thank you very much.

ladies and gentlemen, coming. our topic today is medicare, the largest care player in the american, a huge growing federal entitlement. and a little more than ten years, medicare will increase in enrollment from 65 million to nearly 80 million enrollees and total program spending will double today, roughly. it's $1 trillion. and within ten years it will be nearly $2 trillion. at the same time, medicare is changing. today, half of all seniors are enrolled in medicare advantage or a system of private coverage, which is the alternative to traditional medicare. and medicare advantage is a defined contribution.

and what that means is, is that the government makes a contribution on behalf of a beneficiary to the beneficiary chosen plan. given current trends, medicare advantage will soon be the dominant form of medicare. the question before the house and before the nation is a very, very big one. that is, how do we provide high quality medical care to a huge and, rapidly growing older population, often at a cost that is affordable not only to seniors, but also to america's taxpayer. in our new book, modernizing medicare from johns hopkins university press, it a dozen of our colleagues in the health community have provided very specific answers that question. three of them are with us here today. brian miller is practicing physician and assistant

professor of medicine at johns hopkins university and a fellow at the america and enterprise institute. john goodman is president of the goodman institute. dr. goodman is a prominent health care and he's widely known throughout the united states as the father of health savings accounts. doug holtz-eakin is, president of the american action forum and a former director of the congressional budget office. and now with the debt limit facing the country. you can expect to see doug holtz-eakin, your national television shows dealing with the debt limit and all of the other problems are connected with it. with that, ladies and gentlemen, would like our guest to come up and and join us and we'll a discussion about medicare.

ryan i'm going to start us off with the question for you right now. as you know, millions have senior citizens or are voting with their feet and enrolling in private medicare advantage plans, which is a defined debate. define a defined benefit program. medicare advantage as opposed to traditional, which is a defined benefit program. you would you deal with this in chapter six of the book that has been published, hopkins university press. what are the inherent tradeoffs facing seniors when have to make a decision about whether to enroll in traditional medicare or medicare advantage? so first of all, bob, thank you for having this event and having this conversation about the medicare program. medicare today, really, as you said, two different programs. its traditional medicare, and

it's medicare advantage. when you are in the employer sponsored market and you pick your health benefits, right? you're signing up for a health plan that's either a self-insured health plan or you're purchasing plan product. when you end up in the medicare marketplace, things are a little different. so you turn five, you have developmental stage renal disease, or else you qualify for medicare, you sign up for traditional a-plus plus benefits. right? hospital benefits, and also a physician. then you also have to pick a prescription plan. and then the traditional medicare program has no catastrophic out-of-pocket limit. so you you then pick supplemental coverage. so you've made three choices. the alternative of, of course, is picking medicare advantage where you have one choice. you're getting coverage, you're getting supplement coverage or medigap coverage. you're also 90% of plans include a prescription drug plan. and then you also get

supplemental benefits frequently. but two thirds of plans, three quarters have dental vision and hearing. so if you think about it, if you are 65 years old and entering and you have three or five chronic conditions, you're on a fixed you have a limited number of assets, right? you don't have infinite. you can't spend that you want to. and so making one choice and getting an integrated, comprehensive health benefits package is something you know, it sounds like a bunch of garbled gook, but for the average consumer, it's actually much easier to make choice that choice. as i said it gives them financial protections. they don't have to make as many choices. and then the of course, you're like, there's always a catch there's always a cost. and the cost for the beneficiary is that they accept a network, right? they can't see everything, all doctor, they can see the doctors and the health plan network. but if you've been, you know you were working for 30 years, you had health insurance through your employer, you a health insurance through the exchange, you had a network.

you couldn't see every single doctor. and so that trade off for today's new retirees is not scary. and then also, there's usually some utilization review and some access controls go with that. so it's a trade off. the beneficiaries as i'm going to get more benefits, i'm going to get more financial protections. i can have some limitations on. i use that. so it's richer benefits and more convenience of rich, richer benefits, more convenience. and frankly, it's easier to choose. right? right. because you're making one choice instead of three choices. and at the other end, the other the other evidence is, is that with so many so many plans, basically it's actually more affordable in many cases. yeah, it's more affordable to the beneficiary, right. because if you have to purchase traditional medicare and pay premiums that then you have to pay prescription drug plan premiums and then you have to pay medigap premiums and then good luck. you know, being 78 years old and trying to get vision, dental or hearing coverage in the private market. right. well, actually, you can't get it

in the private you get it through your medicare advantage plan. right. john, in 2003, republicans in congress enacted the medicare modernization act, which created the medicare advantage program, a system of competing private plans as the alternative to traditional medicare. a few years later, congress, with the support of president obama, enacted the affordable care act and called obamacare and obamacare created a system of private plan competition and state based health insurance exchanges on paper. john, they look very similar. they seem very similar. but you make the argument that in fact, they are quite different and that medicare advantage works much better than the health exchanges. could you explain why that why that is true? yes, they are very similar paper and very different in practice.

