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National Health Spending Estimates Under Medicare for All

全民健康支出估算全部为医疗保险

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【来源】: 兰德公司
【时间】: 2019-04-10
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In 2018, RAND conducted a study for the New York State Health Foundation (NYSHealth) to understand the impacts of the comprehensive single-payer health plan (the New York State Health Act—NYHA) being considered by the New York state legislature (Liu et al., 2018). The RAND study assessed how the plan would affect several outcomes, including health care spending. In 2016, co-author Jodi Liu also analyzed a previous proposal by Sen. Bernie Sanders for a national single-payer plan (S. 1782, 113th Congress) in the course of completing her dissertation at the Pardee RAND Graduate School (Liu, 2016).

In this research report, we extrapolate from our previous single-payer research, including the work mentioned above, to estimate the effects of a national single-payer health plan (often referred to as Medicare for All) that would provide comprehensive health care coverage to the population nationwide, including long-term care benefits and no cost sharing. The approach is similar to national single-payer health care proposals that have been discussed in Congress, including a recent plan sponsored by Rep. Pramila Jayapal (Medicare for All Congressional Caucus, 2019). We did not model a Medicare for All plan using a microsimulation approach; rather, we estimated aggregate changes to health spending that might occur under the plan by applying adjustments based on our previous work.

Top-Line Findings

We estimate that total health expenditures under a Medicare for All plan that provides comprehensive coverage and long-term care benefits would be $3.89 trillion in 2019 (assuming such a plan was in place for all of the year), or a 1.8 percent increase relative to expenditures under current law. This estimate accounts for a variety of factors including increased demand for health services, changes in payment and prices, and lower administrative costs. We also include a supply constraint that results in unmet demand equal to 50 percent of the new demand. If there were no supply constraint, we estimate that total health expenditures would increase by 9.8 percent to $4.20 trillion.

While the 1.8 percent increase is a relatively small change in national spending, the federal government’s health care spending would increase substantially, rising from $1.09 trillion to $3.50 trillion, an increase of 221 percent.

Table 1. Medicare for All: Changes in U.S. Health Care Spending, 2019 (in Billions) Spending Category National Health Expenditure Accounts, 2019 (Status Quo) RAND Medicare for All Estimate, 2019 Out of pocket 396.9 66.1 Private health insurance 1,278.2 0 Medicare 800.1 0 Medicaid 623.4 0 Other health insurance programs* 148.8 81.0 Other third-party payers** 575.5 506.2 Medicare for All 0 3,238.7 *Other health insurance programs include CHIP, the Department of Defense, and the Department of Veterans Affairs (VA). We assume that the VA is preserved under the single-payer system. ** Other third-party payers included here are worksite health care; other private revenues; the Indian Health Service, workers’ compensation; general assistance; maternal and child health; vocational rehabilitation; the Substance Abuse and Mental Health Services Administration; other state, local, and federal programs; school health; public health activities; and investment in research, structures, and equipment. We assume that the Indian Health Services, workers’ compensation, private revenues, worksite health care, vocational rehabilitation, school health, government public health activities, and investment would be maintained outside of the single-payer system. NOTE: Totals may not sum due to rounding.

Table 3. Changes to Federal, State and Local, and Private Spending on Health Care, 2019, Medicare for All, in Billions National Health Expenditure Accounts, 2019 (Status Quo) RAND Medicare for All Estimate, 2019 (Federal government does not recoup any state and lcoal spending) Federal government* 1,090.0 3,498.7 State and local government** 638.0 0 Business, households, and other private*** 2,095.0 393.2 Federal health spending in the status quo includes spending on Medicaid, Medicare, other programs (maternal and child health, CHIP, vocational rehabilitation, Substance Abuse and Mental Health Services Administration, Indian Health Service, federal workers' compensation, other federal programs, public health activities, Department of Defense, Department of Veterans Affairs, research, and structures and equipment, Marketplace premium and cost-sharing subsidies), employer contributions to private health insurance premiums, and employer payroll taxes paid to Medicare hospital insurance trust fund. State and local health spending in the status quo includes spending on Medicaid, other programs (state phase-down payments, maternal and child health, public and general assistance, CHIP, vocational rehabilitation, other state and local programs, public health activities, research, and structures and equipment), employer contributions to private health insurance premiums, and employer payroll taxes paid to Medicare hospital insurance trust fund. Business, households, and other private spending under Medicare for All includes out-of-pocket spending on services and products not covered by the Medicare for All plan, workers’ compensation reimbursements to the Medicare for All plan, other private revenue (e.g., philanthropy, institutions’ gift shops, cafeterias, parking lots), worksite health care, school health, and private investment in research, structures, and equipment. Tax payments to finance the spending by the federal government are not shown. NOTE: Totals may not sum due to rounding.

Approach

To estimate aggregate spending at the national level, we started with aggregate health spending as projected by the Centers for Medicare and Medicaid Services, Office of the Actuary (CMS/OACT) for 2019. Those estimates indicate that total U.S. health care spending is projected to be $3,823.1 billion in 2019. Taking the CMS/OACT estimate as a starting point, we made a number of additional adjustments to account for the effects of moving to a Medicare for All plan, described below.

Setting Aside Spending Categories That Would Not Be Affected

We assume the Department of Veterans Affairs and the Indian Health Service would continue to operate independently of a Medicare for All plan, and that the plan would require reimbursement from workers’ compensation carriers. We assume other categories of health spending and offsets that would be outside of the single-payer system include private revenues (e.g., from philanthropy, hospital gift shops, cafeterias, parking), worksite health care, vocational rehabilitation, school health, government public health activities, and investments in research, structures, and equipment. We identified these categories of spending in the tables reported by CMS/OACT and set aside $587.2 billion in spending that we assume would remain unchanged under a Medicare for All plan.

Estimating Changes in Demand for Medical Services

Under a national single-payer system, more people would be covered by insurance, and coverage would be more comprehensive than a typical employer plan or current Medicare coverage—requiring no copays, deductibles, or other cost sharing. The increased availability and generosity of benefits would in all likelihood lead to greater health care consumption. We made separate adjustments to account for changes in spending among people who would become newly insured under a Medicare for All plan, and for increases in spending among previously insured people who would face reduced cost sharing under the plan. To incorporate these adjustments, we assigned 7.2 percent of out-of-pocket spending to currently uninsured individuals, based on estimates published by Catlin et al. (2015). We allocated the remaining 92.8 percent of out-of-pocket spending to those with Medicare and private insurance, and we assume that enrollees with other sources of coverage (i.e., Medicaid, the Children’s Health Insurance Program [CHIP], and other health insurance and third-party payers) would face no out-of-pocket costs1.

After allocating out-of-pocket spending across categories, we made adjustments to