Options for modernization of traditional Medicare

Medicare today is both the same — and very different — from the program launched in 1965.

今天的医疗保险与 1965 年推出的计划既相同，又截然不同。

From the perspective of beneficiaries, the traditional Medicare program (TM) hasn’t changed much in 61 years, except through the addition of Part D in 2003 and through changes in provider reimbursement.

从受益人的角度来看，传统的医疗保险计划 (TM) 61 年来没有发生太大变化，除了 2003 年增加了 D 部分以及医疗服务提供者报销方面的变化之外。

But with the addition of the Medicare Advantage program (MA; originally established as Medicare Part C), which enrolled 54% of beneficiaries in 2025 , the program as a whole has evolved to reflect changes in health care markets that have occurred over the succeeding six decades.

但随着 Medicare Advantage 计划（MA；最初成立为 Medicare C 部分）的加入（到 2025 年将覆盖 54% 的受益人），该计划作为一个整体已经发展到反映了接下来 60 年医疗保健市场发生的变化。

Policymakers and stakeholders today are assessing and debating what the future of Medicare will be.

如今，政策制定者和利益相关者正在评估和讨论医疗保险的未来。

There is considerable sentiment that t raditional Medicare should be maintained, both to offer enrollees more choice and as a check on the MA program.

人们普遍认为应保留传统医疗保险，既为参保者提供更多选择，又作为对 MA 计划的检查。

But there are several serious issues with the TM benefit design.

但TM福利设计存在几个严重问题。

TM is designed as a separate hospital benefit (Part A) and medical benefit ( P art B), with distinct cost-sharing parameters that reflect coverage practices in the mid-1960s and no out-of-pocket (OOP) cap on cost-sharing.

TM 被设计为独立的医院福利（A 部分）和医疗福利（B 部分），具有反映 20 世纪 60 年代中期承保实践的独特费用分摊参数，且费用分摊没有自付费用 (OOP) 上限。

This cost-sharing design, in turn, has contributed to the growth of Medicare supplemental coverage.

这种费用分摊设计反过来又促进了医疗保险补充保险的增长。

The TM benefit design is outdated.

TM福利设计已经过时了。

The lack of an OOP cap means the program provides insufficient risk protection to beneficiaries who incur catastrophic costs.

缺乏 OOP 上限意味着该计划无法为遭受灾难性成本的受益人提供足够的风险保护。

The cost-sharing parameters within each part do not efficiently balance financial protection and incentives to use appropriate services.

每个部分内的成本分摊参数无法有效平衡财务保护和使用适当服务的激励措施。

The overall generosity of the benefit, measured as actuarial value, is substantially poorer than that of MA.

以精算值衡量的总体福利慷慨程度明显低于 MA。

This poor benefit generosity, in turn, leads beneficiaries to obtain supplemental coverage, which increases Medicare costs and further erodes incentives for efficient service use.

这种糟糕的福利慷慨反过来又导致受益人获得补充保险，这增加了医疗保险成本，并进一步削弱了有效利用服务的动力。

Finally, the combination of a two-part benefit and supplemental coverage increases the complexity of decision making required of beneficiaries.

最后，两部分福利和补充保险的结合增加了受益人决策的复杂性。

This paper lays out the challenges in TM’s current design and proposes solutions, beginning with a catastrophic cap, which will address them.

本文列出了 TM 当前设计中的挑战并提出了解决方案，从灾难性上限开始，这将解决这些问题。

A central reason for the existence of health insurance is to protect people against catastrophically large financial risks and alleviate the uncertainties of illness.

健康保险存在的一个核心原因是保护人们免受灾难性的巨大财务风险并减轻疾病的不确定性。

To provide this protection, insurers can lower the price paid for services at the point of care through cost – sharing (e.g. , charging coinsurance and copayments , which are only a fraction of the original service price).

为了提供这种保护，保险公司可以通过成本分摊（例如，收取共同保险和共付额，这只是原始服务价格的一小部分）来降低护理点服务的价格。

They can also target the overall level of annual spending by limit ing total OOP spending.