and that's why 50% of the seniors are in a medicare plan and over in the obamacare, the non subsidized part of that larger was a death spiral. it was going away because no one was buying until. congress came along and added all subsidies, even for people making half a million dollars a year. what's the difference? well, medicare advantage is the only place in our health care system where if a doctor discovers that a patient has a change in medical condition, he can forward that information. the insurer, which in this case is medicare and get a higher premium for his plan. and that is why in medicare advantage, you have special needs that specialize in diabetes and heart care and other illnesses and want to attract people. these problems is the only place in the health care system where this happens there is no employer plan in this country. there was an employee with high health care costs. there's no commercial insurer that wants more. there's nobody in the obamacare

market that wants or they're all trying to attract a healthy and runaway from the sick. now, in regular, traditional, there are 10,000 things that medicare pays doctors to do and not one of those 10,000 task has as as as its objective are states that. your job is to make the patient healthier or to cure disease. over in the medicare advantage plans or by contrast, people lose plans lose money if they don't carry diseases that make people healthier. this is george halvorson, former chairman and ceo of kaiser, who says that in the regular medicare plan, 20% of diabetic patients get foot ulcers, 20% of those turning into amputations. this is spending $8 billion a year on on amputations over in the medicare advanced plan plans.

by contrast, even in the the moderately successful, they have half as many ulcers and a third as many amputees, patients. now they do things that probably not on the list of the 10,000 things that regular medicare pays for. so one of the ways you prevent amputees is ulcers. you make sure your patient has feet and dry socks. well, i don't think, you know, dry feet socks are on the list of 10,000 things. traditional medicare pays for blindness is another problem with older diabetics. again, we have much higher rate and regular than the medicare advantage plans. it costs $100,000 a year, by the way, for the amputations, 20 to $30000 a year for the blindness. congestive heart failure. again, we have a significant difference in outcomes in medicare advantage and traditional medicare. so so these plans act differently than regular their

financial incentives are different. how so says the death rate for dual patients with some conditions is 40% higher than it is in medicare advantage plans. i will say that one thing if you if you read what george halvorson has to say and you read the kinds of articles that have been appearing in health affairs, you will think we're describing two different worlds. my only problem with our subscription is he calls medicare for service and he calls medicare capitated. some of our best medicare advantage plans, however, pay fee for service. the distinction is not you know how the doctors pay. the distinction is over here we have integrated coordinated care with the objective keeping people healthy. and over here. it's not integrative. it's not coordinated. and people actually make more money when the patients get sicker and require more treatment. thank you very much. doug, in chapter 12 of your your

contribution to the book, you you do cost esteemed that show that a comprehensive defined often referred to as premium support system driven by consumer choice and a rather robust competition would result in major savings for both medicare patients and also. your focus the chapter, your focus is primarily on taxpayer beneficiary savings. i think i think the question for a lot of americans would be, well, is the need the desire to move into a premium support system or a comprehensive defined contribution system is is the desire to reduce health care spending. the only reason for moving in that direction or creating a premium support system in

medicare? so absolutely not. you know, i focused on the budget class and the beneficiary out of pocket costs because you told me to, but very good. well, it's the more important part. nice to tell the cbo what to do. i'm going to have to try it more often. the more important part of the story really is try to take some lessons that we've learned in other settings. medicare advantage being one of them. the power having competing plans, deciding which supplemental to patients value, what what things in addition to the the care will allow to stay in better health improve their outcomes look at the the medical care part d program where. we we harness private between manufacturers of pharmaceuticals and and the plan sponsors to deliver robust competition and let individuals pick among plans to get the formularies that

match their needs best. and the outcomes that they prefer. and in that process, we get extraordinarily high satisfaction. if you ask medicare part d beneficiaries, you know, 82 to 90% are extremely happy with where they are, and it's way cheaper for them and the taxpayer than i anticipated. we when we scored it back in 2003. and with we've learned that we infuse into the health care programs, the federal government the respect for individuals values they get to decide what they think is important and the robust competition of the private sector and order to serve both the taxpayer, the beneficiary well, i think respecting the values and enhancing the competition, the important things in and of themselves way more than the dollars saved on the on the federal budget although i would

just stipulate we need to i mean you know fund that you should not use it cocktail parties because you have no friends the medicare program is by itself responsible for one third of all federal debt outstanding. this is a program that has never been designed be financially sustainable. it bleeds red red ink every year. and we want to get that control on behalf of the present and future generations. and want to serve the medicare beneficiaries better. and this is a way to do that. that's a very important point, because medicare, aside from the fact that it spends so much money and as you point out, is contributing to the deficits in the national debt. medicare is governed by a very powerful regulatory regime. the medicare bureaucracy is referred as the center for medicare and medicaid services. cms. and for years, course, this bureaucracy sets prices for as pointed out, sets prices for

