. Medicare Financial Status: In Brief Patricia A. Davis Specialist in Health Care Financing September 19, 2014 Congressional Research Service 7-5700 www.crs.gov R43122 c11173008 Medicare Financial Status: In Brief . Contents Overview of the Medicare Program................................................................................................. 1 Four Parts of Medicare .............................................................................................................. 1 Beneficiary Costs....................................................................................................................... 2 Provider and Plan Payments ...................................................................................................... 2 Medicare Trust Funds and Sources of Revenue............................................................................... 2 Hospitalization Insurance (HI) Trust Fund ................................................................................ 3 Sources of HI Revenue ........................................................................................................ 3 HI Trust Fund Mechanics .................................................................................................... 3 Supplementary Medical Insurance (SMI) Trust Fund ............................................................... 4 Sources of SMI Revenue ..................................................................................................... 5 SMI Trust Fund Mechanics ................................................................................................. 5 Medicare Spending in 2013 ............................................................................................................. 5 2013 HI Operations ................................................................................................................... 6 2013 SMI Operations ................................................................................................................ 6 Estimated Date of HI Trust Fund Insolvency .................................................................................. 7 Projected Medicare Spending Growth ............................................................................................. 8 Growth in Medicare Expenditures Relative to GDP ................................................................. 9 Unfunded and General Revenue Obligations .......................................................................... 10 Comparison to 2013 Estimates ................................................................................................ 11 Alternative Projections ............................................................................................................ 12 Figures Figure 1. Sources of Medicare Revenues: 2013 .............................................................................. 4 Figure 2. Projected Number of Years Until HI Insolvency .............................................................. 7 Figure 3. Historical and Projected Medicare Expenditures ............................................................. 9 Figure 4. Medicare Cost and Non-interest Income, by Source as a Percentage of GDP ............... 10 Tables Table 1. Medicare Expenditures and Enrollment: CY2013 ............................................................. 6 Table 2. Current Value of Estimated Medicare Unfunded Obligations and General Revenue Spending ...................................................................................................................... 11 Contacts Author Contact Information........................................................................................................... 13 c11173008 Congressional Research Service Medicare Financial Status: In Brief .

