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Embedding automatic and gradual budgetary adjustments in Social Security and Medicare would substantially lessen the risk of runaway federal debt. Implementing these adjustments would be more complex in Medicare than in Social Security. The first step should be to inject more discipline into Medicare by modifying its Supplementary Medical Insurance trust fund. A second step should be to eliminate fragmentation in the insurance benefit. With these changes, Congress could balance automatic adjustments between revenue and spending parameters and manage spending by imposing more restraint on payments to service providers and higher costs for beneficiaries. Ensuring permanent Medicare trust fund stability would be consistent with the program's original design and would lessen the frequency and intensity of divisive solvency-restoration debates., The federal government's responsibilities increased dramatically in the second half of the past century. Unfortunately, the processes by which elected leaders plan for and control the financial effects of those [...]

With the right rules, transparent pricing for medical services, which has bipartisan support, could lower health care costs without harming quality. Regulations forcing providers to disclose their charges online have [...]

Medicare's rules specifying payments for covered services are among the most powerful levers in health care. Private insurers use the same codes and formulas as their starting points for payments to avoid reinventing the wheel even as they are forced to 'plus up' the amounts to appease their affiliated providers. (Medicare's size allows the government to adopt take-it-or-leave-it terms.) While the differential between what Medicare and commercial plans pay is said to validate the benefits of price regulation, the empirical bases for the government's rates are not well understood. A partial review shows a pattern of combining dated, imprecise cost reports with idiosyncratic and opaque adjustments that were not constructed to guarantee the best outcomes for the dollars spent. Properly designed competitive pricing, with a focus on value and not just cost, could be used to tether more Medicare payments to the rates that will incentivize efficiency and innovation, leading to optimal patient care. As the debate over how to control health care costs without compromising quality continues, Medicare's regulated prices should not be given unquestioned status as the best available options., Health policy research in recent years has focused regularly on the spread between Medicare's and commercial insurance's payments for the same services and products. The comparisons are usually straightforward because [...]

Chairman Whitehouse, Ranking Member Grassley, and distinguished members of the committee, thank you for the invitation to participate in this hearing. The Medicare HI Signal The headline focus of today's [...]

The UK National Health Service (NHS), now in its 75th year, has devoted supporters inside and outside the country who admire its egalitarian ethic and public-service orientation. However, the rapid deterioration of its performance in recent years, and especially after the COVID-19 pandemic, is too glaring and dangerous to overlook. A major challenge is the health service's near-exclusive reliance on political and bureaucratic processes for resources and organizational direction. Free care at the point of service and publicly owned hospitals sustain the NHS's popularity, but long waits for needed care, even when the services are 'free,' harm patients. Neither major political party appears ready to explore systemic reform, but if political conditions create an opening, UK leaders might consider moving the NHS closer to the public-private models found in other European economies, as has been suggested at various points in its history and also recently. The lesson for other countries from the NHS's ongoing crisis is that full governmental control of medical care brings risks, not just potential and often-overstated rewards., On February 15, 1944, with D-Day approaching, British Prime Minister Winston Churchill chaired a cabinet meeting with an agenda that went beyond the ever-present military and diplomatic concerns. In particular, [...]

Policymakers in the United States have an opportunity to convert bipartisan support for transparent health care prices into savings for patients and taxpayers. While significant new federal rules are forcing more disclosure of previously unseen fee schedules, they need refinement to help consumers play a more active role in the market. The current reliance on pricing tied to insurance billing codes instead of meaningful bundles of services is a major impediment. Four changes to the current suite of requirements would improve results: (1) pricing disclosure of standardized, consumer-focused bundles of services; (2) mandatory (and enforced) provider participation in the disclosure system with regularly scheduled updates; (3) guaranteed access to care for all consumers at the disclosed prices, irrespective of their insurance coverage; and (4) coordination of insurance payments with transparency efforts to ensure patients can benefit fully when choosing low-priced options., The marketplace for medical services is undergoing notable change with the implementation of new federal price transparency rules. Hospitals and insurance plans, heretofore permitted to shield the prices they charged [...]

