Marilyn Moon and Cori Uccello

Proposals to adapt Medicare to extend coverage to new beneficiary populations present a significant set of technical and program design challenges. As a leading hub for health policy experts, the National Academy of Social Insurance formed the Study Panel on Medicare Eligibility to examine the options for, and implications of, extending eligibility for Medicare beyond the current covered populations.

We are pleased to have co-chaired the Academy’s Medicare Eligibility Study Panel. The Panel’s final report, Examining Approaches to Expand Medicare Eligibility: Key Design Options and Implications, is the culmination of over 10 months of extensive deliberations among 27 Panel members from various disciplines.

Study Panel members included experts from economics, health policy, political science, sociology, medicine, and law, as well as people with direct experience working in areas related to public and private health insurance, actuaries, health plan administrators, health care providers, labor representatives, and government regulators. The Panel’s discussions helped all of us appreciate the complexities that arise when trying to improve the functioning of our healthcare system. Our goal was to provide needed technical clarity on the design and implications of proposals to build upon the Medicare program, and we are grateful to the time and care these experts devoted to this effort.

Why focus on Medicare Eligibility? Why is this report essential to read?

Health care is a top issue for voters heading into the 2020 presidential election, as it was in the 2018 midterm elections. Many policymakers and presidential candidates have proposals that build upon Medicare because it would make use of an existing and popular coverage platform and seems to be a straightforward way to address the challenges of affordability, coverage, and cost containment.

Positive impacts on coverage and access to care could result from extending Medicare to more Americans, but such a change also involves substantial challenges in program design and implementation. It is important to be able to balance tradeoffs among these challenges when considering which, if any, represent the best option for improving coverage and lowering the costs of health care.

We hope that the findings in this report will increase understanding of Medicare-based approaches, and be used by researchers, journalists, policymakers, and other audiences to analyze and design feasible policy options.

What is in the Report?

Rather than focusing on the current bills and presidential campaigns, the Study Panel examined three general approaches to changing Medicare eligibility and assessed how variants of these approaches could be designed to address specific policy objectives. The three approaches were:

  • lowering the eligibility age
  • extending Medicare coverage to all
  • creating a Medicare buy-in under which some or all of the population or employers would be eligible to purchase Medicare coverage

This report delineates each approach’s design options, tradeoffs, challenges, and implications. The key policy design decisions examined include:

  • eligibility criteria
  • benefit structure, including covered services and cost sharing
  • premium structure and whether subsidies are available for newly eligible populations
  • provider payment rates and regulations concerning provider participation
  • the roles of Medicare Advantage and private supplemental coverage
  • financing mechanisms
  • the rules regulating interactions with other public and private insurance
  • rules governing the transition to a new or modified program

The Study Panel then examined the potential impacts of the three proposals on various policy goals and objectives including, expanding coverage and improving access to care, containing growth in health care spending, and increasing affordability, equity, and administrative simplicity.

Posted on: March 26, 2020

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