10,000 medical procedures in over 3000 counties throughout the united states. frankly, it doesn't do a real good job at that. but medicare advantage and the coming medicare advantage in basically introduces a new dynamic into the system. and that has an effect on the medicare bureaucracy. see, so i was going to ask ask you, brian, as a medical professional dealing with senior and so on, how does medicare advantage as a as a system this competitive system of private plans, change the role of commerce in the lives of your patients, of senior citizens? before i answer that, actually, i want to respond to something doug said about. beneficiaries and choice of mind. and so i remember i had this patient and she had six doctors, a bunch of meds she took, admitted to the hospital. you know, pretty smart old lady her medicare advantage plan helped her get like, you know,

modifications to her bathroom so she can get it in and out of the bathtub they got her the whole chairlift. so she could go up and down her stairs. she had two storey warehouse and a basement on a fixed income and, you know, she was on a plan, a dual eligibles, special needs plan. she was medicare, medicaid to eligible and she you i remember talking with her and she shouldn't have know good teeth and she's going to get all of her teeth pulled get dentures and go to the dentist. and i her how she did that and she said, oh picked the one plan that would let me do that. and i said, okay. but like what about all your doctors like you have doctors like our all of your doctors in, your network. she said, well, 5 to 6 hours, i picked a new cardiologist for this this year and the next year after i get my teeth fixed when open enrollment is then again, guess switch back to, you know, my other ama plan that has my old cardiologist in it right after she got her teeth picked fixed. so it's like so beneficiaries can be pretty crafty, pretty smart in a good way. right. you know she'd be a multibillion dollar company and that that was

sort fun for me to see as her physician. but like when you think about that. right. if we the plan finder and give beneficiaries better choices, like we show them how they can shop for their comprehensive health benefits package. comparing m-a versus a plus b benefits plus medigap plus part d, which have some of our colleagues like lisa graber and others i've written about like we can empower consumers to make choices and drive beneficiary satisfaction. to your question about like emma and how changes the role of cms, cms right now very much focused on payment levels. it's the annual cycle hips. where all the ops role, all these roles, you know, one of them was like 1500 pages recently. all does is that favors you know the people inside the beltway who can there and read a 1500 page role and analyze it for the appropriate stakeholders. right and you have, you know, the usual cycle of medical specialty societies that show up around the time of that payment levels are set. and there's stream of people

going into the various buildings in the capital. and so cms focuses on payment levels, right? so you have all these bureaucrats focused on levels, whereas everyone from former secretary burwell, formal secretary azar said, we want to transition from volume to value because m is an integrated comprehensive benefits package that allows the potential for cms to stop focusing on writing 1500 page payment level roles. instead, focus on capitation rates to focus on plan regular action, and then start to set population health goals, which is what i think both parties actually want for the medicare program. getting better value for the dollars, right? benefiting seniors very good. can i express a concern of. sure. so that this is for medicare advantage? it's hugely successful, but i don't think cms understands that it's a funding different delivery platform than the traditional fee for service program was. and so if you've got a and then they plan with a quality standard you're providing that

defined contribution and they're not hitting the appropriate quality standard. we talk about making those better. why do they need know what happened in the encounter data? you only need that if you're doing fee for they're trying to micromanage the may in a way that is at odds with. everything people sitting here trying to to accomplish, which is to deregulate delivery system and harness the competition to get better outcomes. so worry about the future of ama, much less getting to a more robust right good point. john goodman. in the private sector, you know, and you were largely responsible for this and in many ways as a result, as a result of your work in congress many years promoting relentlessly the idea of a health savings account so people could take make money, could take make tax free contributions to build up an account where can

use that money for routine medical services and protect themselves against unforeseen health concerns. once, as we have millions of americans today in employment based health insurance who have health savings accounts, but we don't have it in for senior citizens, can't senior citizens have a health savings account? okay. is something that a lot of people understand. the health savings account for, non seniors is the best savings there is. it's better than an ira, it's better than a four and k. and the reason it's better is because during your working years you can save and at the time reach 65 and enroll in. you can use your your medical savings health savings account deposits to pay your part b in part the premiums. you can't that with an ira you can't do that with a one k and even if you were healthy for all your working, you'll probably

exhaust your account paying those premiums during your senior years and you'll never pay taxes on that money at all. so when congress created this account they realized well if we seniors to get a tax deduction for deposits to the health savings account and they turn around and pay their premium with, that's the equivalent of allowing them to do that their part b premiums. and we're already giving so much seniors, they were not in a mood to give another tax deduction, this to this group of people. so that's why seniors weren't allowed to do this. but there is solution and i call it the roth health savings account and the idea is you don't get a tax deduction for making a deposit that you put after tax dollars the account they can grow tax free. but in this way we have account that's not very expensive from budgeting point of view and it

