money for each piece of care than Europe and Canada is our Medicaid Program. Our government in each state sets the prices for our Medicaid program, and the Medicaid prices that are currently set by each of our states look very much like the actual fees paid in Canada and Europe for most service.
The International Federation of Health Plans has a useful report that shows how much is spent on a wide range of health services in a number of other countries, and how much we spend here for both Medicaid and Medicare in addition to our private insurance plans and payers. That report has shown clearly that we Americans spend significantly less on each piece of care purchased by our traditional Medicaid payment approach.
Our fees for most areas of care are far higher than prices in those other countries for both our Medicare program, and our private insurance payment levels. Only our Medicaid programs use the European and Canadian price range to buy care. We use low fee schedules to buy care in every state for our Medicaid program because the states cannot run deficit spending budgets and they use the Medicaid fee schedules as a way of keeping their budgets legal.
Both of our own major government care purchasing programs use the approach used in Europe and Canada to set prices for each piece of care. The model that seems to happen whenever the government gets involved in care funding is that they are comfortable setting prices for pieces of care. Medicaid sets the lowest prices here and Medicare sets prices that are 20 to 30 percent higher than Medicaid prices but much lower than the fees paid by private patients or private insurers.
Our private payers who buy care by the piece all pay more than either Medicaid or Medicare, and the people who have no insurance at all are charged extremely high prices for each piece of care. An emergency room fee that Medicaid might buy for $200 and Medicare might buy for $300, might cost private insurers $400, and might cost consumers with no insurance at all between $1,000 and $10,000 — depending on the hospital.
Those prices are all known to people looking at how much we pay for care in this country.
Medicare and Medicaid both set fees that are lower than the community average payment levels for private payers in our care sites for the purchase of care. Medicare prices tend to fall into the middle, between the private market prices and our Medicaid prices.
For a number of reasons, the fees for Medicare tend to be significantly higher than the fees for Medicaid, but significantly lower than the fees paid by commercial insurance companies and health plans to pay for care in America.
That is an important set of cost differences to understand as we look at extending coverage to all Americans. Both Medicare and Medicaid have used their power as government entitlement programs to administratively determine what they will pay for each piece of care, and those prices are generally significantly lower than the commercial insurance and self-insured plan payments made to our doctors and hospitals for those services.
The Medicare and Medicaid allowable fees are also far lower than fees the hospitals in this country often charge to the uninsured who simply seek care directly and pay hospitals as individuals.
The horror stories about people with no insurance who are bankrupted by those hospital and care site fees have been a shame to us for years.
Prices are extremely important and they need to be understood in order for us to understand the major differences in GDP use by countries for care.
As we look at the total amount spent by other countries to buy care, those actual price-level differences between us and them for each piece of care are important to know. Some people in some public debates and speeches very clearly and explicitly blame health insurance company costs in the U.S. as being the primary reason the health care cost differences between us and Canada.
Most People Who Describe Canadian Health Care Costs Get It Very Wrong
People often compare the percentage of the GDP we spend on care to the percentage of the GDP spent on care in Canada and point out that our percentage is much higher.
We just exceeded 18 percent of our GDP as a care expense this year. The Canadian government currently projects they will spend 11.5 percent of their GDP on care this year. That is a very significant difference in the total relative cost of care in the two countries, and it is one that we generally do not explain very clearly in our discussions on that topic.
The biggest gap in the discussions of the cost differences between the two countries is that many people seem to have no idea at any level that there is actually a very major difference in the amount paid in each country for each piece of care. That huge difference in prices is almost never mentioned in those debates by either side in the debate.
We have data to look at that we should understand.
It is important to know when looking at those care cost numbers for the two countries that our Medicaid program currently has a fee schedule that is almost identical to the fee schedules that are used everywhere to buy all care in Canada.
That is easy to verify. Both our government and the Canadian provinces make those fee schedules visible to the people who deliver care in both settings. Anyone looking at the actual care purchasing fee schedules used in each of those countries can see that the Canadian Provinces and the U.S. government Medicaid program both pay at about the same levels for each piece of care.