他们还可以通过限制 OOP 总支出来确定年度支出的总体水平。

An OOP limit greatly reduces uncertainty , and it ensures the well-being of patients in medical crises.

OOP限制大大减少了不确定性，并确保了医疗危机中患者的福祉。

For this reason, almost all health insurance plans, both public and private, include a cap on people’s OOP spending.

因此，几乎所有公共和私人健康保险计划都包含人们的 OOP 支出上限。

All expenses above that cap are paid by the insurer.

超过该上限的所有费用均由保险公司支付。

TM stands as a stark exception in that it does not have an OOP cap unless beneficiaries purchase supplemental coverage.

TM 是一个明显的例外，因为它没有 OOP 上限，除非受益人购买补充保险。

At the same time, when beneficiaries do not bear the costs of additional health care , there is a risk of an inefficient increase in the utilization of services, a phenomenon known as moral hazard.

同时，当受益人不承担额外医疗费用时，存在服务利用效率低下增加的风险，这种现象被称为道德风险。

Optimal insurance design balances financial risk protection against moral hazard through a combination of coinsurance and OOP limits.

最佳保险设计通过共同保险和 OOP 限额的结合来平衡财务风险保护和道德风险。

The current TM cost-sharing structure is a consequence of the historical evolution of the Medicare program.

目前的 TM 费用分摊结构是 Medicare 计划历史演变的结果。

It does not achieve the desired balance between moral hazard and risk protection.

它没有达到道德风险和风险防护之间理想的平衡。

Medicare’s cost-sharing design is built on its original, bifurcated design.

医疗保险的费用分摊设计建立在其原始的分叉设计的基础上。

TM beneficiaries have separate deductibles for Part A and Part B services.

TM 受益人对于 A 部分和 B 部分服务有单独的免赔额。

The architecture of Part A cost – sharing is especially baroque.

A 部分成本分摊的架构尤其巴洛克式。

The inpatient hospital deductible for Part A is $1,736 in 2026 .

2026 年 A 部分的住院免赔额为 1,736 美元。

After 60 days, cost – sharing is $434 per day.

60 天后，费用分摊为每天 434 美元。

After the 90 th day, a beneficiary begins drawing on lifetime reserve days (of which they have 60) at a cost of $868 per day.

第 90 天后，受益人开始提取终生储备日（其中有 60 天），每天的费用为 868 美元。

After all lifetime reserve days are expended, the beneficiary pays all costs.

所有终生保留天数结束后，受益人支付所有费用。

S killed nursing facilitie s (SNFs) have a separate daily copayment , which kicks in after 21 days at $217 per day.

Skilled 护理机构 (SNF) 有单独的每日共付额，21 天后开始支付，每天 217 美元。

Cost-sharing should be designed to reduce inefficient use of services by targeting those with high responsiveness to price.

成本分摊的目的应该是通过针对那些对价格敏感的人来减少服务的低效使用。

But under today’s prospective hospital payment incentives, there is little reason to impose costs on beneficiaries for long hospital stays (which they cannot control and which hospitals have no reason to induce).

但根据当今预期的医院支付激励措施，没有理由向受益人征收长期住院费用（他们无法控制，医院也没有理由诱导）。

Part A cost-sharing is the opposite of what we would expect under optimal design.

A 部分的成本分摊与我们在优化设计下的预期相反。

Part B cost-sharing is relatively simple.

B 部分的费用分摊相对简单。

The Part B deductible is $283 for 2026.

2026 年 B 部分免赔额为 283 美元。

Most Part B services have coinsurance of 20%.

大多数 B 部分服务的共同保险为 20%。

Coinsurance provides people with incentives to reduce the use of costly care and choose lower – cost providers.

共同保险为人们提供激励，以减少昂贵护理的使用并选择成本较低的提供者。

Commercial insurance has evolved to favor copayments, rather than coinsurance, for routine primary care visits, simplifying decisions and encouraging use of these services ( 66% of commercially insured workers have flat copayments for primary care).

