Medicare, on a strong foundation, has broader responsibilities

The responses to the latest Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders survey indicate just how successful the program has been in achieving its basic mission, but just how far it has to go in realizing its potential as a key driver of improved health system performance. A vast majority of leaders in health care and health policy said they believe Medicare has been successful in providing access to care and stable coverage to the elderly and disabled individuals. Medicare has not, however, played an important role in achieving broader goals, like using its role as the country's largest purchaser of health services to improve quality, promote more coordinated care, or control costs. There is strong support for sweeping changes to Medicare that would help control program costs and also enhance health system performance.

Because of Medicare's unique position, it can be an important testing ground for cost and quality innovations. There is strong support for policies to encourage such development, including expanding the power of the Secretary of Health and Human Services to put payment pilot programs on a "fast track" and to work with private payers and providers to establish multi-payer initiatives. Similarly, there is strong support for creation of an independent Medicare advisory council with broad authority to develop, test, and implement payment reforms rapidly and flexibly, collaborate in multi-payer initiatives, and alter beneficiary incentives based on effectiveness of services, drugs, and devices.

Specific policy options to improve coverage also are strongly favored, including using Medicare's leverage to negotiate pharmaceutical drug prices and filling in the so-called Medicare "doughnut hole"—the Medicare Part D coverage gap, through which beneficiaries are responsible for all of their covered drug costs—through some combination of increased copayments, government funding, and drug price discounts. There is also strong support for eliminating the two-year waiting period currently required of 1.8 million disabled beneficiaries before they become eligible for benefits; delaying coverage for them can have dire consequences—both financial and physical.

Among options to reinforce Medicare’s long-term solvency, there is strong support for raising payroll taxes, having high-income beneficiaries pay higher premiums, and increasing funding for the Recovery Audit Contractor program to reduce fraud and waste, as well as for a variety of actions to increase quality and efficiency in the program, but not for requiring beneficiaries to pay a higher share of their health care costs or reducing payments to providers.

These responses portray a Medicare program that is extremely successful, popular, and important to its beneficiaries, but can be improved in several ways and, at the same time, must step into its larger role as a key part of health care reform and a platform for improvements that can address the problems that it has in common with the rest of the health care system: the need for increased value for the dollars spent on care.