Medicare Financial Status: In Brief

August 10, 2015 (R43122) Overview of the Medicare Program Medicare, administered by the Centers for Medicare & Medicaid Services (CMS), is the nation’s 's federal insurance program that pays for covered health services for most persons ageaged 65 years and older and for most permanently disabled individuals under the age of 65.11 As a health insurance program, Medicare reimburses health care providers and suppliers, such as hospitals, physicians, and medical equipment companies, for the services and products they provide to Medicare beneficiaries. Medicare is prohibited by law from interfering in the practice of medicine or controlling the manner in which medical services are provided, and. It also is required to pay for covered services provided to eligible persons so long as specific criteria are met. As such, the growth in per person Medicare expenditures largely reflects the medical practices, use of technology, and underlying costs in the broader health care system. Spending under the program (except for a portion of administrative costs) is considered mandatory spending and is not subject to the appropriations process. Thus, there are generallygenerally are no limits on annual Medicare spending. Since its enactment in 1965, the Medicare program has undergone considerable change. Because of its rapid growth, both in terms of aggregate dollars and as a share of the federal budget, the Medicare program has been a major focus of deficit reduction legislation passed by Congress.2 2 With a few exceptions, reductions in program spending have been achieved largely through freezes or reductions in payments to providers, primarily hospitals and physicians, and by making changes to beneficiary premiums and other cost-sharing requirements. Most recentlyFor example, the Patient Protection and Affordable Care Act (ACA, ; P.L. 111-148 as amended) made numerous changes to the Medicare program that modify provider reimbursements, provide incentives to improve the quality and efficiency of care, and enhance certain Medicare benefits.3 3 Four Parts of Medicare Medicare consists of four distinct parts, A through D: • Part A covers inpatient hospital services, skilled nursing care, home health and hospice carehospice care, and some home health services. Most persons aged 65 and older are automaticallyautomatically are entitled to premium-free Part A because they or their spouse paid Medicare payroll taxes for at least 40 quarters (10 years) on earnings covered by either the Social Security or the Railroad Retirement systems. • Part B covers a broad range of medical services, including physician services, laboratory services, durable medical equipment, and outpatient hospital services. 1 For additional information on the Medicare program, see CRS Report R40425, Medicare Primer, coordinated by Patricia A. Davis and Scott R. Talaga. More detailed information on Medicare’s financial status may be found in CRS Report R41436, Medicare Financing, and CRS Report RS20946, Medicare: Insolvency Projections, both by Patricia A. Davis. 2 For a brief history of changes to the Medicare program, see CRS Report R40425, Medicare Primer, coordinated by Patricia A. Davis and Scott R. Talaga, and the Medicare chapter of the House of Representatives, Committee on Ways and Means Greenbook at http://greenbook.waysandmeans.house.gov/2012-green-book/chapter-2-medicare. 3 For details on individual Medicare provisions in the ACA, see CRS Report R41196, Medicare Provisions in the Patient Protection and Affordable Care Act (PPACA): Summary and Timeline, coordinated by Patricia A. Davis. c11173008 Congressional Research Service 1 Medicare Financial Status: In Brief . laboratory services, durable medical equipment, and outpatient hospital services. Enrollment in Part B is optional; however, most beneficiaries with Part A also enroll in Part B. • Part C (Medicare Advantage, or MA) is a private plan option for beneficiaries that covers all Parts A and B services, except hospice. Individuals choosing to enroll in Part C must be eligible for Part A and must alsoalso must enroll in Part B. About 28 30% of Medicare beneficiaries are enrolled in MA. • Part D covers outpatient prescription drug benefits. This portion of the program is optional. About 75% of Medicare beneficiaries are enrolled in Medicare Part D or have coverage through an employer retiree plan subsidized by Medicare. Beneficiary Costs In addition to paying premiums for Medicare Parts B and D,44 beneficiaries must also pay other out-of-pocket costs, such as deductibles and coinsurance, for services provided under all parts of the Medicare programprogram. There is no limit on beneficiary out-of-pocket spending, and most beneficiaries have some form of supplemental insurance through private Medigap plans, employer-sponsored retiree plans, or Medicaid to help cover a portion of their Medicare premiums and/or cost-sharing. deductibles and coinsurance. Provider and Plan Payments5 Payments Under traditional Medicare, Parts A and B, the government generally pays providers directly for services on a “fee-for-service” basis using different prospective payment systems, or fee schedules.65 Under Parts C and D, Medicare pays private insurers a monthly “capitated” per capitated per person amount to provide coverage to enrollees. The capitated payments are adjusted to reflect the differences in the relative cost of sicker beneficiaries with different risk factors including age, disability, or end-stage renal disease. Medicare Trust Funds and Sources of Revenue The Medicare program has two separate trust funds—the Hospital Insurance (HI) trust fund for Part A and the Supplementary Medical Insurance (SMI) trust fund for Parts B and D.7 (For 4 Beneficiaries enrolled in a Medicare Advantage (Part C) plan must pay Part B premiums as well as any additional premium required by the MA plan. 5 For additional information, see CRS Report RL30526, Medicare Payment Updates and Payment Rates, coordinated by Paulette C. Morgan. 