商业保险已经发展为在常规初级保健就诊时支持自付额，而不是共同保险，从而简化决策并鼓励使用这些服务（66% 的商业保险工人对初级保健有固定的自付额）。

This logic is even more salient for Medicare, which sets all provider prices , leaving less rationale for using coinsurance rather than simple copayments for services .

这种逻辑对于医疗保险来说更为突出，它规定了所有提供者的价格，从而减少了使用共同保险而不是简单的服务自付额的理由。

The complicated coinsurance and deductible structure, together with the lack of an OOP cap, leave s beneficiaries with significant risk.

复杂的共同保险和免赔额结构，加上缺乏 OOP 上限，给受益人带来了巨大的风险。

In many cases, they respond to this risk by buying supplemental coverage that covers part of the TM cost-sharing.

在许多情况下，他们通过购买涵盖部分 TM 费用分摊的补充保险来应对这种风险。

Many TM enrollees purchase a supplemental insurance plan called a Medigap plan.

许多 TM 参保者购买了名为 Medigap 计划的补充保险计划。

Other enrollees receive supplemental coverage from a former employer.

其他参保者从前雇主那里获得补充保险。

These supplemental insurance (SI) plans can often eliminate so much risk that they result in substantial moral hazard, increasing utilization and raising program costs for all enrollees.

这些补充保险 (SI) 计划通常可以消除大量风险，从而导致重大道德风险、提高利用率并提高所有参保者的计划成本。

At the same time, they can be inaccessible both because they are very costly and because they are often underwritten.

与此同时，它们也可能难以获得，因为它们的成本非常高，而且通常是有承保的。

The result is a bifurcated program that fails to prevent moral hazard for some enrollees and leaves coverage gaps for others.

结果是一个分裂的计划，无法防止某些参与者的道德风险，并为其他参与者留下了覆盖范围的空白。

The TM cost-sharing structure has also generated an imbalance between the value of TM and MA plans.

TM 成本分摊结构也造成了 TM 和 MA 计划价值之间的不平衡。

Actuarial value is one way to measure the relative generosity of benefits covered by an insurance plan.

精算价值是衡量保险计划所涵盖的福利相对慷慨程度的一种方法。

It measures the average share of health spending covered by the plan, as opposed to being paid out of pocket by the beneficiary, accounting for cost – sharing features such as coinsurance, deductibles, and OOP limits.

它衡量该计划涵盖的医疗支出的平均份额，而不是由受益人自掏腰包，并考虑到共同保险、免赔额和 OOP 限额等成本分摊功能。

It does not consider premiums.

它不考虑保费。

The actuarial value of Medicare Advantage Prescription Drug (MA-PD) plans in 2025 has been estimated at 92.2% , while t raditional Medicare plus Prescription Drug Plans (TM-PDP) without supplemental insurance have an actuarial value of just 85.6%.

2025 年 Medicare Advantage 处方药 (MA-PD) 计划的精算价值估计为 92.2%，而没有补充保险的传统 Medicare 加处方药计划 (TM-PDP) 的精算价值仅为 85.6%。

This difference in actuarial value favors the choice of an MA plan.

这种精算价值的差异有利于 MA 计划的选择。

In general, MA and TM enrollees both pay Part B premiums ($185 per month in 2025).

一般来说，MA 和 TM 参保者均需支付 B 部分保费（2025 年每月 185 美元）。

However, MA plans sometimes rebate part of the Part B premium.

然而，MA 计划有时会回扣 B 部分保费的一部分。

MA enrollees also get an OOP cap and often drug coverage, while paying an average of only $17 a month in plan premiums on top of Part B in 2025.

MA 参保者还可以获得 OOP 上限，并且通常会获得药物承保，而到 2025 年，除了 B 部分之外，每月平均只需支付 17 美元的计划保费。

By contrast, adding Medigap can significantly increase the actuarial value of TM , but TM beneficiaries pay substantial costs for that additional coverage.

相比之下，增加 Medigap 可以显着增加 TM 的精算价值，但 TM 受益人要为额外的保险支付大量费用。

Medigap added an average of $217 a month in premiums in 2023.

2023 年，Medigap 每月平均保费增加 217 美元。

Even then , a TM beneficiary still needs a separate drug plan.