The US is an outlier among advanced economies in that its national government does not fully control, through regulation and budgeting, health insurance coverage and the provision of medical care. [...]

The HI Trust Fund's Shortfall Points to Much Larger Fiscal Challenges This subcommittee is to be commended for holding this hearing because the subject matter it will address--the financial outlook [...]

Medicaid plays a larger role in US health care than was anticipated at its 1965 enactment. The country's heavy reliance on voluntary, job-based insurance leaves gaps in protection for people who are unemployed or who have low earnings and cannot afford premium payments. Further, the disabled and frail elderly need social services in addition to traditional medical care. Medicaid and the Children's Health Insurance Program (CHIP) have, by default, become the nation's safety-net programs for these societal obligations. Medicaid's joint federal-state architecture and open-ended matching system for program financing have facilitated rapid spending and enrollment growth, but they also complicate political accountability, budget and cost discipline, and consistent and fair national administration. Reform can strengthen Medicaid and CHIP by improving incentives for cost control while ensuring all Americans have a basic level of protection. Medicaid and CHIP can support market incentives by filling in gaps and reinforcing competitive pressures where possible., Medicaid is the largest public insurance program in the US by total enrollment, which would surprise many of the people who voted it into existence in 1965. In part, that [...]

Over the past year, the global vaccination campaign to end the COVID-19 pandemic has progressed from tests of vaccine efficacy to over six billion (and counting) administered doses. Highly structured clinical trials facilitated strong statistical examinations of the vaccines because randomization accounts for unobserved confounders that could bias the analysis. Post-approval assessments have limitations because they rely on data from less structured, real-world settings. Several post-approval studies show the existing mRNA vaccines launched initially in the US effectively prevent, as predicted, the worst outcomes of COVID-19, while the vaccines many other countries use are less effective but still invaluable in fighting the pandemic. An observed erosion in vaccine efficacy this year, relative to the clinical trials of 2020, may be a function of the new variants of the virus, waning acquired immunity against infection over time, or other factors, such as the higher incidence of prior infections in the unvaccinated population and the tendency for random error (such as false-positive COVID-19 tests) to attenuate measured efficacy rates. Taken together, the studies make it plain that vaccinating the unvaccinated with any of the globally approved vaccines remains the most important step for lessening the pandemic's severity., Governments worldwide have administered over six billion COVID-19 vaccines since late 2020 (Our World in Data 2021a), using inoculations developed by both Western companies and state-directed enterprises in other parts [...]

The US has mature health-sector institutions and long-standing insurance and care arrangements that limit the scope of potential future reforms. The realistic path is incrementalism one way or another: toward either tighter government regulation of prices paid for insurance and services (especially in private insurance) or a structured market that leads the sector's suppliers of medical services to set competitive prices on their own. How each option would fare when implemented through the nation's actual political and administrative processes is an important consideration. Medicare and Medicaid reveal that payment regulation can produce the desired reductions in spending but also lead to special-interest influence and rigidity. A structured market, with the right safeguards, can deliver strong results by self-correcting and being more resilient to outside manipulation. It will only be adopted, however, if consumers believe it will lead to financial benefits and no risks., Health policy is not implemented in an apolitical vacuum. Market failures in the health sector force political leaders in all countries to actively supervise both their insurance systems and how [...]