We tend to have three tiers of prices in the U.S. Our standard non-government fee levels are the highest payments — and those fees tend to be negotiated by the various health plans and health insurance companies in America for the purchase of care. Those fees tend to vary from plan to plan based on negotiating realities for each plan and each setting.
A given care site might have six patients in a row getting the same exact piece of care, and the care site for those patients could easily have six completely fees charged for that same piece of care.
The second payment tier in our country is the Medicare fees. Medicare fees are not negotiated. The government imposes them annually, and they tend to be 20 to 40 percent lower than the average fees paid for that same care by commercial insurers. Multiple studies are available to show that to be true.
The third payment tier in our country is Medicaid. Medicaid fees are also completely non-negotiated and they tend to be about 30 percent below the Medicare fees. They are the very lowest fees paid in each setting for most pieces of care.
We know what those price differences and fee levels are, because they are also all public knowledge.
Anyone looking at our public records and our payment patterns for fees can also easily see that Medicare pays more than Medicaid for just about every piece of care.
That is not a secret. Every caregiver business unit in America can easily recite those differences in fees because those fees are used every day in our country by Medicare and by Medicaid to buy care.
For a number of reasons, our government has chosen to pay significantly more for each piece of care on our Medicare fee schedule than we pay for those same services for our Medicaid patients.
The relative and potential higher political impact of our senior patients versus the lower direct political clout of our low-income patients might be part of that difference in price between the two programs.
It is important to recognize and understand that the two programs have different payment sources even though they are both government programs. Medicaid is basically a state program and spends state money in addition to spending Federal money to buy care. States run Medicaid and states set each of the Medicaid fee schedules.
That is important to understand, because the functional reality we face is that state budgets tend to be subject to laws that do not allow states fund operating budget deficits. That reality puts major pressure on state created fees to stay under the state budget that is not as intense as the Federal government cost pressure for Medicare fees, because deficit spending actually is allowed for Federal budgets.
In any case, the undeniable and clear situation we face is that our Medicare fees are higher than our Medicaid fees in every single state and those differences are significant.
We also all need to know and understand that Canada buys care for everyone in the country using the Medicaid level fees.
We need to understand what that tells us about relative costs of health care spending in both countries.
That piece of information tells us that the Medicare fee schedule we use to buy care for our Medicare patients and that some people propose we should use to buy care for everyone in our country is actually much higher than the Canadian fee schedule that they use to buy their care for everyone.
Fees set by the Canadian government single-payer insurance system have great power over providers of care in Canada. The government will impose significant penalties on any caregiver who charges more than those fees. Doctors in Canada are very clearly forbidden by law from adding even $1 to that government fee.
So being a single payer for all care has obvious cost advantages for Canada relative to the price and cost of care.
When you look at actual care cost numbers, that fee schedule is the single biggest advantage for Canada of using a single-payer system to buy care. Because their government program is the only allowed payer for each piece of care in Canada, they can absolutely control costs by setting care their care fees at levels that meet their current government cost-control goals in each province.
This is not secret. They are very open about that process. The facts about what they decide to pay for each piece of care are clearly visible to anyone looking at the Canadian care delivery situation.
As we debate the impact of possibly using the Canadian single payer approach to care for our country, it is useful to calculate and understand what would happen to health care costs in Canada, and what would happen to the percentage of the Canadian GDP that would be spent on care if they decided to abandon their current fee schedule, and if the Canadians directly replaced their current fee schedule with our Medicare schedule.
What would happen to Canada if they used our Medicare prices to buy care?
We currently spend 18 percent of our GDP on care. Canada spends roughly 12 percent of their GDP on care.
If Canada Used Only Our Medicare Fees, Their Total Costs for Universal Coverage Would Jump 30 Percent Overnight
If Canada decided to follow our lead, and if the Canadians only converted to using our current Medicare fee schedule and if they used it instead of their current fee schedule to buy every piece of care — the Canadian government would probably need to raise taxes or do massive budget cuts in other areas of their budgets because they would immediately increase their total spending to buy health care in Canada by more than a third.