即便如此，TM 受益人仍然需要单独的药物计划。

The value proposition between MA and TM is increasingly skewed.

MA 和 TM 之间的价值主张日益倾斜。

Sources : Milliman, 2025 ; Actuarial Research Corporation (2024)

资料来源：Milliman，2025；精算研究公司 (2024)

Note: Affordable Care Act (ACA); Health Maintenance Organization (HMO); Preferred Provider Organization (PPO); Medicare Advantage Prescription Drug ( MA-PD); Prescription Drug Plans ( PDP)

注：《平价医疗法案》(ACA)；健康维护组织（HMO）；首选提供商组织 (PPO)； Medicare Advantage 处方药 (MA-PD)；处方药计划 (PDP)

Finally, the enrollment process for TM is too complicated.

最后，TM的注册流程太复杂。

New beneficiaries must make separate choices about Part A and B enrollment, prescription drug plans, and Medigap coverage.

新受益人必须对 A 部分和 B 部分的注册、处方药计划和 Medigap 承保范围做出单独的选择。

Once enrolled , they face complicated cost-sharing arrangements , including separate plan deductibles and an OOP cap for drug coverage , but not for other forms of medical spending.

一旦加入，他们将面临复杂的费用分摊安排，包括单独的计划免赔额和药物承保的 OOP 上限，但其他形式的医疗支出则不然。

They can also face penalties for switching between MA and TM , such as underwriting , if they opt into Medigap.

如果他们选择加入 Medigap，他们还可能因在 MA 和 TM 之间切换而面临处罚，例如承保。

By unifying the deductible and reducing the importance of Medigap, this paper moves toward a simpler choice set for enrollees.

通过统一免赔额并降低 Medigap 的重要性，本文为参保者提供了更简单的选择集。

In what follows , we consider benefit design improvements in TM , which are intended to address these issues, noting interactions with MA throughout.

接下来，我们考虑 TM 的效益设计改进，旨在解决这些问题，并自始至终注意到与 MA 的交互。

We review options in TM in three main areas: adding an OOP cap (catastrophic coverage), modifying coinsurance and deductible parameters, and restricting/reforming supplemental insurance.

我们在三个主要领域审查 TM 的选项：添加 OOP 上限（灾难性保险）、修改共同保险和免赔额参数以及限制/改革补充保险。

In each case, we discuss the implications for both TM and MA.

在每种情况下，我们都会讨论对 TM 和 MA 的影响。

We conclude with recommendations for action from among these options.

最后，我们从这些选项中提出了行动建议。

We also emphasize that these reforms should not come at the expense of the solvency of the Hospital Insurance (HI) trust fund.

我们还强调，这些改革不应以牺牲医院保险（HI）信托基金的偿付能力为代价。

The first step in reforming the TM benefit design is to add an out-of-pocket spending cap.

改革 TM 福利设计的第一步是增加自付费用上限。

Such a cap would protect people from catastrophic risk and improve the actuarial value of TM relative to MA.

这样的上限将保护人们免受灾难性风险的影响，并提高 TM 相对于 MA 的精算价值。

The numbers from the Urban Institute model (Table 4) imply that adding a $5,000 cap to TM would increase actuarial value by about 5 percentage points.

Urban Institute 模型中的数字（表 4）表明，为 TM 添加 5,000 美元的上限将使精算价值增加约 5 个百分点。

MedPAC focus groups suggest that adding OOP protection is the most desired change to TM offerings.

MedPAC 焦点小组建议，添加 OOP 保护是对 TM 产品最期望的改变。

Similarly, a recent survey found that one-fifth of MA enrollees reported choosing MA over TM because MA plans do provide an OOP limit.

同样，最近的一项调查发现，五分之一的 MA 注册者表示选择 MA 而不是 TM，因为 MA 计划确实提供了 OOP 限制。

Introducing an OOP cap would help reduce cost – sharing burdens.

引入 OOP 上限将有助于减少成本分摊负担。

Importantly, this is most protective for those beneficiaries with serious health issues.

