The Unprepared Caregiver.

Years of studying health care financing and delivery does not prepare you for the actuality of dealing with a serious health event. The practical challenges of our extremely fragmented and complex health care system make it difficult to navigate this world-even when someone is there to help the patient. And, being a caregiver is a far cry from being a health care analyst. There are many lessons to be learned for improving our system: the need for skilled co-ordination support, the need for simplifying and re-orienting the various silos of postacute care, the importance of generating ways to support caregivers, and not least, promoting simple lessons in civility for providers of services.

Serving Older Adults with Complex Care Needs: A New Benefit Option for Medicare.

Medicare was originally designed to protect beneficiaries from the financial burden of acute episodes of illness. As lifespans lengthen, Medicare must adapt to serve beneficiaries with substantial long-term physical or cognitive impairment who need personal care assistance. These beneficiaries often incur high out-of-pocket costs for Medicare-covered services as well as home and community care not covered by Medicare. This latter category of care is often key to continued independence. To improve Medicare's capacity to serve such beneficiaries, and to prevent unnecessary institutionalization, this issue brief, one in a series on Medicare's future challenges, proposes a complex care benefit option that would include home and community services, and describes how it might be structured to balance the goals of improving care for beneficiaries and ensuring affordability.

Medicare and the affordable care act.

The recently enacted Patient Protection and Affordable Care Act made modest changes to improve Medicare and obtained a substantial share of funding for the Act's broader reforms from future spending reductions in the program. Drug benefits and preventive services were improved. While painful, the spending reductions will have only moderate impacts on beneficiaries and should help achieve the goals of health care reform: encouraging better primary and preventive care, making providers conscious of finding ways to increase the productivity of care delivered and changing the relative levels of payment across certain providers. Additional costs to beneficiaries will arise from changes in private plan payments and increasing income-related premiums.

Toward a rational, value-based drug benefit for Medicare.

A major challenge facing Congress is what changes, if any, to make to Medicare Part D. With the apparent failure of the Democrats' attempt to remove the prohibition on government intervention in drug price negotiations, the party's next steps are unclear. One suggested option is a plan administered by the Centers for Medicare and Medicaid Services (CMS), to compete with private plans and facilitate a transition to a more rational structure. We discuss issues surrounding the design of such a mechanism and how it might provide a transition toward a more rational and sustainable drug benefit in the longer term.

Medicare extra: a comprehensive benefit option for Medicare beneficiaries.

The proposed Part E, Medicare Extra, outlined in this paper adds a comprehensive benefit option to Medicare, eliminating the need for beneficiaries to purchase a private drug plan and Medigap supplemental coverage. Financed by a budget-neutral beneficiary premium, it has the advantages of greater simplicity, efficiency, and value without adding to federal costs. Beneficiaries now enrolled in Medigap plans would save money, as could employers by choosing a lower-cost alternative to current retiree health plans. Eliminating some of the excess payments to Medicare Advantage plans would yield savings that could be used to help finance premium subsidies for low-income beneficiaries.

Are women better off because of the new Medicare drug legislation?

The passage of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 will help to reduce the out-of-pocket burdens women will face in 2006 once the full drug benefit is introduced. Nonetheless, the legislation is less than ideal and creates a number of issues that should be improved to meet women's needs. Three key elements of the legislation that were essential in gaining its passage stand in the way of such improvements: limits on the amount spent on the benefit, requirements to rely on the private sector, and a failure to adequately arrange for future financing. A major overhaul is unlikely, but it is possible that modest improvements to aid Medicare beneficiaries will be considered in the future. Several of those improvements are described here.

Medicare means-testing: a skeptical view.

In response to claims that Medicare is unsustainable over time, Mark Pauly has suggested a means-testing approach as a solution to its financing problems. To obtain enough resources in this way, however, it is necessary to ask middle-class beneficiaries to pay much more for their health care, by subjecting them to vouchers. The spending limits Pauly suggests are arbitrary and would likely place an untenable burden on beneficiaries with modest incomes. A better approach to financing would be to examine the ability of both taxpayers and beneficiaries to pay in the future-likely resulting in a different outcome.

How beneficiaries fare under the new Medicare drug bill.

The Medicare Prescription Drug Improvement and Modernization Act (MMA) provides the largest benefit expansion in Medicare's history while enacting major changes to the program's structure. Offering $410 billion in new drug benefits will certainly help many beneficiaries now struggling with the costs of prescriptions, particularly those with low incomes. It is difficult to determine, however, whether beneficiaries will be better off in the long run. The drug benefits will not grow with the needs of beneficiaries, and other changes that prove to be unworkable or that place some beneficiaries at risk will create added costs. In the meantime, favorable treatment of private plans will create new inequities. Additional legislation and carefully crafted regulations could mitigate a number of these issues; in the meantime, they will require close scrutiny.

Comparing Medicare and private insurers: growth rates in spending over three decades.

Over the past three decades both Medicare and private insurers have initiated cost containment mechanisms to control the growth of spending on personal health care. To compare spending growth between these two payers, we present four measurement principles that should be implemented when drawing such comparisons, and we apply them to the National Health Accounts data files. We attribute Medicare's ability to equal--and using our measures, actually exceed-the private sector in controllingthe rate of health spending growth to Medicare's ability to price aggressively for the services it covers.

Medicare Matters: Building on a Record of Accomplishments.

Medicare's successes over the past 35 years include doubling the number of persons age 65 or over with health insurance, increasing access to mainstream health care services, and substantially reducing the financial burdens faced by older Americans. Medicare reform remains high on the list of priorities of many policymakers because of rapid past and expected future growth in Medicare. If the original goals of the program-including providing mainstream care, pooling of risks, and offering help to those most in need-are to be protected, however, a go-slow approach for greater reliance on the private sector is in order.

Healthcare for everyone, but how?

What system will ensure that all Americans can get medical care? How should it be financed? Can a standard benefits package ever be fair? Is a national health board a good idea? Recently, POSTGRADUATE MEDICINE arranged an exclusive exchange at the National Press Club in Washington, DC, between two senior fellows from groups that study such issues, with Glen C. Griffin, MD, asking the questions. The liberal viewpoint was represented by Marilyn Moon of the Urban Institute and the conservative viewpoint was represented by Peter Ferrara of the National Center for Policy Analysis.