would allow the third party payer to put in in this account to for the chronically ill. you might say to a diabetic, you know, if you'll manage some of your care, we'll put money in an account for you. if you're company on drugs and you stay away from emergency room, you're going to have that money is for you. and if you're not compliant it and you go to the emergency room, you you're going to bear the costs. so you get the benefits of your good decisions. you bear the costs of your bad ones. so so need an account. it just needs to be a roth account, not a traditional health savings account. doug opponents of this concept of defined contribution, comprehensive pre defined contribution as a way to finance referred to often as premium support have often demonized this as voucher izing medicare. i've heard this and over again, i mean, frankly, going all the way back, you know, the 1990s,

you know with the bro thomas proposal and so on. how did how you respond to that criticism? well one it doesn't matter if it's a voucher. it depends what the voucher gets you can get you something really good and vouchers are fine. but but more to the point, i think at the time of the discussion, you know, 15, 20 years ago, the dominant medicare was the traditional fee for service program. and the contribution option looked radically different and unfamiliar and and it was easy to scare seniors with vouchers. medicare and privatizing it. all of things that have worked everywhere else in the economy. so now with medicare advantage, you have a subsidy from the government and private competition plans and get to pick the one you want and it's the most popular form of medicare. it will be that more than half

of the enrollees so next year and so doesn't look all that different. and so people have already voucherize their medicare voluntarily and happily. and we are just trying to improve the quality of what they get for the decision to go into that kind of a system that's. i know the thing that remarkable about this. i was at the democratic national convention. i think it was a couple of conventions. there was a lady who got up, addressed the country, and she said basically the republicans were going to give senior citizens. a certify a voucher where they would have to go out and negotiate with private health insurance company and was the source of the demagoguery mean it was the idea that, you know, and i've always i, i remember i got into a rather spirited debate somebody in the media and i asked them i said, well, let me ask you this. does the federal employees get a voucher? and of course, the answer no.

and you know, this has been going on for a long time. i think the point of it was psychological. it's really scare senior citizens that they would be left alone somehow. but basically the yeah i mean, this was the oldest thing in politics. get there first try to characterize your ideas as their ideas is bad and there's the war over getting their initial characterization an attempt to to damage that brand deliberately. people still the terms trickle down economics remember, i have no idea what they're talking about at this point. it's just the words they've they've chosen to signify. they're just they're just like the thing. so the most important part of that story that gets lost is the one that john pointed out at the beginning if you're sick or you get more if you need more care to get outcomes, the system provides with more resources, and that's that's far from a voucher it and making it just a certificate everyone gets that's tailoring it to needs of the beneficiary which is what we ought to be doing right and if i you know, it's interesting also

that the private medicare marketplaces that competition produces health benefits, innovation, which is not an oxymoron. right. you know, not something that you see on a slate tv commercial or in the movie office. health benefits, innovation is a real thing. if you go back to the 1980s and you look at private medicare plans, medicare fee for service didn't have a prescription drug benefit. something like 4/5 of private medicare plans in the eighties. right, when we had the brick cell phones. so fast forward 2003 passed the ama, get that prescription drug benefit, which is an option for fee service beneficiaries subsidized by the government delivered by the private marketplace through private competition. that's 17 year delay. and if you remember the recent debate we had over adding, you know, progressive wanted to add dental vision and hearing to traditional medicare. well, where did that come from? that came private market competition, a marketplace where those are already available. so i think that one of the

things that this shows is that for the future of medicare for beneficial is actually private market competition, something that will benefit them. right. let me ask you this. what do you think is the source of this intense opposition to, this movement mean? i'd like to ask all three of you this the idea of transforming medicare into competitive market. what what what is the real guts of this opposition? what in other words, what is the motivation at the end it comes from the idea that self-interest is a bad in health care and everything you ever heard of bernie sanders say there should be no profit anywhere in health care. we really believes it. and he's not the only one. and think that's the biggest problem that. they don't they don't like markets. they don't like for profit businesses. they don't like nonprofits that really act like for profits. and i think that's a it's also

it breaks down payment silos. we have a lot of payment and you know everybody in that in every health care stakeholder i've ever talked to is all for innovation and change as long as it's not disruptive and doesn't mess with their payment silo and that's a big source of opposition, i would say it's something different it's fear and lots control right so that annual payment cycle with fee for service, you know when that role is going to come out, there's proposed rule, there's comments, there's the whole game with that right you know hundreds of pages of comments from every possible stakeholder that has you know, a financial stake in that. and then there's the final rule. and they they are with that, right? that's a central authority that they can go argue with. if we take that away or create it as one of many options, which is more likely and more practical, then they lose that power and the world as they know it has changed. and it's a very, very it's a