重要的是，这对于那些有严重健康问题的受益人来说是最具保护性的。

According to a 2017 study of Medicare beneficiaries with a cancer diagnosis , the mean annual OOP costs in the first two years after diagnosis were $11,585 (inflation – adjusted) for TM beneficiaries without supplemental insurance, implying that many beneficiaries have even higher OOP spending .

根据 2017 年对诊断为癌症的 Medicare 受益人进行的一项研究，对于没有补充保险的 TM 受益人来说，诊断后头两年的平均年度 OOP 费用为 11,585 美元（经过通货膨胀调整），这意味着许多受益人的 OOP 支出甚至更高。

1 Overall, TM beneficiaries in the 90th percentile of spending or higher spent an average of $10,535 OOP on health services, adjusted for inflation.

1 总体而言，支出 90% 或以上的 TM 受益人在医疗服务上的平均支出为 10,535 美元（根据通货膨胀进行调整）。

For context, the median annual household income for those over 65 was $56,680 in 2024 , and this tends to decline substantially with age .

就背景而言，到 2024 年，65 岁以上老年人的家庭年收入中位数为 56,680 美元，而且随着年龄的增长，这一数字往往会大幅下降。

Clearly, OOP costs of $10,535 or more are catastrophic for the typical Medicare beneficiary, and they can be even more overwhelming for many low-income beneficiaries.

显然，10,535 美元或更多的 OOP 成本对于典型的 Medicare 受益人来说是灾难性的，对于许多低收入受益人来说甚至可能更加难以承受。

For instance, a senior living at 150% of the poverty line is not eligible for dual enrollment in Medicaid , and $10,535 would represent almost half of their annual income .

例如，生活在贫困线 150% 的老年人没有资格参加医疗补助计划，而 10,535 美元几乎相当于他们年收入的一半。

For those using TM without supplemental insurance , OOP costs can grow especially fast.

对于那些在没有补充保险的情况下使用 TM 的人来说，OOP 成本增长得特别快。

In 2016, this group had average OOP spending on services of $7 , 820 ( inflation – adjusted ) .

2016 年，该群体在服务上的平均 OOP 支出为 7, 820 美元（经通货膨胀调整）。

Consistent with these high OOP levels , 11% of Medicare beneficiaries delayed medical care due to cost concerns in 2017, disproportionately driven by those with annual incomes below $25,000.

与这些高 OOP 水平相一致，2017 年，11% 的 Medicare 受益人由于费用问题而推迟了医疗护理，其中年收入低于 25,000 美元的人所造成的比例不成比例。

These figures highlight that an OOP cap aligns well with our goals for benefit redesign.

这些数字凸显了 OOP 上限与我们重新设计福利的目标非常吻合。

It improves the risk – bearing structure of TM , increases parity between MA and TM, and reduces coverage gaps for those without supplemental insurance.

它改善了 TM 的风险承担结构，提高了 MA 和 TM 之间的平价性，并缩小了那些没有补充保险的人的承保差距。

An OOP cap already exists for Part D spending, and this paper focuses on the implementation of an OOP cap in Medicare Parts A and B.

D 部分支出已经存在 OOP 上限，本文重点讨论 Medicare A 和 B 部分中 OOP 上限的实施。

Many proposals over the years have considered adding an OOP cap to Medicare.

多年来，许多提案都考虑在医疗保险中增加 OOP 上限。

Appendix Table 1 surveys several comprehensive proposals that have been made since the Affordable Care Act (ACA).

附录表 1 调查了平价医疗法案 (ACA) 以来提出的几项综合提案。

Importantly, we do not adjust for inflation when reporting numbers from the OOP cap proposals in this paper.

重要的是，在报告本文中 OOP 上限提案的数据时，我们没有根据通货膨胀进行调整。

Both the cap level and any cost estimates are reported directly and in the dollar-years chosen by the authors.

上限水平和任何成本估算均以作者选择的美元年直接报告。

Because many of these estimates pre date 2025, the figures may be lower than their 2025 dollar equivalents.

