ACC Corner | Finding a Middle Ground on Medicare & Medicaid Reform

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 - Jack Lewin, MD
Jack Lewin, MD

In order to provide quality cardiovascular care and continue to make headway in improving outcomes, it is necessary to develop middle-ground policy positions related to the future design of more sustainable Medicare and Medicaid programs.

Over the last several decades, precipitous increases in healthcare spending have adversely impacted the abilities of individuals, businesses and government to continue to fund health coverage. In particular, the rising costs of Medicare and Medicaid contribute to alarming increases in the national deficit. Solutions exist, but Congress and many policy leaders are seemingly entrenched in partisan positions, grid-locking movement toward viable "middle of the road" strategies to improve care and reduce spending.

Perhaps the most contentious area of the entitlement debate is how to address the escalating growth of Medicare spending, which is expected to grow from $523 billion in 2010 to $7 trillion over 10 years. The Patient Protection and Affordable Care Act (PPACA) proposed $500 billion in cuts to Medicare over 10 years and the deficit reduction process may cut an additional $200 billion. Regardless, costs will continue to increase as the number of beneficiaries and services increase. The medical profession, which has been generally silent on these issues to date, has the potential to lead the development of a viable middle-ground policy on Medicare reform that would:

Promote robust competition among private insurers to improve quality and lower costs, but guarantee funding to ensure a defined benefit.

Preserve the choice of traditional Medicare for at least the next decade at an equal per capita funding as Medicare advantage for those patients and physicians who prefer this.

Gradually increase means-tested premiums and co-pays for affluent seniors.

Propose Medicare cost containment mechanism(s) to replace the flawed Independent Payment Advisory Board concept.

Address Medicare eligibility for uninsured persons under 65, provided that premium costs do not add to deficit spending.

Similarly, the Medicaid program is approaching $500 billion in annual spending, serving more than 45 million beneficiaries. If fully implemented, PPACA will add up to 20 million new beneficiaries in 2014. The program is significantly troubled, partly because it is a state and federal partnership that differs in reimbursement levels and income eligibility from state to state. Also, it is awkwardly comprised of three patient populations: traditional Medicaid services for lower-income women, children and eventually men; the dual-eligible Medi-Medi (Medicaid and Medicare) program; and long-term care services.

A middle ground on Medicaid needs first to recognize the need for state and federal cost negotiation and clarity of responsibility on the three arms of the program. Adoption of existing models that achieve better care at lower costs also is important. A middle ground on Medicaid policy might include:

Shifting federal support for Medicaid services for women, children and low-income men to delivery by private insurer and public co-op competition with minimum benefits.

The Medi-Medi program should be a highly managed federal carve-out from traditional Medicaid and Medicare with defined benefits, social support systems and significant savings. It is estimated that 5 percent of Medicare beneficiaries in the Medi-Medi cohort spend nearly 43 percent of total Medicare spending, and many of them have NYHA Classes III and IV heart failure.

Medicaid long-term care needs to be a separately managed, jointly funded federal-state program. Tax incentives for long-term insurance may be a better way to finance this.

Healthcare is the biggest sector of the national economy and the largest contributor to its fiscal instability. As such, the reasoned input of healthcare providers should be heard. In particular, cardiovascular professionals are responsible for managing the biggest source of morbidity, mortality and cost in Medicare. This call to action must challenge and inspire us to come together as a profession as never before. It is not only our accountability and responsibility, it is our patriotic calling.

Dr. Lewin is CEO of the American College of Cardiology.