They would spend about 16 percent of their GDP on care if they used our Medicare fee schedule.
The bulk of the fairly dramatic and frequently discussed and often cited in American political debates total cost difference that exists today between us and Canada for care would disappear in an instant if they made the decision to use our current Medicare fee schedule to pay all of their providers of care. They would be spending slightly over 16 percent of their GDP on care immediately if they just used our current Medicare Fees schedule to buy care in Canada.
They would spend even more of their GDP on care if they followed us entirely, and if the Canadians used our average fee levels for our private insurance market to pay for their care.
They would actually get very close to 18 percent of their own GDP if they allowed their caregivers to raise their prices to full private insurance company American price levels for both hospital care and medical care and if they just used the average prices we spend for each piece of care in this country to buy each piece of care.
The caregivers in Canada might not object to being paid those much higher American level fees, but their provincial governments would all be in immediate and significant financial difficulty and even collapse if they raised those payments for each piece of care to our standard levels for our Medicare program. They would be financially destroyed immediately in every Canadian province if they paid American prices for each piece of care at just what we pay for our Medicare patients today and the situation would be far worse if they paid average levels of full American care site prices for each piece of care.
Our Premiums Would Drop by More Than 30 Percent if We Used Canadian Fees
Another useful way of looking at the relevance and the impact of those price differences between us and Canada for each piece of care is that if we went in the exact opposite direction and if we dropped our costs in this country by using the current Canadian national fee schedule to pay for each test and for each piece of medical care and each prescription drug, and if we used their average cost per day for our American hospital care — and if we delivered every single piece of care and every single test and every single prescription that we do today — our percentage of the GDP we spend on care would also drop from 18 percent to slightly over 12 percent — immediately.
The health insurance premiums charged in our country would also be forced by our current premium settings laws to drop by 30 percent or more almost immediately because our current health insurance loss ratio limit laws that govern our insurance industry pricing today would force premiums in our country down to match the 85 percent cost ratio limits that we now use to price our insurance premium levels.
Some people who have been giving speeches about the cost impacts of the way we buy care in the US versus the Canadian single-payer model point to health insurance profits as being the major difference between the two countries. A number of speeches in recent debates have cited our insurance company profits as being the primary driving difference in costs between the two countries. Those insurance company profit numbers for our country are also available for review and consideration.
Total health insurance company profits in the United States last year equaled $23 billion. That represented 3.3 percent of total revenue for the insurers and a much smaller percentage of our total American dollar spend on health care.
The profits from just the six largest insurers equaled $6 billion.
One can debate whether or not a $6 billion profit for six companies is appropriate, but it also isn’t hard to point out that that the $6 billion is a relatively small percentage of the total $3.7 trillion health care expense for America and it is a relatively small percentage of the $l.3 trillion cost last year for insured care in America and it is definitely not — as a number of political speeches have claimed — the primary and driving reason that health care costs are higher here than they are in Canada or in Europe.
The differences in the unit prices paid in each country for each piece of care make up almost the entire difference in health care costs between the two countries.
No one who looks at the real numbers paid for each piece of care in those countries can debate that conclusion.
The relevant care prices used today in each country to buy each piece of care are visible to the world, so the math involved is fairly obvious, simple, and clear.
It is also true that we spend significantly more than the Canadians to administer our health insurance companies, and to run our multi-payer payment model.
Fees for care clearly have a bigger impact on the relative total costs in each country than the differences in insurance system-related administrative costs between the two countries, but administrative expenses are clearly too high here and should be significantly reduced as part of our overall new payment model for care.
As part of this transition, we should now mandate that the Medicare Advantage plans do everything needed to bring down the administrative burden on care givers here, using best practices and electronic linkages for the payment models to reduce most administrative costs to a fraction of their current levels. The right sets of information-flow linkages should reduce the burden on our care sites significantly, and we can better serve patients with that information as well.
We Should Improve Care and Reduce Costs
We are not likely to move to a Canadian fee schedule to buy care — but we can do a number of very basic things to improve care and bring down the cost of care here.