由于其中许多估算是在 2025 年之前进行的，因此这些数字可能低于 2025 年的美元等值。

Most reform proposals would both cap OOP spending and change cost – sharing structures and financing more generally.

大多数改革提案都会限制 OOP 支出并更广泛地改变成本分摊结构和融资。

The Congressional Budget Office (CBO), for instance, has regularly released an estimate on the effect of instituting an OOP cap while simultaneously creating a combined Part A and B deductible and uniform 20% coinsurance rate.

例如，国会预算办公室 (CBO) 定期发布对设立 OOP 上限的影响的估计，同时创建 A 部分和 B 部分的组合免赔额以及统一 20% 的共同保险率。

The most recent estimate (2024) was for an OOP cap of $8,500 with a combined Part A and B deductible of $850.

最近的估计（2024 年）OOP 上限为 8,500 美元，A 部分和 B 部分的免赔额合计为 850 美元。

While the OOP cap would increase costs to the Medicare program, the addition al changes to the combined deductible and coinsurance would reduce these costs.

虽然 OOP 上限会增加医疗保险计划的成本，但对组合免赔额和共同保险的额外更改将减少这些成本。

In the CBO proposal, the deductible is set higher than the current Part B deductible but lower than the current Part A deductible.

在 CBO 提案中，免赔额设置为高于当前 B 部分免赔额，但低于当前 A 部分免赔额。

While a decrease in Part A cost-sharing for those with high inpatient spending pushes up costs for Medicare, this is more than offset by an increase in cost-sharing for the majority of beneficiaries who have only Part B spending .

虽然对于住院支出较高的人来说，A 部分费用分摊的减少推高了 Medicare 的费用，但这完全被大多数只有 B 部分支出的受益人的费用分摊的增加所抵消。

On net, introducing these policies would save around $3 billion per year from 2028 to 2034.

从净值来看，从 2028 年到 2034 年，引入这些政策每年将节省约 30 亿美元。

It is also helpful to know what the effect of an OOP cap would be on budgets and beneficiaries when it is considered separately from other policies.

了解 OOP 上限与其他政策分开考虑时对预算和受益人的影响也很有帮助。

This provides a sense of the possible budget outcomes and factors affecting spending.

这提供了对可能的预算结果和影响支出的因素的了解。

These estimates should be used with caution since changes to the OOP cap will interact with Medigap, deductibles, and coinsurance adjustments in ways that may be difficult to predict.

应谨慎使用这些估计值，因为 OOP 上限的变化将以难以预测的方式与 Medigap、免赔额和共同保险调整相互作用。

An OOP cap is also likely to reduce Medicaid spending , since Medicare is the primary payer for those who are dual eligible for both programs.

OOP 上限也可能会减少医疗补助支出，因为医疗保险是同时符合这两个计划资格的人的主要付款人。

Two recent analyses that focus on the effect of an OOP cap alone are a 2022 Urban Institute proposal and a 2020 KFF proposal .

最近两项单独关注 OOP 上限影响的分析是 2022 年城市研究所提案和 2020 年 KFF 提案。

The three key parameters that determine the cost to the Medicare program of an OOP cap are how the cap will affect service utilization, how it will affect decisions to enroll in TM versus MA, and how it will affect decisions to enroll in supplemental insurance.

决定 OOP 上限的 Medicare 计划成本的三个关键参数是上限将如何影响服务利用率、它将如何影响参加 TM 与 MA 的决策，以及它将如何影响参加补充保险的决策。

When beneficiaries do not bear the costs of additional health care , there is a risk of moral hazard.

当受益人不承担额外医疗费用时，就会存在道德风险。

This happens because after enrollees reach the cap, their cost-sharing for services falls to zero , and people are much more likely to use services when the price is zero.

发生这种情况的原因是，在注册人数达到上限后，他们的服务成本分摊降至零，并且当价格为零时，人们更有可能使用服务。

This reduction in cost-sharing has been shown to increase service use , even among those with high initial utilization.

事实证明，成本分摊的减少可以增加服务的使用，即使对于那些初始利用率较高的服务也是如此。

There is, however, considerable uncertainty about the extent of this utilization effect, especially in the Medicare program .

