[Budget of the United States Government]
[VI. Investing in the Common Good: Program Performance in Federal Functions]
[24. Medicare]
[From the U.S. Government Publishing Office, www.gpo.gov]


 
                              24.  MEDICARE

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                              Table 24-1.  FEDERAL RESOURCES IN SUPPORT OF MEDICARE
                                            (In millions of dollars)
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                                                                               Estimate
               Function 570                   1998   -----------------------------------------------------------
                                             Actual     1999      2000      2001      2002      2003      2004
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Spending:
  Discretionary Budget Authority..........     2,723     2,989     2,926     2,926     2,926     2,926     2,926
  Mandatory Outlays:
    Existing law..........................   190,233   202,037   214,944   229,182   233,195   251,244   265,201
    Proposed legislation..................  ........  ........    -1,243    -1,496    -1,526    -1,673    -1,824
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  Created by the Social Security Amendments of 1965, and expanded in 
1972, Medicare is a Nation-wide health insurance program for the elderly 
and certain people with disabilities. The program, which will spend an 
estimated $217 billion in 2000 on benefits and administrative costs, 
consists of two complementary but distinct parts, each tied to a trust 
fund: (1) Hospital Insurance (Part A) and; (2) Supplementary Medical 
Insurance (Part B).
  Over 30 years ago, Medicare was designed to address a serious, 
national problem in health care--the elderly often could not afford to 
buy health insurance, which was more expensive for them than for other 
Americans because they had higher health care costs. Medicare was 
expanded in 1972 to address a similar problem of access to insurance for 
people with disabilities. Through Medicare, the Federal Government 
created one insurance pool for all of the elderly and eligible disabled 
individuals while subsidizing some of the costs, thus making insurance 
much more affordable for almost all elderly Americans and for certain 
people with disabilities.
  Medicare has very successfully expanded access to quality care for the 
elderly and people with disabilities, but at an increasing cost. The 
Balanced Budget Act (BBA) of 1997 improved Medicare's financial outlook 
for the near future, yet its trust funds face financing challenges as 
the Nation moves into the 21st Century. Along with legislative proposals 
discussed elsewhere in the budget, the Health Care Financing 
Administration (HCFA), which runs Medicare, is working to improve 
Medicare through its regulatory authority and demonstration programs.
  Because it serves almost 40 million Medicare beneficiaries, HCFA has 
been designated as a High Impact Agency by the National Partnership for 
Reinventing Government. To meet the challenges of the changing health 
care system and increase responsiveness to its constituencies, HCFA has 
begun a process of management reform (see Section IV). Included in this 
reform are increased management and program flexibilities, increased 
accountability to constituencies, structural reforms, and legislative 
changes to promote competition and increase efficiency in Medicare 
contracting.
  The Department of Health and Human Services (HHS), which houses HCFA, 
is the Federal Government's lead agency for health programs. HHS' 
Strategic Plan states the agency mission as: ``to enhance the health and 
well-being of Americans by providing for effective health and human 
services and by fostering strong, sustained advances in the sciences 
underlying medicine, public health, and social services.'' Medicare 
supports HHS' second, third, fourth and sixth strategic goals, as 
described in Chapter 23, ``Health.''

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Part A

  Part A covers almost all Americans age 65 or older, and most persons 
who are disabled for 24 months or more and who are entitled to Social 
Security or Railroad Retirement benefits. People with end-stage renal 
disease (ESRD) also are eligible for Part A coverage. Part A reimburses 
providers for the inpatient hospital, skilled nursing facility, home 
health care related to a hospital stay, and hospice services provided to 
beneficiaries. Part A's Hospital Insurance (HI) Trust Fund receives most 
of its income from the HI payroll tax--2.9 percent of payroll, split 
evenly between employers and employees.

Part B

  Part B coverage is optional, and it is available to almost all 
resident citizens age 65 or older and to people with disabilities who 
are entitled to Part A. About 94 percent of those enrolled in Part A 
have chosen to enroll in Part B. Enrollees pay monthly premiums that 
cover about 25 percent of Part B costs, while general taxpayer dollars 
subsidize the remaining costs. For most beneficiaries, the Government 
simply deducts the Part B premium from their monthly Social Security 
checks.
  Part B pays for medically necessary physician services; outpatient 
hospital services; diagnostic clinical laboratory tests; certain durable 
medical equipment (e.g., wheelchairs) and medical supplies (e.g., 
oxygen); home health care; physical and occupational therapy; speech 
pathology services; and outpatient mental health services. Part B also 
covers kidney dialysis and other services for ESRD patients.