We have some major opportunities to bring down the total cost of care in this country — and we should definitely be taking very intentional advantage of those opportunities.
Our care will quickly be much better than the care delivered in most European countries because all the major countries have made the decision not to use computer databases to improve care. Most of the countries in Europe do not allow electronic sharing of care data. As a result, there are major areas of care where care improvement will not happen.
We actually are on the cusp of having much better care at multiple levels than Germany and France because they cannot track care in some areas because of massive restrictions on the use of electronic data. That is not likely to change soon — so our country actually is on the verge of having better care at many levels than Europe. That is another set of topics.
There is some very low hanging fruit in our country now for reducing costs.
If we focused on the 70 percent of the health care costs for this country that relate to chronic care by enrolled everyone in full service Medicare Advantage plans and managed care Medicaid health plans that worked directly on those issues, we could drop our costs for those patients by anywhere from 10 to 20 percent with relatively minimal effort once they are enrolled, and we would provide all those patients with better and more coordinated care in the process.
Likewise, if we simply split the difference between us and Europe on the prescription drug prices over time, and if we had the care systems who contract with each plan working within the per capita payment cash flow determine how to pay and fund their caregivers in the context of their cash flow, we could have a very large impact on those costs, and we could do it without having any negative impact on the quality of care.
Care can and will get much better in the context of a guaranteed cash flow per patient. That is true at a very practical and basic level because all care systems and care sites in this country who can’t afford to improve care in any way now for fear that reducing current volumes of billable events could re-engineer care delivery using the wonderful new care support tool kits that are possible now, and they could use those tools and approaches to make care more accessible and convenient in very patient-centered ways, if they knew they could depend on and use package payments for the care they deliver.
Medicare Advantage buys care monthly for each member, and that creates the cash flow context needed to improve and re-engineer care.
As part of this strategy and agenda, we need each Medicare Advantage Plan to demonstrate that it is buying care in ways that facilitate the cash flow needed to re-engineer care in patient-centered ways. Those approaches exist now, and need to be both improved and expanded.
Patient Centered Medical Home models for both primary care and specialty care exist, and we need to encourage, support, and fund those models, and we need to inform every patient and prospective patient about their availability.
We need patient feedback loops on care services and outcomes, and we need this data from and about patients to feed into well-designed quality assurance reporting on care services, results, and consequences.
That is all much easier to do as a nation and a care infrastructure when patients join care systems and report on their experiences and results.
The key point to understand and appreciate in thinking about this issue is that if we moved all of those patients to Medicare Advantage Plans, then we would immediately control overall and macro health care costs as a country because of the way that program buys care.
We would control costs as a nation immediately because there is only one number needed to control all costs when you buy care by the month and not by the piece. That controllable number is the per capita capitation number set for the Medicare Advantage capitation. That number determines the total cost of care — because all the plans are required by contract and by law to deliver care for that amount of money.
That is massive economic power that we should use to create a world of best care for our country.
All of the plans will have to figure out how to deliver their care for that amount of money — but there is so much waste in the system now and so many opportunities to make care better and less expensive that the $1.4 trillion that would be paid to the plans in that first year is more than enough money to meet their financial needs as plans and businesses for all coverage and care.
We Need Massive Reductions in Administrative Expenses
As a component part of living within that capitation model for buying care, we need to focus and take full advantage of the huge opportunity that is created by the fact that roughly a third of the health care costs in too many settings in this country are now created by administrative expenses in care settings driven by Medicare, Medicaid, and multiple private payer claims filing and verification processes. Hospitals have entire floors of workers whose only job today is to process paper for payment purposes.
We can and should massively reduce those costs. If we both computerize our care settings and change our payment models to eliminate those claims filing administrative burdens and infrastructures, we should be able to cut those administrative cost levels in some care sites by half or more. Those savings, alone, would pay for covering the 20 million currently uninsured Americans.
We need to set specifications for the Medicare Advantage plans to cut administrative costs massively for the care sites by setting up electronic data flows for all payment processes and approaches.