real dramatic change. the loss of control over the loss of basically what you're talking about is a radical reduction in the army of lawyers and consultants. yeah, well, my generation, i think thanks to i was going to say my generation will finally be able to afford a house in dc as millennials who who've dared to recessions. oh yeah, but but i will say know the the loss of is not necessarily a bad thing because what it does is it puts in the hands of beneficiaries and the whole point of the medicare program is to give health benefits for beneficiaries, not for corporations or doctors or, bureaucrats or cms or lobbyists. it's for the beneficiaries. and so if we do start to work on these changes slowly time, that's actually good for the population, right? it's you mention that because our our colleague eliza meier always used to refer to medicare

as the provider centric system. it's not a patient centric systems providers system. and all of the activity in the house and the senate is ultimately trying to figure out how to rejigger the formulas to get the right formula for them, usually at the expense their colleagues who are performing perhaps a different specialty in medicine. i want follow up with you, brian, on something has preoccupied and that is the whole question. fiscal responsibility. you know, i mean, a of us who were watching the debate on the debt limit and the debate on spending and so on, you know, we're looking at what seems like, you know, crazy spending. the congressional, you know, and i know i'm showing my age, but the idea of, you know annual trillion dollar deficits, it's stunning. i really mean, it's just incredible. and we're we're developing as as doug pointed i mean, it's we're

looking at a situation where we're having we're accumulating a very large and dangerous debt. your friends doug at the cbo talk about, the potential of a fiscal crisis, which i don't think americans understand the gravity of this. you know, i don't know how far away we are from it. but in the case of medicare advantage, just going back to the medicare advantage program. brian kind following up with what doug raised, and that is the framework way the medicare advantage structured. it's the way it's programmatically organized. how do you see contributing to the promotion of long term fiscal sanity? yes. that sense of sanity in health care policy would be a nice change it's something that we don't get very often. right.

and, you know, the medicare advantage program and fee service like we need benchmark reform. that's something that doug has been intimately involved in and knows about in great detail that that aside benchmark reform just so people understand the benchmark reform refers to the basis upon which the federal makes a contribution to the different plans. right. and so so that that is something that needs to be addressed. and i think the policy community will eventually address. but medicare writ large, it's like putting your house on a budget, right? so, you know, we have our mortgage that we pay our grocery bill, etc. there's an amount that we spend every month, the amount that we spend every year. medicare advantage is structured the same way. it's risk adjusted capitation. so it's risk adjusted for health status and capitation. so it's paid per member per month or per per month. so there's a that's good framework for budgeting. we can debate about what the appropriate capitation rates are. we can debate about what the appropriate adjustment methodology is and we have those debates and we are everyone having those debates right now in medicare advantage.

it can be quite exhausting emotionally. see, article after article about medicare risk adjustment so that i'll get sorted. but the general principles of having a population budget for the medicare is something that could allow us to potentially better budget medicare for maybe the first time in a thoughtful fashion ever. you know doug, you have some observations on that. yeah, two things that number one, i think the single most important thing we could do for medicare from fiscal perspective is to have it on a budget at the moment, everyone has an open ended draw on the treasury and they behave accordingly. and if the the providers, the device manufacturers, the pharmaceutical manufacturers, the beneficiaries all realized there was a finite amount of money available to do good things. they would behave differently. so getting it on a budget by some mechanism is incredibly desirable from a fiscal of view. i'll point out there's a lot of agreement on this across the aisle, and i don't think they

realize it on the left, you hear a lot of talk about how we have to create in the medicare program bundles going to have a hip bundle and the bundle where have a set of services, a bundle has to have a quality that's putting that set of services on a budget and for a quality outcome on the right, you have medicare advantage. it's one big bundle. it's got quality metrics and it's got this capitated contribution. that's that's it. there's an about how to do this. it's this one's more comprehensive. neither is perfect. there's a great deal of improvement. for example that i think would come from better quality metrics. the most important metric is a consumer willing to buy your service. we don't have that anywhere. so so so that's that's the advantage of doing this. there's not that much disagreement. it's just the scale it's the scale. yeah right. all right. well, that's remarkable. you think that there's actually a bipartisan. i didn't say i didn't say that.