Fee-for-Service vs. Managed Care

  Beneficiaries can choose the coverage they prefer. Under the 
traditional fee-for-service option, beneficiaries can go to virtually 
any provider in the country. Medicare pays providers primarily based on 
prospective payment, an established fee schedule, or reasonable costs. 
About 85 percent of Medicare beneficiaries now opt for fee-for-service 
coverage.
  Alternatively, beneficiaries can enroll in a Medicare managed care 
plan, and the 15 percent who do are concentrated in several geographic 
areas. Generally, enrollees receive care from a network of providers, 
although Medicare managed care plans may offer a point-of-service 
benefit, allowing beneficiaries to receive certain services from non-
network providers. Additional kinds of managed care plans, including 
provider sponsored organizations and preferred provider organizations, 
will be phased in for Medicare beneficiaries over the next few years as 
part of Medicare + Choice.
  Most managed care plans receive a monthly, per-enrollee capitated 
payment that covers the cost of Part A and B services. As of March 1998, 
72 percent of all Medicare beneficiaries lived in a county served by at 
least one Medicare managed care plan.

Successes

  Medicare has dramatically increased access to health care for the 
elderly--from slightly over 50 percent of the elderly in 1966 to almost 
100 percent today. According to a recent Medicare Payment Advisory 
Commission report, 97 percent of Medicare fee-for-service beneficiaries 
(94 percent for managed care) reported no trouble obtaining care. 
Further, 88 percent of fee-for-service Medicare beneficiaries (92 
percent for managed care) reported having a physician or physician's 
office as a usual source of care. Medicare beneficiaries have access to 
the most up-to-date medical technology and procedures.
  Under the BBA and other recent legislation, Medicare beneficiaries now 
have expanded access to many important preventive care services 
including mammographies, prostate and colorectal cancer screening, bone 
mass measurements and diabetes self-management services. These benefits 
will help prevent or reduce the complications of disease for millions of 
beneficiaries.
  Medicare also gives beneficiaries an attractive choice of managed care 
plans, which can provide coordinated care that is focused on prevention 
and wellness. As of December 1, 1998, over six million beneficiaries 
have enrolled in 346 Medicare managed care plans. During the 12-month 
period ending December 1, 1998, enrollment in the capitated managed care 
plans called ``risk contracts'' grew by 16 percent.

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  In addition, Medicare is working to protect the integrity of its 
payment systems. Building on the success of Operation Restore Trust, a 
five-State demonstration aimed at cutting fraud and abuse in home health 
agencies, nursing homes, and durable medical equipment suppliers, 
Medicare is increasing its efforts to root out fraud and abuse. Recent 
legislation provides mandatory Federal funds and greater authority to 
prevent inappropriate payments to fraudulent providers, and to seek out 
and prosecute providers who continue to defraud Medicare and other 
health care programs. Since 1993 the Federal Government has assigned 
more Federal prosecutors and FBI agents to fight health care fraud. As a 
result, it has increased prosecutions by over 60 percent, convictions by 
240 percent, and saved $20 billion in health care claims. The budget 
also proposes legislation that can save Medicare another $2 billion over 
the next five years.

Spending and Enrollment

  Net Medicare outlays will rise by an estimated 31 percent from 1999 to 
2004--from $201 billion to $264 billion. \1\ Part A outlays will grow by 
an estimated 30 percent over the period--from $130 billion to $169 
billion--or an average of 5.4 percent a year. Part B outlays will grow 
by an estimated 33 percent--from $71 billion to $95 billion--or an 
average of six percent a year.
---------------------------------------------------------------------------
  \1\ These figures cover Federal spending on Medicare benefits, but do 
not include spending financed by beneficiaries' premium payments or 
administrative costs.
---------------------------------------------------------------------------
  Medicare is consuming a growing share of the budget. In 1980, Federal 
spending on Medicare benefits was $31 billion, comprising 5.2 percent of 
all Federal outlays. In 1995, Federal spending on Medicare benefits was 
$156.6 billion, or just over 10 percent of all Federal outlays. By 2004, 
assuming no changes in current law, Federal spending on Medicare 
benefits will total an estimated $264 billion, or almost 14 percent of 
all Federal outlays.
  Medicare enrollment will grow slowly until 2010, then explode as the 
baby boom generation begins to reach age 65. From 1995 to 2010, 
enrollment will grow at an estimated average annual rate of 1.5 percent, 
from 37.6 million enrollees in 1995 to 46.9 million in 2010. But after 
2010, average annual growth will almost double, with enrollment reaching 
an estimated 61.3 million in 2020.