We Need to Cover Everyone and Improve Care
We can very intentionally implement quality reporting systems and consumer feedback mechanisms and care connectivity information sharing mechanisms that will both empower our decisions, and protect us against caregivers who shortchange us in any way.
We need to implement, support, and continuously improve those systems and we need to make their performance a major agenda item for both legislators and Members of Congress going forward to get the optimal benefit from this approach.
We need interactive consumer-based communications tools that keep us all current on care delivery and caregiver performance. Those tools exist now — and we need to make them more consistent and better. We need connected care sites, and we need data that follows patients everywhere.
That goal should be clear.
We Should be the Country with the Best Care on Earth
We spend more than anyone else on care by a wide margin, and we can and should use that massive amount to lead the world in creativity and use of technological tools to do patient and customer-focused things with our care resources that create the very best care.
We need to put in place a Medicare Advantage care purchasing tool approach that uses clear and well-designed performance specifications to become a highly skilled and effective and purchaser of care as a nation — and then we need to use those plans to put all of those tools in place for all of our people.
We should cover everyone and do it really well.
If we put all of these tools and processes in place, we will have the best care in the world because the other countries that have universal coverage will not match us in key areas of connectivity, data use, and innovative tool building. Some of the other countries have currently set up significant and very intentional barriers to computer-supported care, and some actually render important care connectivity tools un-usable and illegal.
Because we are going to be using the full scope of knowledge and tools in our country, our care will actually surpass theirs, and we will return very quickly to a time where the U.S. enjoys the best care in the world.
We will control the cost of care as a country by simply setting that annual capitation payment at a level that meets our care control needs. That capitation tool has immense power — and it can both control costs and put us on a highly beneficial pathway to better care.
We should build on our traditions, history, massive care delivery expertise, and commitment to the best care by putting together a sane, balanced, well designed, and entirely affordable health care purchasing system and approach that covers everyone and does it extremely well — and we can then build, deliver, and provide our people with the best care in the world in the process.
We can use that 20 percent payroll tax to create universal coverage on January 1 and we can give all of our hospitals the assurance that every patient who goes through their doors on January one will have coverage from a credible and functioning source.
Care systems are losing hundreds of millions of dollars right now, and they need to rebuild. They are damaged and they need immediate money. Some grants from the government will be needed to make that happen.
They also need income security.
They need to know what their future flow of cash will be and they need to be able to depend on having that cash coming to them.
They all will be very well served if they are part of a cash flow for care that is committed to having care continuously improve.
We need a cash flow as quickly as possible to shore up and maintain the COVID damaged hospitals and other care sites
We need to impose the20 percent tax and use that money to prop up and sustain all of the care infrastructure damaged by COVID through a systematic and dependable flow of cash to those sites.
We need to create that cash flow now — and use it to make care better over time as well.
Let’s use Medicare Advantage for All now and achieve all of those goals by becoming an highly competent purchaser of care instead of just a payer for care.
Let’s do it now.
COVID demands it.
The reports and the media articles shown below all contain information that is useful in helping to understand this Medicare Advantage for All proposal:
“NHE-Fact-Sheet.” CMS.gov Centers for Medicare & Medicaid Services. February 14, 2018. Accessed March 23, 2018. https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html.
“How Do Medicare Advantage Plans Work?” Medicare.gov – the Official U.S. Government Site for Medicare. Accessed March 23, 2018. https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/medicare-advantage-plans/how-do-medicare-advantage-plans-work.
“Don’t Let Health Care Bankrupt America.” Institute for InterGroup Understanding. Accessed March 27, 2018. https://www.intergroupinstitute.org/books/don-t-let-health-care-bankrupt-america/chapters.
Halvorson, George. “The Way We Buy Care in This Country Is Flawed, Dysfunctional, and Often Perverse.” California Journal of Politics and Policy. January 09, 2015. Accessed March 27, 2018. https://escholarship.org/uc/item/0gp2v32t.
“Social Security.” How Is Social Security Financed? | Press Office | Social Security Administration. Accessed March 23, 2018. https://www.ssa.gov/news/press/factsheets/HowAreSocialSecurity.htm.