然而，这种利用效应的程度存在相当大的不确定性，特别是在医疗保险计划中。

A cap will also affect the decision to enroll in MA rather than TM.

上限也会影响注册 MA 而不是 TM 的决定。

One of the benefits of MA plans is that they do incorporate a cap on OOP expenses.

MA 计划的好处之一是它们确实包含 OOP 费用上限。

In the short run, evidence suggests that an OOP cap will induce only a small amount of switching.

从短期来看，有证据表明 OOP 上限只会引起少量的切换。

Medicare beneficiaries show some sensitivity to OOP cost protection for prescription drugs , but often undervalue it relative to its worth .

医疗保险受益人对处方药的 OOP 成本保护表现出一定的敏感性，但往往低估其相对价值。

And historically, even when differences between plans are reflected in salient premium prices, rates of switching between MA and TM are low .

从历史上看，即使计划之间的差异反映在显着的保费价格中，MA 和 TM 之间的转换率也很低。

In the longer run, the survey evidence above suggests that an OOP cap in Medicare might induce new enrollees to forego initial enrollment in MA.

从长远来看，上述调查证据表明，医疗保险中的 OOP 上限可能会导致新参保者放弃 MA 的初始参保。

Finally, a cap on OOP costs may affect beneficiaries’ decisions to purchase Medigap supplemental insurance .

最后，OOP 费用上限可能会影响受益人购买 Medigap 补充保险的决定。

Some (though not all) SI plans currently include an OOP cap.

一些（尽管不是全部）SI 计划目前包含 OOP 上限。

In MedPAC focus groups , future beneficiaries expressed that a cap on costs would reduce their desire for supplemental insurance.

在 MedPAC 焦点小组中，未来的受益人表示，成本上限将降低他们对补充保险的渴望。

Many proposals assume that an OOP cap (and other improvements to the generosity of cost-sharing) would push beneficiaries away from SI.

许多提案认为，OOP 上限（以及对慷慨的成本分摊的其他改进）将使受益人远离 SI。

For example, the KFF 2016 model assumes that the OOP cap, combined with a proposal requiring SI plans to cover at most 50% of the Part A/B deductible, would lead 600,000 enrollees to drop their SI coverage.

例如，KFF 2016 模型假设 OOP 上限，加上要求 SI 计划承保最多 50% A/B 部分免赔额的提案，将导致 600,000 名参保者放弃他们的 SI 承保范围。

Much of this projected change, however, is likely due to the restriction on SI cost-sharing, rather than the cap.

然而，这一预计变化很大程度上可能是由于对 SI 成本分摊的限制，而不是上限。

In the absence of this restriction on SI cost-sharing, there is less reason to believe that an OOP cap would have a strong effect on SI preferences.

如果没有对 SI 成本分摊的限制，就没有理由相信 OOP 上限会对 SI 偏好产生强烈影响。

SI plans reduce all cost-sharing (often to zero for older plans), not just high-end cost-sharing.

SI 计划减少所有成本分摊（旧计划通常为零），而不仅仅是高端成本分摊。

This reduction in cost-sharing, rather than the OOP cap, may be the attraction for most beneficiaries.

这种成本分摊的减少，而不是 OOP 上限，可能对大多数受益人有吸引力。

That’s particularly true for those already enrolled in Medigap, whose preferences appear to be especially sticky .

对于那些已经加入 Medigap 的人来说尤其如此，他们的偏好似乎特别粘。

Indeed, an OOP cap might even encourage enrollment in SI by reducing SI premiums.

事实上，OOP 上限甚至可能通过降低 SI 保费来鼓励参加 SI。

An OOP cap would mean Medigap insurers w ould no longer be on the hook for beneficiaries with OOP spending beyond the cap.

OOP 上限意味着 Medigap 保险公司将不再为 OOP 支出超出上限的受益人承担责任。

The Urban Institute estimates that SI providers would realize $12 billion per year in savings from a $5,000 OOP cap, representing a 26.5% reduction in expenditures relative to current law.