6 Under a prospective payment system (PPS), Medicare payments are made using a predetermined, fixed amount based on the classification system for a particular service. CMS uses separate PPSs to reimburse acute inpatient hospitals, home health agencies, hospice, hospital outpatient departments, inpatient psychiatric facilities, inpatient rehabilitation facilities, long-term care hospitals, and skilled nursing facilities. A fee schedule is a listing of fees used by Medicare to pay doctors or other providers/suppliers. Fee schedules are used to pay for physician services, ambulance services, clinical laboratory services, and durable medical equipment, prosthetics, orthotics, and supplies in certain locations. 7 Many government programs are financed through trust funds. Despite the name, federal trust funds are not the same as private sector trust funds. A trust in the private sector is “a fiduciary relationship in which one person (the trustee) holds property for the benefit of another (the beneficiary).” The trustee must follow the express terms of the trust instrument and administer the trust for the benefit of the beneficiary. Most federal trust funds are not based on a legal (continued...) c11173008 Congressional Research Service 2 Medicare Financial Status: In Brief . Part A and the Supplementary Medical Insurance (SMI) trust fund for Parts B and D.⁶ (For beneficiaries enrolled in Medicare AdvantageMA (Part C), payments are made on their behalf in appropriate portions from the HI and SMI trust funds.) Both the HI and SMI trust funds are maintained by the Department of the Treasury and are overseen by a Board of Trustees that reports annually to Congress concerning the funds’' financial status.87 Financial projections are made using economic assumptions based on current law, including estimates of consumer price index (CPI), workforce size, wage increases, and life expectancy. The Medicare trust funds are financial accounts in the U.S. Treasury into which all income to the program is credited, and from which all benefits and associated administrative costs of the program are paid. The trust funds are solely accounting mechanisms—there is no actual transfer of money into and out of the funds. As long as a trust fund has a balance, the Treasury DepartmentDepartment of the Treasury is authorized to make payments for it from the U.S. Treasury. Hospitalization Insurance (HI) Trust Fund Trust Fund The Part A portion of Medicare is financed through the HI trust fund. Sources of HI Revenue The HI trust fund is mainly fundedfunded primarily by a dedicated payroll tax of 2.9% of earnings, shared equally between employers and workers. (See Figure 1.) Unlike Social Security, there is no upper limit on wages subject to Medicare payroll taxes. Beginning in 2013, the ACA imposeshas imposed an additional tax of 0.9% on high-income workers with wages over $200,000 for single tax filers, and over $250,000 for joint filers.98 Other sources of income to the HI trust fund include premiums paid by voluntary enrollees who are not entitled to premium-free Medicare Part A, a portion of the federal income taxes paid on Social Security benefits, and interest on federal securities held by the trust fund. HI Trust Fund Mechanics HI operates on a “pay-as-you-go” basis; the taxes paid by current workers and their employers are used to pay Part A benefits for today’'s Medicare beneficiaries. When the government receives Medicare revenues (payroll taxes), income is credited by the Treasury to the HI trust fund in the form of special -issue interest-bearing government securities.109 (Interest on these securities also is is also credited to the trust fund.) The tax income exchanged for these securities then goes into the general fund of the Treasury and is indistinguishable from other cash in the general fund; this (...continued) fiduciary relationship. Congress creates trust funds that involve a commitment to use monies for a specific purpose, but can alter the terms (e.g., receipts, outlays, or purpose) of the trust fund at any time. For additional information on how federal trust funds operate within the context of the federal budget, see CRS Report R41328, Federal Trust Funds and the Budget, by Mindy R. Levit. 8 These reports may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-andReports/ReportsTrustFunds/index.html. 9 See archived CRS Report R41128, Health-Related Revenue Provisions in the Patient Protection and Affordable Care Act (ACA), for more detail. 10 Unlike marketable securities, special issues can be redeemed at any time at face value. Investment in special issues gives the trust funds the same flexibility as holding cash. c11173008 Congressional Research Service 3 Medicare Financial Status: In Brief . general fund of the Treasury and is indistinguishable from other cash in the general fund; this cash may be used for any government spending purpose. When payments for Medicare Part A services are made, the payments are paid out of the general treasury and a corresponding amount of securities is deleted from (written off) the HI trust fund. Figure 1. Sources of Medicare Revenues: 2013 Payroll Taxes 38% General Revenues 73% 73% Beneficiary Premiums 88% Payments from States 41% 13% 2% 2% 6% 3% TOTAL MEDICARE REVENUE $576 Billion 1% Interest and Other 2% 5% HI - PART A $251 Billion 14% 25% Taxation of Social Security Benefits SMI - PART B $255 Billion 13% SMI - PART D $70 Billion Source: 2014 Report of the Medicare Trustees, Table II.B1. Notes: Totals may not add to 100% due to rounding.

