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.


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