城市研究所估计，SI 提供商每年将从 5,000 美元的 OOP 上限中节省 120 亿美元，相对于现行法律，支出减少 26.5%。

These savings would eventually be passed on to beneficiaries in the form of lower premiums.

这些节省最终将以较低保费的形式转嫁给受益人。

The Commonwealth Fund estimates that a $3,500 cap would lower Medigap premiums by at least $3.7 billion per year overall.

联邦基金估计，3,500 美元的上限将使 Medigap 保费每年至少降低 37 亿美元。

The Commonwealth Fund estimated costs of implementation for 2016 ; as with other estimates in the paper, the change would be substantially larger in 2025 dollars.

英联邦基金估计 2016 年实施成本；与本文中的其他估计一样，以 2025 年美元计算，变化将大得多。

If an OOP cap lowers premiums for Medigap plans, it could promote more enrollment in Medigap.

如果 OOP 上限降低了 Medigap 计划的保费，则可能会促进更多人加入 Medigap。

The effect of changes to an OOP cap or cost – sharing on employer – sponsored supplemental insurance plans is even less clear because these plans are more diverse and more opaque.

OOP 上限或雇主赞助的补充保险计划的成本分摊的变化的影响甚至更不明确，因为这些计划更加多样化且更加不透明。

The Commonwealth Fund estimates that employer – sponsored supplemental insurance plans would save $6.5 billion per year if a $3,500 OOP cap were introduced.

联邦基金估计，如果引入 3,500 美元的 OOP 上限，雇主赞助的补充保险计划每年将节省 65 亿美元。

By contrast, the CBO estimated in 2019 that introducing a unified deductible of $750 plus a $7 , 500 OOP cap would increase employer- sponsored insurance costs by 4.2% overall from 2022 to 2028.

相比之下，国会预算办公室在 2019 年估计，引入 750 美元的统一免赔额加上 7 美元、500 美元的 OOP 上限将使雇主资助的保险费用从 2022 年到 2028 年总体增加 4.2%。

It is unclear how much of this divergence is driven by differences in the proposals v ersus differences in modeling.

目前尚不清楚这种分歧在多大程度上是由提案的差异与建模的差异造成的。

Regardless, it makes clear the unpredictable effect of a cap on the provision of employer-sponsored SI.

无论如何，它清楚地表明了对雇主资助的 SI 的提供上限的不可预测的影响。

The Urban Institute and KFF analyses make different assumptions about these key parameters and reach different conclusions about costs.

Urban Institute 和 KFF 的分析对这些关键参数做出了不同的假设，并就成本得出了不同的结论。

The Urban Institute estimates that the Medicare program would incur costs of $39 billion in the first year of implementation under a $5,000 cap, and $25 billion under a $7,550 cap .

城市研究所估计，在 5,000 美元的上限下，医疗保险计划在实施的第一年将产生 390 亿美元的成本，在 7,550 美元的上限下将产生 250 亿美元的成本。

It is important to note that some of these increased costs are already borne by the Medicaid program, so the total effect on the federal budget is meaningfully lower than this headline number.

值得注意的是，其中一些增加的成本已经由医疗补助计划承担，因此对联邦预算的总影响明显低于这个标题数字。

How the cap affects different payers is shown in the chart below , which shows projections for the implementation of a cap in 2023.

下图显示了上限对不同付款人的影响，其中显示了 2023 年实施上限的预测。

When the OOP cap is hit, cost – sharing drops to zero.

当 OOP 上限达到时，成本分摊降至零。

A variety of experimental and quasi-experimental evidence has shown that reduced cost – sharing , and especially zero-dollar cost – sharing , leads to substantial increases in the use of discretionary care.

各种实验和准实验证据表明，减少成本分摊，尤其是零美元成本分摊，会导致酌情护理的使用大幅增加。

The Urban Institute accounts for this demand response but not for the effect of an OOP cap on the decision to switch between TM and MA or the decision to enroll in SI.

城市研究所考虑了这种需求响应，但没有考虑 OOP 上限对在 TM 和 MA 之间切换的决定或注册 SI 的决定的影响。