Figure 1. Sources of Medicare Revenues: 2014

Source: Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, The 2015 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, Table II.B1, July 22, 2015. (Hereinafter 2015 Report of the Medicare Trustees.)

Notes: Totals may not add to 100% due to rounding. HI = Hospital Insurance; SMI = Supplementary Medical Insurance.

In years in which the trust fund spends less than the income it receives, the trust fund securities exchanged for any income in excess of spending show up as “assets”assets on the financial accounting balance sheets and are available to the system to meet future obligations. The trust fund surpluses are not reserved for future Medicare benefits, but are simply bookkeeping entries that indicate how much Medicare has lent to the Treasury (or alternatively, what is owed to Medicare by the Treasury). From a unified budget perspective, these “assets”assets represent future budget obligations and are treated as liabilities. If the HI trust fund is not able to pay all of current expenses out of current income and accumulated trust fund assets, it is considered to be insolvent.11 Supplementary Medical Insurance (SMI) Trust Fund The SMI trust fund consists of two accounts: Part B and Part D. 11 From time to time, it is reported that Medicare is on the verge of “bankruptcy,” however, in the context of federal trust funds, this term is not meaningful. It is true that a trust fund’s spending can be greater than its income and trust funds can have a zero balance, but, unlike private businesses, the federal government is not in danger of “going out of business” or having its assets seized by creditors. c11173008 Congressional Research Service 4 Medicare Financial Status: In Brief . Sources of SMI Revenue insolvent.¹⁰ Supplementary Medical Insurance Trust Fund

The SMI trust fund consists of two accounts: Part B and Part D.

Sources of SMI Revenue Unlike the HI portion of Medicare, the SMI program was not intended to be supported through dedicated sources of income. Instead, it relies primarily on general tax revenues and beneficiary premiums as revenue sources.12 11 The Part B portion of SMI is mainly fundedfunded mainly through beneficiary premiums (set at 25% of estimated program costs for the aged)1312 and general revenues (most of the remaining amount, approximately 73%). In 20142015, most enrollees pay a monthly premium of $104.90; however, . However, certain low-income enrollees receive assistance with their premiums from Medicaid (joint federal-state funding), and since, starting in 2007, high-income enrollees pay higher premiums. Beginning in 2011, additional revenues from an annual fee imposed on certain manufacturers and importers of branded prescription drugs are alsoalso are credited to the SMI trust fund.14 13 Part D is financed through a combination of beneficiary premiums (set at 25.5% of the estimated cost of the standard benefit), general revenues, and state transfer payments (to cover a portion of the costs of beneficiaries enrolled in both Medicare and Medicaid—the “dual-eligibles”). Actual Part D premiums may vary depending on which plan the enrollee selects. Low-income enrollees may receive premium assistance through the Part D low-income subsidy (all federal funding), and , starting in 2011, higher income enrollees pay higher premiums. SMI Trust Fund Mechanics The level of SMI funding is automatically updated each year to cover expenditures in the upcoming year. If actual costs exceed those estimated when the funding was set, the amount of financing in the next year (i.e., general revenues and beneficiary premiums) may be adjusted to recover the shortfall. Similarly, if actual costs are less than expected in a given year, income levels needed for the next year may be adjusted downward. Because of these automatic adjustments, the SMI trust fund is always kept in balance and cannot become insolvent. Medicare Spending in 201315 2014¹⁴ In calendar year (CY) 20132014, Medicare provided benefits to about 52.353.8 million people (43.5 million age44.9 million people aged 65 and over, and 8.89 million disabled people) at an estimated total cost of $583613 billion.16 15 Most of that amount, $575almost $605 billion (99%), was spent on program benefits, with the remaining amount used for program administration. (See Table 1.) Table 1. Medicare Expenditures and Enrollment: CY2014  

HI - Part A

SMI

Total

   

Part B

Part D

  Table 1.) 12 There have been reports that Medicare beneficiaries receive more from the program than what they have paid throughout their working years in payroll taxes; however, as noted, unlike Part A, the costs of Medicare Parts B and D were designed in the original statute to be subsidized by the government and not through dedicated taxes. 13 For additional information, see CRS Report R40082, Medicare: Part B Premiums, by Patricia A. Davis. 14 This revenue source is included in “Interest and Other” for Part B in Figure 1. For additional detail, see archived CRS Report R41128, Health-Related Revenue Provisions in the Patient Protection and Affordable Care Act (ACA). 15 Data is from the 2014 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, July 28, 2014. 16 This amount reflects Medicare total spending regardless of revenue source; it does not net out non-federal income (e.g., premiums, state-transfers). By law, the Medicare Trustees report focuses on the financial status of the program’s trust funds and does not examine the impact of Medicare spending on the overall Federal budget. c11173008 Congressional Research Service 5 Medicare Financial Status: In Brief . Table 1. Medicare Expenditures and Enrollment: CY2013 SMI HI - Part A Part B Part D Total Expenditures (billions)        