Medicare is the most decisive force in US health care. The program's payment regulations heavily influence how hospitals, physician groups, and other providers organize themselves to maximize profits while delivering medical services to their patients (Medicare and non-Medicare alike). Advocates of government-enforced cost control favor using Medicare's payment rules over private options and market incentives to discipline expenses. Market advocates must offer an alternative that builds on the program's existing consumer-oriented features. Program changes should emphasize strengthened price competition, informed and structured coverage options, and better financial incentives for migration toward low-cost, high-value care. Further, the program's trust funds and insurance benefit need to be updated to complement and reinforce market discipline and to limit the financial burden imposed on current and future taxpayers. Market reforms in Medicare would encourage conforming changes in the commercial sector, which is one reason they encounter stiff resistance from advocates of full governmental control., Medicare is the health insurance plan, and regulator, that few facilities or practitioners can afford to eschew or ignore. It is the nation's largest payer of medical claims, and its [...]

Governments of advanced economies should ensure health coverage and ready access to needed medical care for their entire populations. Patients without insurance are at risk of experiencing avoidable health problems and higher mortality because they forgo care or get treatments later than is optimal. The US has moved, in halting steps, toward population-wide insurance enrollment but has not yet made spells without coverage an uncommon occurrence. The United States' reliance on multiple, competing insurance plans to provide coverage is necessary for using market incentives, but it also allows breaks in protection to occur. Policymakers can close many existing coverage gaps and move the nation closer to continuous population-wide enrollment without wholesale change by focusing on three reforms: building a nationwide automatic enrollment system for non-group insurance, giving employers options to increase take-up by more workers, and compromising on Medicaid as the nation's safety-net insurance plan. Immigration reform should address the large number of uninsured persons who reside in the US without proper authorization to do so., The US has made progress toward covering the uninsured in recent years, but it has not fully eliminated breaks in protection. One reason is the view held by some proponents [...]

Medical care cannot be delivered efficiently or equitably through an unregulated market. Patients prefer insurance to out-of-pocket expenses, and insurance severs consumption from point-of-service pricing. Patients rely on expert practitioners [...]

The US can emerge from the depths of the COVID-19 crisis in the coming months if the federal government leads and executes an effective vaccination campaign (and if, as appears to be the case, emerging SARS-CoV-2 variants do not fully evade vaccine-induced immunity). The limiting factors on the pace of population protection are the manufacturing capacity of the approved vaccines' sponsors, the efficiency of administering available supply, and Americans' willingness to take the shots. A system dynamics model of vaccine inventory and daily vaccinations is useful for estimating when important objectives might be met. Under a base case scenario, the US could reach a target of 75 percent of the population protected by the end of July, assuming three million shots per day can be sustained over several months and vaccine hesitancy recedes. The expected arrival of another approved vaccine (from Johnson &Johnson) and the possibility of a slower, or more rapid, pace of daily vaccinations would alter the outlook in different ways., February 2021 In early December 2020, then-President-elect Joe Biden set a goal of administering 100 million COVID-19 vaccinations in his first 100 days in office (Reuters 2020). The pace achieved [...]

A fertile field of research in theoretical computer science investigates the representation of general recursive functions in intensional type theories. Among the most successful approaches are: the use of wellfounded relations, implementation of operational semantics, formalization of domain theory, and inductive definition of domain predicates. Here, a different solution is proposed: exploiting coinductive types to model infinite computations. To every type A we associate a type of partial elements Partial(A), coinductively generated by two constructors: the first, return(a) just returns an element a:A; the second, step(x), adds a computation step to a recursive element x:Partial(A). We show how this simple device is sufficient to formalize all recursive functions between two given types. It allows the definition of fixed points of finitary, that is, continuous, operators. We will compare this approach to different ones from the literature. Finally, we mention that the formalization, with appropriate structural maps, defines a strong monad., Comment: 28 pages

Employer-sponsored insurance (ESI) has been a central part of US health care for the entirety of the postwar era and is valued by working-age Americans for its adaptability and the ready access to medical care it provides to its enrollees. It is not without flaws, however. Not all employers offer ESI to their workers, and even when they do, it can be insecure for employees at risk of losing their jobs. Most troubling, its rising costs are becoming a heavy financial burden and inhibit wage growth. These problems are systemic; they cannot be addressed by individual firms that must compete for qualified workers in part through the generosity of their health benefits. Congress should modernize ESI by reforming its tax treatment to control costs and entice more firms to offer plans, ensuring all workers have meaningful choices of coverage, and giving preferential status in the market to high-quality managed care plans and multi-firm private exchanges., The COVID-19 pandemic and the deep global recession it precipitated are crises of such severity that they could lead to permanent changes in American society. In health care, job-based health [...]

