In an era of rising inflation and trillion-dollar deficits, there appears to be growing bipartisan support for fiscal restraint. President Biden’s recent budget proposal featured more than $1 trillion in deficit-reducing policies. And his administration is now promising that the proposals once comprising the president’s Build Back Better agenda will be, at worst, deficit neutral.
But despite the changing fiscal environment, many in Congress are still eager to enact a costly and risky expansion of Medicare.
This idea seems simple: lower the eligibility age of Medicare from 65 to 60 to make out-of-pocket health care costs and premiums more affordable for millions of Americans. Supporters of the idea point to Medicare’s popularity among the elderly and argue that the policy would extend coverage at the stage of life when health care costs begin to rise.
This seemingly simple idea, however, would come with significant downsides and unintentional consequences. With support from the Partnership for America’s Health Care Future, we scored the distributional and fiscal impacts of lowering Medicare’s eligibility age on both the newly eligible population and on health care providers.
Expanding coverage wouldn’t be cheap. We estimate that the federal deficit would rise by as much as $42.6 billion in the first year of the program and $452 billion over its first 10 years — not counting increased interest costs to the federal government.
But the fiscal costs are only part of the story. Medicare at 60 poorly targets those in need and relies on cost-shifting to hide its true cost.
One of the justifications for lowering the eligibility age for Medicare is to help those in need of purchasing health insurance. Yet our analysis finds that compared to the 18- to 59-year-olds who would remain ineligible, the newly eligible population would be less likely to be uninsured and more likely to have incomes above 400% of the federal poverty line.
And even among the newly eligible, it is far from clear whether the policy would help low-income Americans. Many of these individuals are already receiving health care subsidies through the Affordable Care Act, so shifting them to Medicare could mean higher premiums and increased out-of-pocket spending. We estimate that 36% of Affordable Care Act enrollees would see their combined premiums plus out-of-pocket spending rise under Medicare at 60. Even worse, the group most likely to see their combined costs rise are those with incomes between 150% to 250% of the federal poverty line. Conversely, 90% of ACA recipients with incomes above 400% of the poverty line would see their combined costs fall under Medicare at 60.
There’s one other group that would be financially affected by Medicare at 60: doctors, hospitals, and other health care providers. Previous efforts to rein in growing costs have focused on paying physicians and hospitals less for their services, and Medicare at 60 is no different.
The issue is that physicians and hospitals receive less for providing the exact services to patients covered by Medicare or Medicaid than they receive for those who are privately insured. Medicare at 60 would shift more reimbursements from private rates to government-mandated Medicare rates, resulting in revenue cuts for health care providers.
Actuaries at the Centers for Medicare & Medicaid Services project that, under current law, reimbursement rates for Medicare services relative to private insurers will continue to fall. In the absence of cost-cutting measures or large increases in utilizations, reductions in inpatient hospital service payments from Medicare at 60 would reduce annual profits by about 25% for the median hospital and by even larger amounts for hospitals with below-average margins. Physicians would be less affected in the short term, but face steeper growth in cuts in the long term.
These cuts would have significant financial effects on hospitals and providers. Congress’s past behavior suggests these cuts may not come to fruition. From 2003 to 2014, Congress repeatedly overrode scheduled cuts to providers as part of the near-annual legislation that came to be known as the “doc fix.” But if Congress succumbs to political pressures and prevents reimbursement rates from falling any further, we estimate the fiscal cost of Medicare at 60 would rise by $72 billion during the 10-year budget window. The trade-off is inevitable: either Medicare at 60 will mean steep revenue cuts for physicians and hospitals, or much higher costs for taxpayers.
Lawmakers are now admitting that the federal government faces a genuine budget constraint. That makes it an odd time to think about expanding Medicare to 60-to 64-year-olds. Even under optimistic fiscal assumptions, the proposal would add billions to federal deficits, while poorly targeting those in need and straining the finances of hospitals and physicians.
Tom Church and Daniel L. Heil are policy fellows at the Hoover Institution, a public policy think tank at Stanford University.