i think i think there's hope. i think there's hope at the level of policy design, there's an agreement about some of the incentive. and that's what you see going on at the level of selling reforms and getting legislation, legislation. congress, there's a lot of work to do right. although i would add that the seniors are choosing for us. right, because the medicare advantage market penetration in the medicare program writ large is increased by 1 to 1 absolute percentage point. i think every year for the past decade and recently surpassed 50% right now, the family foundation just came out with a report which said, you know, it's 50% now, which is which is quite remarkable. what's even more remarkable is that our friends in the you know, who who write the the medicare trustees report, you know, every year have always underestimated the growth of medicare advantage, which i always thought was kind of interesting. john, i have a question that i

wanted to ask you about your kind of provocative proposals in your and in the book, modernize medicare. most people think that you sign up for insurance. you should sign up, you know, once a year and. that's it. and i basically, you know, the argument is, of course we want markets. we don't we want we want stability in the market. and if you have an enrollment season, people make their decisions they enroll, they get their and that's it until the next season. now we do that we've been doing that in private health insurance for forever. we do it huge federal employee health benefits program and we're doing it medicare advantage you however john want to change that you want you want to have a situation where people can make a decision to enroll in different plans when they think that they should enroll in

different i imagine some of our friends in, the insurance companies would be very very nervous about this proposal. but why i would like to hear your argument. i think other people anybody listening to this program on youtube and so on around the country would like to hear, you know, why you think that ought to be a continuous open. well, quite continuous, but close to it. we have a straight asymmetry here. if you're chronically ill and whether you're in the obamacare exchange, you're in medicare advantage, you're going to look at the networks of different plans here. you can choose from among and you're going to choose plans based what doctors are in that plan. but basically, after you've made your choice, you're stuck for the next 12 months. the insurance company, the other hand, is not stuck. and after you've made your choice and the open enrollment period ends, they can change your network.

and this has happened and and there are some tragic consequences of. this happening where people have been denied access. us cancer specialists, for example, they thought they were going to have access to. so you're right, the insurance industry says if we had continuous open enrollment that be disruptive, although i'll point out that we used to have in the individual market open enrollment and i don't remember a lot of disruptive this, what i propose is you're going to be stuck with a plan you choose unless as your health condition changes. you have a new health condition and you get a heart condition. for example, you should be able to go immediately to the special heart player and and severally to the diabetic plan or so change in health condition, change in in the network that you had access especially if there was a doctor you and now that doctor is no longer in the network that that ought to be condition for for switching

plans and and so we are let's call it partial or continuous open enrollment and. i think that would benefit everybody. right. let me ask you this. how do you respond to folks in the insurance industry and elsewhere who might say, well, you know, john, that sounds great, but you're really promoting adverse selection in the system that we will have more instability in the market as a result of that and that jeopardize the the viability. a lot of plans if we actually had that kind of a system, how would you respond to that? well, again, i think the the symmetry is unfair. the insurance company change its network at the drop of a hat, but the patient can't make switches. i think what senator widen yesterday announced that his found that for several medicare advantage plans these aren't the good ones but for several of them the networks were ghost networks that.

doctors that they claim were in their network weren't really to be would be grounds for allowing enrollees to switch to some other plan. so so we need to make it possible for people switch plans, especially when their health is at stake, not not because they just happen to change minds on a whim, but for some serious health care reason, there ought to be a way to do and remember the whole idea behind medicare advantage is you have risk adjusted premiums and when your health condition, you you your plan entitled to a different premium, probably higher premium. and and that's the way system works and that's why it works so well. and that's we have the special needs plans. all right. let me follow up this a little bit. yeah. doug, i'm sorry so there exists special enrollment periods, for example, in the visual you have here for medicare advantage, you have your your six week period and then you have few more months when you can make a

change but beyond that, you really can't change plans until the next open enrollment. so i'm my point was sounds like what you're proposing is really just for exogenous things that happen to you. we have special enrollment here. it's much more generously to allow people switch. yes but it needs to be. it needs to be close continuous open enrollment. it be it's when the events happen, then you get you know, you get an event. so you then get four weeks to go sign up for a new plan. yes. have health condition change, provide or network change. they lied to you about the network. all those things within sures are afraid of is discretionary medical care that you're hopping around to have them pay for. and i'm leaving, that's all. all right. i think is exhausted. no, i'm trying to agree with you. it's not me. oh. oh, all right.

yeah, well, remember what talking about somebody who used to tell congress what to do with congressional. oh, in the in the exchanges. terrible example here in virginia, a couple had a daughter, a rare cancer, and they had this one clinic, the only clinic and, northern virginia, that dealt with this cancer. and they chose the and after the open closed that the plan kicked that clinic out of their network and and and by the way and the and the miami if you go out of network plan base nothing almost everywhere so this family was really mistreated. yeah and i think that wrong okay look let me ask you this. i mean we're talking about you know, we're talking about continuous enrollment and it brings up another question, it's not another whole which is somewhat controversial with

regard to medicare advantage. and that is the way in which we have a risk adjustment. a risk adjustment and medicare advantage. some of the arguments that are being made, especially by some of our friends in health affairs, is that the risk adjustment act is so flawed that it basically such a fundamental flaw in the system that it it basically is is an argument against the system. risk adjustment is a complicated area, but it is an important area with regard to medicare advantage, medicare advantage going going. doug, do you have any about how we should improve the risk adjustment system. i think the most important thing would be to stop developing the risk measures on the fee for service population and then applying them in medicare advantage. i mean, you ought to do the adjustment and may on the ama