“How Does Health Spending in the U.S. Compare to Other Countries?” Peterson-Kaiser Health System Tracker. Accessed March 23, 2018. https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/.
Squires, David, and Chloe Anderson. “U.S. Health Care from a Global Perspective.” Spending, Use of Services, Prices, and Health in 13 Countries – The Commonwealth Fund. October 08, 2015. Accessed March 23, 2018. http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective.
“Healthcare in the Netherlands.” Healthcare | Expatica the Netherlands. Accessed March 23, 2018. https://www.expatica.com/nl/healthcare/Healthcare-in-the-Netherlands_100057.html.
Knox, Richard. “Most Patients Happy With German Health Care.” NPR. July 03, 2008. Accessed March 23, 2018. https://www.npr.org/templates/story/story.php?storyId=91971406.
“Explaining Sluggish Savings under Accountable Care | NEJM.” New England Journal of Medicine. Accessed March 23, 2018. http://www.nejm.org/doi/full/10.1056/NEJMp1709197.
“2015-01-26-3.” CMS.gov Centers for Medicare & Medicaid Services. March 16, 2015. Accessed March 23, 2018. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html.
Luthra, Shefali, and Kaiser Health News. “Medicaid Is Rural America’s Financial Midwife.” Kaiser Health News. March 12, 2018. Accessed March 23, 2018. https://khn.org/news/medicaid-is-rural-americas-financial-midwife/.
Guterman, Stuart, Laura Skopec, and Stephen Zuckerman. “Do Medicare Advantage Plans Respond to Payment Changes? A Look at the Data from 2009 to 2014.” Do Medicare Advantage Plans Respond to Payment Changes? – The Commonwealth Fund. March 14, 2018. Accessed March 23, 2018. http://www.commonwealthfund.org/publications/issue-briefs/2018/mar/do-medicare-advantage-plans-respond-to-payment-changes.
“Medicare Advantage.” The Henry J. Kaiser Family Foundation. February 01, 2018. Accessed March 27, 2018. https://www.kff.org/medicare/fact-sheet/medicare-advantage/.
Shaw, Bernard. “Author’s Preface.” The Literature Network: Online Classic Literature, Poems, and Quotes. Essays & Summaries. Accessed March 23, 2018. http://www.online-literature.com/george_bernard_shaw/doctors-dilemma/0/.
Scheffler, Richard M., Brent D. Fulton, Donald D. Hoang, and Stephen M. Shortell. “Financing Universal Coverage In California: A Berkeley Forum Roadmap.” healthaffairs.org. March 29, 2018. Accessed March 29, 2018. https://www.healthaffairs.org/do/10.1377/hblog20180327.614142/full/.
PBS News Hour. “George Halvorson Talks Differences in Health Care between U.S. and World.” YouTube. January 17, 2014. Accessed March 27, 2018. https://www.youtube.com/watch?list=PLokPei6Lm-OlTAsfltkWlXOwrpspVxOLc&time_continue=1&v=d6CaCPmXBrg.
“Don’t Let Health Care Bankrupt America.” Institute for InterGroup Understanding. Accessed March 23, 2018. https://www.intergroupinstitute.org/books/don-t-let-health-care-bankrupt-america.
Health Care Cost & Quality Atlas | IHA. Accessed March 23, 2018. https://atlas.iha.org/story/medicare.
Janda, Ken, and Vivian Ho. “Medicare for All.” The Hill, August 27, 2019. https://thehill.com/opinion/healthcare/458783-medicare-advantage-for-all.
Wynne, Billy. “Creating Medicare Advantage Premium Support For All, Part 5: Which Proposal Is Actually Medicare?” Health Affairs. Accessed August 15, 2018. https://www.healthaffairs.org/do/10.1377/hblog20180814.124908/full/.
eHealth. (n.d.). Average Cost of Employer-Sponsored Health Insurance. EHealth. Retrieved from https://www.ehealthinsurance.com/resources/small-business/average-cost-of-employer-sponsored-health-insurance
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