Medicare efficiency
Looking back over the period from 1970 to 1997, Medicare's cost containment performance has been better than that of private insurance. Starting in the 1970s, Medicare and private insurance plans initially grew very much in tandem, showing few discernible differences (see Chart 1). By the 1980s, per capita spending had more than doubled in both sectors. But Medicare became more cost-conscious than private health insurance in the 1980s; and cost containment efforts, particularly through hospital payment reforms, began to pay off. From about 1984 through 1988, Medicare's per capita costs grew much more slowly than those in the private sector.
This gap in overall growth in Medicare's favor stayed relatively constant until the early 1990s, when private insurers began to take the rising costs of health insurance seriously. At that time, growth in the cost of private insurance moderated in a fashion similar to Medicare's slower growth in the 1980s. Thus, it can be argued that the private sector was playing catch-up to Medicare in achieving cost containment. Private insurance thus narrowed the difference with Medicare in the 1990s, but as of 1997 there was still a considerable way for the private sector to go before its cost growth would match Medicare's achievement of lower overall growth.
It should not be surprising that the per capita rates over time are similar between Medicare and private sector spending, because all health care spending shares technological change and improvement as a major factor driving high rates of expenditure growth. To date, most of the cost savings generated by all payers for care has come from slowing growth in the prices paid for services but making only preliminary inroads in reducing the use of services or addressing the issue of technology. Reining in the use of services will be a major challenge for private insurance as well as Medicare in the future, and it is not clear whether the public or private sector is better equipped to do this. Further, Medicare's experience with private plans has been distinctly mixed.
Reform options such as the premium support approach seek savings by allowing the premiums paid by beneficiaries to vary so that those choosing higher-cost plans pay substantially higher premiums. The theory is that beneficiaries will become more price conscious and choose lower-cost plans. This in turn will reward private insurers that are able to hold down costs. And there is some evidence from the federal employee system and the Calpers system in California that this has disciplined the insurance market to some degree. Studies that have focused on retirees, however, show much less sensitivity to price differences. Older people may be less willing to change doctors and learn new insurance rules in order to save a few dollars each month. Thus, what is not known is how well this will work for Medicare beneficiaries.
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