population and risk adjustment is different than for casting the particular procedures. a patient's going to get and people start going down that road and they're in a fee for service mindset. you have a characteristic of individual, they have an age, they have an identified preexisting or two or three married on married, whatever. take, take those characteristics and then you you just do that. you don't pay attention to what goes on inside the care bubble. and you ask what's what's the outcome in terms of cost of care for a particular level of quality that, you need the the before and the after. and you do that math and it's math that does that. and and and then stop tinkering with all the stuff in between. and they're tinkering i think because they have a fee service mentality. john what what what's happening in the health affairs articles is they're comparing the medicare advantage plan to

traditional medicare. and the problem with those kinds of comparisons is that their medicare advantage doctors know or should know that they're going to get more money if they find real medical problems and. so there's pressure put upon them to to very careful about documenting medical conditions, whereas over traditional medicare, there's no no extra for a doctor being careful to get everything down on paper. but about about the patients. now, the reason article, the new york times a and in health affairs made a big deal about the fact that among the medicare plans some find more heart disease and others and some find more diabetes with complications than others. and the implication was that these plans are finding a lot of problems are making it up and i think it's the other way around. i the plans are finding a lot problems are finding because it's in their financial

interests. i don't think they're making up those numbers. it's in their financial the best plans keep people healthy and the way keep people healthy is you discover you know, the pre-diabetic is pre-diabetic. don't wait till his foot needs to be amputated. and these plans not all equally good. and if i have one overall improvement that needs be made in medicare advantage as it needs to be more competitive, there are plans there that ought to lose. they ought to go out of business because then they're not not doing what they should do. the best plans in houston, for example. if you have diabetes, they make insulin free. they make the trip. the visit to the canada that's free. and and it's free because it you keep the patient out of the hospital, you make money and in the more we make this market the better is going to be the quality of care and i have a thought so as practicing hospitalist i can definitely say

i agree with you. like in traditional medicare, you don't have an incentive to to code all those diagnoses. right. and i know you don't have an i have my iphone in my pocket there's an app on it which tells me if my diagnosis coding in the hospital is not enough, i get an alert and you know, the hospital is harassing me as they're practicing dac to add diagnoses codes and i can tell you you you know it's a huge business right because doctors ignore that they ignore the mind, you know they ignore the mentorship or binding or oversight and ignore phone. and so, yeah, i would say fee for service probably is definitely undercounted. i think what we see in the health affairs articles is we see a confusion between app coding and coding intensity up. coding is fraud, right? that's coding something that is not usually there right. a coding intensity is what we're all talking about, which is finding the diagnoses that are there that have not been accounted for or specifying more complications or just adding

specificity, adding clinical specificity is good for clinical communication. now it is also upon know the market regulator and the program design. if plans and plans are more diseases or coding more diseases is is more accurate and coding the complications thereof. it's incumbent upon policymakers to give plans incentive to do something with that information. right. so i'm not really angry at health plans necessarily finding or diagnoses or finding more specificity. we can and should have a debate about. what degree of that is accurate and what degree not. but if they are finding more specificity, we should give them an incentive to use that information to help the beneficiary. right now rather than the incentive to code. okay. so it seems, though, that when we're going forward both on risk adjustment and on payment, we've got a lot of work to do in terms of crafting some reforms for medicare advantage. i'm right about that.

as i correct, i mean, this is going to be some serious heavy lifting. is that right? i mean, doug, do you think? i think i'm sorry. okay let me ask you this. do you think that there is a bipartisan could there be a bipartisan interest in medicare advantage or do you think that there's hostility to know that that's interesting question. you have to understand the democratic. they don't like medicare advantage. those are for profit firms. they really like medicaid. i'm not sure they realize that that most medicaid are being taken care of by for profit managed care companies and but if they could get over that, yes, of course, the two parties could come together because a lot of this is just sense. i think less disagreement than historically.