Benefits

$264.9

$261.9

$77.7

$604.5

Hospital

139.2

44.1

—

183.3

Skilled Nursing

28.8

—

—

28.8

Home Health Care

6.6

11.2

—

17.8

Physician Services

—

69.2

—

69.2

Private plans (Part C)

74.0

85.7

—

159.7

Prescription Drugs

—

—

77.7

77.7

Other

16.3

51.7

—

68.0

Administrative Expenses

$4.5

$4.0

$0.4

$8.8

Total Expenditures

$269.3

$265.9

$78.1

$613.3

Enrollment (millions)

       

Aged

44.6

41.3

NA

44.9

Disabled

8.9

8.1

NA

8.9

Total Enrollment

53.5

49.3

40.5

53.8

Average expenditures per enrollee

$4,951

$5,308

$1,920

$12,179

Source: 2015 Report of the Medicare Trustees, Table II.B1.

Notes: Totals do not necessarily equal the sums of rounded components; NA = data not available.

2014 HI Operations

At the beginning of CY2014, the HI trust fund had an asset balance of a little over $205 billion. During 2014, Part A expenditures were about $269 billion. Approximately $227 billion of that amount was funded by payroll taxes and $34 billion by interest income and other sources. (See "Sources of HI Revenue.") Because expenditures exceeded revenue income, close to $8 billion was drawn out of accumulated assets in the HI trust fund to make up the difference. At the end of 2014, the HI trust fund had an asset balance of approximately $197 billion. This means that if or when HI spending exceeds income in future years, the trust fund will be able to spend a total of $197 billion in addition to what it receives in income.¹⁶

2014 SMI Operations In CY2014, total spending for Part B was close to $266 billion, with general revenues financing approximately $189 billion of that amount and premiums covering most of the remainder. Total spending for Part D reached about $78 billion in 2014, with more than $58 billion of that amount paid for by general revenues. In addition, approximately $9 billion was covered by state transfer payments and $11 billion was covered by beneficiary premiums. It should be noted that although beneficiary premiums are set at a rate to cover 25.5% of the costs of standard Part D benefits, the program pays for the premiums of about one-third of enrollees because these enrollees qualify for low-income assistance. As a result, Part D premiums cover only about 15% of program costs. (See Figure 1.) Estimated Date of HI Trust Fund Insolvency

Since 2008, Part A expenditures have exceeded HI income each year, and the assets credited to the trust fund have been drawn down to make up the deficit. The 2015 report of the Medicare Trustees projects slight surpluses in years 2015 through 2023,¹⁷ and then a return to deficits in 2024 and thereafter until the HI trust fund becomes depleted (insolvent) in 2030. At that time, there no longer will be sufficient funds to fully cover Part A expenditures; although HI would continue to receive tax income, the funds would be sufficient to pay for only 86% of Part A expenses. The Trustees suggest that, under these circumstances, beneficiary access to Part A services "would rapidly be curtailed."

