Patient CARE Act Posts

On Monday, January 27, 2014 Republican Senators Richard Burr (N.C.), Tom Coburn (OK) and Orrin Hatch (UT) released a fairly detailed outline of a new health reform plan: (The Patient Choice, Affordability, Responsibility, and Empowerment Act, or PCARE). I will aggregate my posts on this proposal in this post:

Senators Burr and Coburn (and Rep Paul Ryan and Devin Nunes) introduced the Patients’ Choice Act in May, 2009. Here are several links to that proposal (that differs in important ways from the most recent proposal)

In February, 2012 Senators Burr and Coburn introduced the Seniors Choice Act, that focuses on Medicare. The most recent proposal does not mention Medicare, nor SCA

Seniors’ Choice Act and under-65 Medicare

Harold Pollack asked me via twitter (@haroldpollack) on Tuesday “What happens to the under-65 Medicare population in the Seniors’ Choice Act?”

The short answer is that the Seniors’ Choice Act white paper is not very clear on how Medicare beneficiaries younger than 65 (end stage renal disease, permanently disabled, etc.) would be treated. The language in the white paper focuses on “seniors” and of course the impact of any such proposal on elderly Medicare beneficiaries can be expected to capture most of the policy–and all of the political–discussion. A few thoughts on how the proposal would treat under-65 Medicare beneficiaries.

  • Maximum out-of-pocket protection would apply to all Medicare beneficiaries, and the extra cost-share for higher income beneficiaries would as well. The under-age 65 Medicare beneficiaries would be disproportionately low-income, and those who are not dual eligibles (also eligible for Medicaid) could benefit from this maximum out of pocket benefit.
  • The voluntary care coordination benefit could help medically complex patients, such as those with permanent disability or end stage renal disease. Page 3 of the white paper says, “All Medicare beneficiaries that fit certain medical and clinical criteria would be eligible for a new, voluntary care coordination benefit. All seniors in the traditional Medicare program could select this care coordination benefit, but it would only be activated if they met certain medical criteria.” This seems to include, and perhaps to even target Medicare beneficiaries younger than age 65 for care coordination. It is not clear exactly what such coordination would consist of, and it is possible I am parsing the words of a first-step white paper too finely (all v. Seniors above). The care coordination benefit aspect of the proposed policy is interesting, and the authors assert that it will allow focus on disease-identified groups of patients in ways that ACOs will not; we need to hear more about this.
  • Premium Support/Competitive bidding could apply to the under 65 Medicare population. Around 1 in 10 Medicare Advantage patients are currently enrolled in so-called Special Needs Plans which are private insurance plans. The big idea in the proposal is to transform the how of the private insurance Medicare option into a competitive bidding approach, and there is no technical reason why this could not be done for under age 65 Medicare beneficiaries. You can imagine many questions that will need to be clarified for particularly vulnerable under age 65 beneficiaries. This series of posts I did on Special Needs Plans outlines some of the issues (post 1, post 2, and a 3 part interview on SNPs with Marsha Gold, part 1, part 2 and part 3).

All of these details will need to be clarified if this is to be a serious proposal, especially for the proposed care coordination benefit. Some of my past blogging on how to best care for the dual eligibles (some of whom are younger than age 65) could be relevant to this discussion (here and here). Further,  I have proposed federalizing the care of the duals. While that could be viewed as the opposite of seeking to move them into private insurance Medicare options, both share a basic goal of making one payer responsible for improving the care that very vulnerable and expensive beneficiaries receive. Both ideas would seem to be helped by the poor nature of the status quo.


(Past TIE Seniors’ Choice Act blogging: here, here, here)

Update: Marsha Gold has a piece in NEJM today on private insurance in Medicare.


One more thing on Seniors’ Choice Act

Even if we managed to get the details straight for Sens. Burr and Coburn’s proposal to move toward a competitive bidding/premium support approach in Medicare (my early take, Austin’s thoughts; more this morning on premium support), it is impossible to fully evaluate their proposal without knowing what they plan to do about the ACA. Their latest proposal assumes implementation of the ACA, but they continue to call for its repeal and presumably, replacement. And of course the Seniors’ Choice Act would increase the eligibility age for Medicare, making the question of access to health insurance for the near elderly even more important.

Sens. Burr and Coburn co-sponsored a proposal to address coverage for younger persons in the last Congress (The Patients’ Choice Act), but it has never been scored by the CBO. Presumably, that could change, and it would be a useful step. You cannot fully evaluate the Seniors’ Choice Act without knowing the health insurance plan for the under-65 age group that would operate along side it.