if you just look at the map, a lot of their constituents are in any plans because they're in their heavily concentrated urban areas that are easier to serve in. may and so low income or. absolutely. if you look at the minorities, low income. absolutely. so i think i don't think it divides as neatly as it did historic right i would so one yet you're right in the medicaid market 72% of medicaid benefits in a medicaid managed care organization. the irony there of not liking medicare being 50.2% medicare advantage is sort of entertaining and like when we think about, you know, we talk about premium subsidy, competitive bidding, whatever we want to call it, right. like that, the fee the federal health benefits program, which you mentioned, we've talked about many times before in the past you know, that's a premium subsidy program. was it 72% of the weighted average? that's yes. you know, the aca exchanges are also a premium subsidy. right. so what is wrong thinking about how we can be fiscally

responsible for medicare and creating on a better platform so that future generations or my generation has access to medicare? well, speaking of generations, i want to go back to doug for a moment. i mean, this this an important question. it's a simple question, and i think we've already answered it a way. but i would like, doug, you to perhaps expand on this a little bit. the whole point of moving to a comprehensive defined contribution system, premiums pork is to harness power of consumer choice to basically enable people to make the choices that are best for them and at the same time that will drive efficiencies in the health care system. but here's the issue and hear it over and over again. you're talking about a population that is, you know, 65, 75, 80 and so on. is really a sensible strategy for older americans to make the kind these kinds of choices

effectively. and i raised this because if you look going all the way back to new york times back in the 1990s, the base, the basic argument against moving in this direction was that the complexity of health care so, so, so overwhelming that ordinary people could not actually make these decisions and that experts could make these decisions. doug, you've talked about. so tell us what you think about that problem so we're not asking a senior to sit on a desert island and decide for themselves out everything in their lives. we're asking them to make important choices with trusted advisors and family members and they can talk to providers and doctors there's no reason they can't do that. so idea that somehow in health care, in health care alone, you're by yourself. you have to make really complicated decisions. it's just it's it's a red

herring. that's not the reality and we make complicated decisions a lot and we don't understand technical aspects of them. we all buy these. how do they work? i know i'm right. so so you've got advisor networks, you've got no need to. be a technical expert on the thing to actually consumer. we do that and in markets we do that in product. we do this everywhere in the economy. and those same seniors are not making those same decisions. you know, i'm still not sure why my nine year old mother needs a cooperman, but she's got one right? so, you know, they're participating in another places. so there's this, that sort philosophy of of respecting their ability to make choices and getting help they need to make them. we've also done it. why? we did it in part d, everyone said they'll never be able to this. it's too hard. seniors. and it has worked very, very well. perfectly, no, but very well.

and i think that's that's that's some evidence that we should take seriously. yeah. john, you had to the most natural person for senior to turn to for advice about health care plans is that seniors primary care physician and we've really muzzled these guys under during the obama years the could not tell the patient if the patient was accountable care organizations which has some of the same financial incentives as as a medicare advantage plan even under trump there's been some deregulation a doctor cannot incur age his patient to join a medicare plan that he's a member of. so we need to earn muscle for the doctors who have them by way, the most information about plans and how they work and what would be good for the patients are yeah yeah. and i would say improving the plan finder right i zillow to go look for house you know your booking.com kayak.com travelocity for booking airfare

hotels you can even use airbnb. you can a house in another continent right like we make complex decisions the time with help from others by providing information and you know in a structured fashion which can should do that for medicare. we can prove the plan finder a thought about premium legging that i have on premiums support. part of premium support is also fee for service and may plans putting them on an equal playing field right. if we're upset about risk adjustment, why don't we think about how we would apply risk to all market participants? traditional medicare? yes, right. why don't we apply a star ratings to traditional medicare? this is not you know, none of this should be a handout or subsidy to private plans. we need to treat the market participants in that viable public option and preserve it for the future. but that's a conversation i. don't think the policy community has had no. a vitally important point because we all make we all are participate in many complex sectors of the economy for

example, like retirement and financial planning and so on, which most us have, you know, limited expertise in these areas. and we rely upon we rely advocates, we rely upon family friends and so on, in order to make these decisions. and and i am told by the economists of course, that is, you know, you guys that there are market leaders, many cases where in other words, you get maybe ten or 12% of the entire demand side of the equation will actually determine the direction in which things go and seems that in this case, medicare advantage seems to be doing pretty well with regard to the rather massive increase enrollment over the last several years. ladies and gentlemen i think we are coming the end of our program. i would say this, that, you know over the next ten years, we are going to spend lot more on medicare than we do today simply because of the sheer size of the senior population.

and with rapid medical technology the cost of delivering medical care on a per capita basis is also going to increase. so the issue is really not so much how much we spend, but ultimate issue is are we getting the best for our medicare dollars, the higher quality of care and are at affordable cost, higher quality care is and i think or our would be higher quality of care is not a product of better bureaucratic central planning. our our colleague is who have contributed to this wonderful effort have the point that the choice competition in fact work. it is demonstrable if you're interested in the details of how choice and competition can work, improving the medicare program, check out. our new book, modernizing

harnessing the power of personal choice and market competition. from johns hopkins university press. all good things come to an end. and so our program at its end, please give our panelists hand and thank you all very, very much for joining. and thank all for coming to the heritage foundation. thank you. let me take the liberty of on behalf of the panel and everyone involved, the book thanking bob and marie for their leadership. and thank you very much. thank you,

thank you for coming out to this panel about a very important subject health inequality and health, justice. we have here