Where We Are and Where We Need to Go to Enhance Medicare for All Beneficiaries
Today we celebrate the 55th anniversary of the Medicare and Medicaid programs. Just days ago we celebrated the 30th anniversary of the Americans with Disabilities Act (ADA). These landmark laws have vastly improved the lives of Americans and remain legislative monuments to what policymakers can achieve when they truly focus on the needs of their constituents.
In 2015, for Medicare’s 50th anniversary, the Center for Medicare Advocacy published a series of articles entitled Medicare Matters: 50 Insights for Medicare’s 50th Anniversary. These articles highlighted Medicare’s past, including its key role in integrating hospitals, reducing poverty, providing economic security, expanding coverage to certain individuals with disabilities in 1972, adding coverage for hospice care in 1983, and moving forward through the Affordable Care Act (ACA) enhancements in 2010. As noted by former U.S. Senator Christopher J. Dodd, who contributed to the Center’s 50th Anniversary series:
For half a century our nation, through Medicare, has made a sacred trust, a promise to our seniors. A promise which says that after a lifetime of hard work and paying into the system, they could enjoy the dignity of a secure retirement that includes quality, accessible health care. […] I can think of no more successful or widely supported federal program within the last century, and the American people must continue to fulfill this promise by supporting and strengthening Medicare for another 50 years and beyond.”
The 50th anniversary series also highlighted how much work remains to be done in order to make the Medicare program work better for all those it serves. This includes the need to fill in coverage gaps, including oral health, vision, hearing, and long-term care; strengthening cost-sharing protections; and addressing the danger of further privatization of the program.
In the 5 years since these articles were written, there have been several bills signed into law that are a mixed bag for Medicare beneficiaries. For example, the 2015 Medicare and CHIP Reauthorization Act (MACRA) overhauled the flawed Medicare physician payment system, and made permanent the Qualified Individual (QI) program, which helps low-income beneficiaries. However, MACRA also added deductibles to Medigap plans, thereby limiting options for people who want to remain in traditional Medicare. MACRA also further means-tested Parts B and D premiums for high-income beneficiaries, further undermining the universality of the Medicare program. The 2016 21st Century Cures Act (CURES), on the one hand allows people with end-stage renal disease (ESRD) to enroll in Medicare Advantage plans starting in 2021, but, on the other hand, did not correspondingly expand federal Medigap rights for those with ESRD, and reinstated an enrollment period which favors beneficiaries in Medicare Advantage plans vs. those in traditional Medicare. The Bipartisan Budget Act of 2018 (BBA) repealed the harmful Medicare outpatient therapy caps and included the Steve Gleason Enduring Voices Act which permanently fixes restrictions in the law that limited Medicare coverage and access to Speech Generating Devices (SGDs), but it also made changes to the home health provider payment system that have reduced access to Medicare-covered home care, and yet again, further means-tested Parts B and D premiums for higher-income individuals.
In addition to these legislative changes, over the last 5 years Medicare has experienced a growing imbalance between Medicare Advantage and traditional Medicare, which threatens the future of the universal Medicare program. The ACA, and all that it has done for Medicare, remains under threat. (Threats to the ACA include a pending Supreme Court case; see, e.g., an amicus brief filed by the Center along with AARP and Justice in Aging.)
Coverage for medically necessary services to which people are entitled under Medicare law remain difficult to obtain, especially for people with longer-term, chronic, and debilitating conditions. This is demonstrated by the Center’s ongoing efforts to implement the Jimmo v. Sebelius settlement, which successfully challenged an inappropriate “improvement standard;” confirming that coverage is available for skilled care to maintain or slow decline of an individual’s condition. As we have regularly highlighted, there are also ongoing and growing barriers to accessing necessary home health care (as described in the Center’s recent Medicare and Family Caregivers Issue Brief.)
Furthermore, the current COVID-19 pandemic is demonstrating the tangible harm endured by beneficiaries in a climate of regulatory rollback; this is most evident in the tragedies witnessed in nursing facilities. As noted by Center Senior Policy Attorney Toby Edelman, in recent testimony before the House Ways & Means Health Subcommittee, “[t]hese past several months have brought to fuller public awareness the deadly consequences of poor care, inadequate staffing levels, and treatment of regulations intended to ensure good care for residents as burdens on facilities that need to be eliminated. Although many of these problems in nursing facilities have been identified for decades, they have been made worse by recent deregulatory actions and the coronavirus pandemic. Essential changes are needed.”
In addition, while a wide-ranging array of temporary Medicare waivers and flexibilities have allowed beneficiaries to access care through telehealth, there is currently a rush to make these changes permanent, even before the pandemic has subsided. This could fundamentally alter the way care is delivered, and potentially add to health care disparities. (See, e.g., Joint Principles from Center for Medicare Advocacy and Medicare Rights Center: Medicare Expansion of Telehealth Helps Beneficiaries Access Care During the Pandemic – But Caution is Needed Before Making These Changes Permanent).
Looking forward, and beyond the pandemic, additional challenges to Medicare remain. The Medicare program must be expanded, but in a manner that provides better coverage and cost-sharing protections for all beneficiaries – rather than just a subset of those that choose to enroll in private plans. The Center has recently updated our Medicare Platform: Principles to Improve Medicare for All Beneficiaries Now and In the Future. We hope that policymakers will consider the Platform when developing future Medicare laws and policies, and follow the path begun by H.R. 3, The Elijah Cummings Lower Drug Costs Now Act, passed by the House in December 2019. H.R. 3 would reinvest significant savings due to changes in Medicare drug payment policies into expanding traditional Medicare benefits, including adding oral, vision, and dental coverage for all beneficiaries, expanding rights to purchase Medigap coverage, and expanding eligibility for low-income assistance.
As the Center concludes in our Medicare Platform, “We need to improve Medicare, not privatize or cut it. Renew it, strengthen it. Then expand access for generations to come.”