The Two Trust Funds

  HI Trust Fund: As noted earlier in this chapter, the HI Trust Fund is 
financed by a 2.9 percent payroll tax, split evenly between employers 
and employees. In 1995, HI expenditures began to exceed the annual 
income to the Trust Fund and, as a result, Medicare began drawing down 
the Trust Fund's accounts to help finance Part A spending. Prior to the 
BBA, the Government's actuaries predicted that the HI Trust Fund would 
become insolvent in 2001. The BBA, however, extended the solvency of the 
Trust Fund until 2008.
  Medicare Part A still faces a long-term financing challenge. Since 
current benefits are paid by current workers, Medicare costs associated 
with the retirement of the baby boomers starting in 2010, will be borne 
by the relatively small number of people born after the baby boom. As a 
result, only 2.3 workers will be available to support each beneficiary 
in 2030--compared to today's four workers per beneficiary. The President 
plans to work with Congress and the bipartisan Medicare Commission to 
develop a long-term solution to this financing challenge.

  SMI Trust Fund: The SMI Trust Fund receives about 75 percent of its 
income from general Federal revenues and about 25 percent from 
beneficiary premiums. Unlike HI, the SMI Trust Fund is really a trust 
fund in name only; the law lets the SMI Trust Fund tap directly into 
general revenues to ensure its annual solvency.

Balanced Budget Act Implementation

  HCFA continues to implement the many changes in Medicare payment 
methodologies and provider options that were mandated in the BBA. 
Although HCFA has been forced to delay some provisions due to the year 
2000 (Y2K) computer problem, the agency has issued major rules that 
implement the new Medicare + Choice program, PSO solvency standards, an 
interim payment system for home health services and a prospective pay

[[Page 246]]

ment system for skilled nursing facilities. According to the Board of 
Trustees for the Part A Trust Fund, the reform measures enacted in the 
BBA extended the solvency of the Part A Trust Fund from 2001 to 2008 and 
lowered its projected 75-year deficit by about one-half.

Performance Plan

  HCFA has developed a set of performance goals to measure its progress 
in ensuring that Medicare beneficiaries receive the highest quality 
health care. HCFA's performance goals relate to four critical areas: 
quality assurance; access to care for the elderly and disabled; 
administrative efficiency; and a reduction in fraud and abuse. For 
example, HCFA's 2000 goals include:
   Increasing the percentage of Medicare beneficiaries who 
          receive a mammogram once every two years from 55 percent in 
          1994 to 60 percent in 2000;
   Increasing the number of Medicare beneficiaries over age 65 
          receiving vaccinations for influenza from 55 percent in 1995 
          to 60 percent in 2000;
   Increasing the percentage of Medicare beneficiaries who have 
          at least one managed care choice from 70 percent in 1997 to 80 
          percent in 2000.
   Decreasing the one-year mortality rate among Medicare 
          beneficiaries hospitalized for heart attacks from 31.4 percent 
          in 1995 to 27.4 percent in 2000.
   Reducing the telephone busy rate for Medicare carriers, for 
          which measurement will begin in 2000. By 2001, the number of 
          Medicare carriers who answer calls within two minutes and the 
          number who answer 80 percent of calls within one minute will 
          increase.
   Reducing the payment error rate under Medicare's fee-for-
          service program from 14 percent in 1996 to seven percent in 
          the year 2000 and five percent by the year 2002; and
   Ensuring that all systems necessary for continuity of HCFA 
          payments and other mission critical outputs through and beyond 
          2000 will be Y2K computer compliant. Specifically, all systems 
          will be certified compliant (mission-critical certified by the 
          independent contractor and others by appropriate HCFA 
          personnel) prior to the need for those systems to process new 
          dates.
  The budget includes legislative proposals relating to the Patients' 
Bill of Rights, long term care, and several proposals expanding Medicare 
access. Appropriate performance measures will be developed as 
legislation is enacted and implemented.