The global campaign to identify effective vaccines against COVID-19 has entered the final stage of testing for regulatory approval--Phase III trials--for several promising candidates. Evaluation will be guided by criteria established by the Food and Drug Administration and the World Health Organization. The minimum threshold for efficacy is observed reduction of disease incidence of at least 50 percent, with high statistical confidence of efficacy above a minimum of 30 percent. Full safety reviews of the vaccine candidates may take several months, to ensure any adverse events are given sufficient time to become evident and then studied. For efficacy, however, statistically valid determinations can be made after approximately 150 confirmed cases of COVID-19 among trial participants, which may occur relatively quickly given the prevalence of the virus in many communities. Consequently, on the question of whether a vaccine works to prevent progression from the virus to the disease, a clear signal is likely to occur in a few months after the trial begins rather than over the longer time frames that may be necessary for evaluation of their safety profiles., An intense global scramble is underway to identify and manufacture safe and effective vaccines against COVID-19. Social-distancing protocols, when implemented vigorously, can slow the transmission of the SARS-CoV-2 virus that [...]

The 2020 Medicare trustees' report released in April did not incorporate how the coronavirus pandemic would affect program finances. Even so, the trustees project that the Medicare Hospital Insurance (HI) [...]

The US was facing a challenging fiscal outlook even before the coronavirus pandemic. The current crisis and the financial crash of just over a decade ago have made matters much worse. Both required aggressive policy responses and significant federal borrowing. Federal debt is now likely to escalate more rapidly than even pessimistic scenarios predicted a few years ago. Beyond the crises, the primary causes of fiscal pressure are population aging and rising health expenses. The large federal entitlement programs--Social Security, Medicare, and Medicaid--have grown rapidly over the past half century and are expected to continue doing so in coming decades. When the crisis recedes, Congress should enact reforms that lower the long-term costs of these programs. The emphasis should be on promoting longer working lives, more progressive benefits, and efficiency in the provision of health and long-term care services., Reckless borrowing is one of the main routes to dissipating a country's power and international influence. It would be disastrous globally if the United States were to weaken itself and [...]

In the US, the federal government is supposed to defer to the states on matters not reserved for it by the Constitution, such as regulating the medical profession. State medical boards, created and empowered by state legislatures, establish the criteria that must be met before physicians are issued licenses and allowed to care for patients without supervision. Since the latter half of the 19th century, the medical profession has been effectively regulating itself through heavy influence over the licensing process and control of the organizations that certify educational and training institutions. The federal government participates in (but does not directly control) residency programs through partial funding provided mainly by Medicare. Further, it writes the laws that regulate the influx of foreign graduates of international medical schools. The federal government should encourage a more adaptive and flexible pipeline of physicians entering the US market by (1) shifting away from the excessively hospital-centric orientation of current funding for residency training and directing the aid to the residents themselves; (2) promoting new forms of institutional certification with fewer ties to the economic interests of existing practitioners and academic medical centers; (3) adjusting the Medicare fee schedule, which sets income expectations for physicians, based on the market prices revealed through transparency initiatives; (4) promoting and testing a shorter and less costly education option that merges a traditional undergraduate curriculum with medical school; and (5) enacting immigration policies that accommodate a larger influx of well-trained and talented foreign-born physicians., The United States has high expenditures for medical care compared to other industrialized countries. Among the 36 members of the Organisation of Economic Co-operation and Development (OECD), the US ranks [...]