Almost from its inception, the HI trust fund has faced a projected shortfall and eventual (billions) Benefits $261.9 $243.8 $69.3 $575.0 136.8 41.8 — 178.6 28.4 — — 28.4 Home Health Care 6.8 11.5 — 18.4 Physician Services — 68.6 — 68.6 73.2 72.7 — 145.9 — — 69.3 69.3 16.7 49.2 — 65.8 $4.3 $3.3 $0.4 $7.9 $266.2 $247.1 $69.7 $582.9 43.1 40.0 n/a 43.5 8.8 7.9 n/a 8.8 51.9 47.9 39.1 52.3 $5,045 $5,092 $1,773 $11,910 Hospital Skilled Nursing Private plans (Part C) Prescription Drugs Other Administrative Expenses Total Expenditures Enrollment (millions) Aged Disabled Total Enrollment Average expenditures per enrollee Source: 2014 Report of Medicare Trustees, Table II.B1. Notes: Totals do not necessarily equal the sums of rounded components; n/a = data not available. 2013 HI Operations At the beginning of CY2013, the HI trust fund had an asset balance of a little over $220 billion. During 2013, Part A expenditures were about $266 billion, and approximately $221 billion of that amount was funded by payroll taxes and $30 billion by interest income and other sources. Because expenditures exceeded revenue income, close to $15 billion was drawn out of accumulated assets in the HI trust fund to make up the difference. At the end of 2013, the HI trust fund had an asset balance of approximately $205 billion. This means that if or when HI spending exceeds income in future years, the trust fund will be able to spend a total of $205 billion in addition to what it receives in income.17 2013 SMI Operations In CY2013, total spending for Part B was close to $247 billion, with general revenues financing approximately $186 billion (73%) of that amount, and premiums covering most of the remainder. Total spending for Part D reached about $70 billion in 2013, with over $51 billion (73%) of that 17 c11173008 In years in which income exceeds expenditures, the surplus amount(s) would be added to this balance. Congressional Research Service 6 Medicare Financial Status: In Brief . amount paid for by general revenues. In addition, approximately $9 billion was covered by state transfer payments, and $10 billion by beneficiary premiums. It should be noted that although beneficiary premiums are set at a rate to cover 25.5% of the costs of their standard Part D benefits, the program pays for the premiums of about one-third of enrollees because they qualify for low-income assistance. As a result, Part D premiums only cover about 14% of program costs. (See Figure 1.) Estimated Date of HI Trust Fund Insolvency Since 2008, Part A expenditures have exceeded HI income each year, and the assets credited to the trust fund have been drawn down to make up the deficit. The 2014 Trustees report projects slight surpluses in years 2015 through 2022,18 and then a return to deficits in 2023 and thereafter until the HI trust fund becomes depleted (insolvent) in 2030. At that time, there will no longer be sufficient funds to fully cover Part A expenditures; although HI would continue to receive tax income, the funds would only be sufficient to pay for 85% of Part A expenses. The Trustees suggest that, under these circumstances, beneficiary access to Part A services “would rapidly be curtailed.” Almost from its inception, the HI trust fund has faced a projected shortfall and eventual insolvency (see Figure 2), with insolvency dates ranging from 2 years to 28 years from the year of the projection. However, to date, the HI trust fund has never become insolvent, and there are no provisions in the Social Security Act that govern what would happen if that were to occur. For example, there is no authority in law for the program to use general revenues to fund Part A services in the event of such a shortfall. Unless action is taken prior to the expected date of insolvency to increase HI revenues or decrease expenditures, Congress may need to appropriate additional funding to make up for these deficits and to allow for full and on -time payments to Part Part A providers.

Figure 2. Projected Number of Years Until HI Insolvency 30 28 28 25 25 20 15 12 10 5 2 2 4 13 14 15 13 10 10 5 7 7 23 19 17 13 16 14 10 10 6 7 7 5 16 15 15 12 12 13 11 12 13 8 4 0 Hospital Insurance Insolvency Source: Intermediate projections of various Medicare Trustees' reports, 1970-2014. Note:2015. Notes: No specific estimates were provided by the trustees for years 1973-1977 and 1989. 18 The Trustees attribute this expected period of surplus to ACA provisions that are expected to reduce Part A spending, to an assumed strengthening economy, and to the sequestration of 2% of Medicare benefit spending. c11173008 Congressional Research Service 7 Medicare Financial Status: In Brief . Trustees for years 1973-1977 and 1989. Because income (general revenue and premiums) to the SMI trust fund is updated automatically updated each year to ensure that the program has enough money to continue operating, the SMI trust fund is kept in balance and is always solvent. However, the Medicare trusteesTrustees continue to express concerns about the rapid growth in SMI costs. Projected Medicare Spending Growth Although the 20142015 Medicare Trustees' report notes a recent slowing in the growth of U.S. national health expenditures,1918 the Trustees still project that U.S. health care expenditures, including Medicare spending, will grow faster than Gross Domestic Productgross domestic product (GDP) in most future years. For Medicare, the projected growth in the prices of health services plus anticipated increases in utilization rates and in the complexity of services provided are expected to contribute to rising costs of Medicare relative to GDP. The aging of the baby boom population is alsoalso is expected to contribute to significant increases in benefit expenditures.20 19 Over the next 10 years, the Medicare Trustees estimate that total Medicare expenditures will increase from $583613 billion in 2013 to close to $1.12014 to more than $1.2 trillion in 20232024. Of the $1.12 trillion, about $447 $480 billion is expected to be spent on Part A services, $485553 billion foron Part B services, and $172 $197 billion foron Part D services. (See Figure 3.)

Figure 3. Historical and Projected Medicare Expenditures Source: 2015.) 19 The Trustees are uncertain whether this slowing is of limited duration, e.g., due to recent economic downturns, or whether this may be a longer term trend due to structural changes in the health care industry. 20 When Medicare first began, there were about 19 million beneficiaries. This number has grown to about 52 million enrollees in 2013, and is expected to increase to about 87 million in 2035, and to 117 million in 2085. c11173008 Congressional Research Service 8 Medicare Financial Status: In Brief . Figure 3. Historical and Projected Medicare Expenditures $1,200 Historical Estimate Billions $1,000 Part D $800 Part B $600 Part A $400 $200 Source: 2014 Report of the Medicare Trustees, Expanded and Supplementary Tables (historical data); and Report Tables III.B4; III.C4; and III.D3 (projected data). Growth in Medicare Expenditures Relative to GDP A comparison of Medicare expenditures (for Medicare Parts A through D, combined) to GDP provides a measure of the amount of financial resources that will be necessary to pay for Medicare services relative to the output of the U.S. economy. Under current law, the trustees Trustees expect total Medicare expenditures to increase from 3.5% of GDP in 20132015 to about 5.34% of GDP by 2035, mainly due to the rapid growth in the number of beneficiaries, and then to 6.90% of GDP in 2088 in 2089, with growth in health care cost per beneficiary becoming the more significant factor in those years, especially for Part D. (See Figure 4.) .) Over the next 75 years, general revenues and beneficiary premiums are expected to play an increasing role in financing the program. For example, the level of general revenues needed to fund SMI is expected to increase from 1.45% of GDP in 20142015 to an estimated 3.32.8% in 20882089 under current law.2120 Similarly, income from beneficiary premiums is expected to increase from 0.5% of GDP in 20142015 to 1.20% in 20882089. In 20132014, about 13.87% of total federal income taxes collected that year were used to fund the general revenue portion of SMI. It is expected that the portion of personal and corporate income taxes needed to fund SMI will increase to about 2122% in 2030, and to almost 3126% in 2080. This amount is in addition to the payroll taxes used to fund the Part A (HI) portion of the program. 21 Total Part B outlays are expected to be about 1.5% of GDP in 2014, and the Trustees project that they will grow to almost 3.2% by 2088. The Trustees also estimate that total Part D outlays will increase from 0.4% of GDP in 2014 to about 1.4% in 2088. c11173008 Congressional Research Service 9 2023 2021 2019 2017 2015 2013 2011 2009 2007 2005 2003 2001 1999 1997 1995 1993 1991 1989 1987 1985 1983 1981 1979 1977 1975 1973 1971 1969 1967 $0 Medicare Financial Status: In Brief . Figure 4. Medicare Cost and Non-interest Income, by Source as a Percentage of GDP 7% Estimated Historical 6% Total Spending HI Deficit 5% General Revenue 4% State Transfers & Drug Fees 3% Premiums 2% 1% Payroll Taxes Taxes on Benefits 0% 1970 1980 1990 2000 2010 2020 2030 2040 2050 2060 2070 2080 to the payroll taxes used to fund the Part A (HI) portion of the program.

Figure 4. Medicare Cost and Non-interest Income, by Source as a Percentage of GDP Source: Summary of the 20142015 Annual Reports of the Social Security and Medicare Boards of Trustees, Chart C, at http://www.ssa.gov/oact/TRSUM/index.html. . Unfunded and General Revenue Obligations The Trustees' report provides estimates of the present value of the HI deficit—the “unfunded obligation” unfunded obligation—over both a 75-year horizon and an “infinite”"infinite" horizon. (See Table 2.) This unfunded obligation represents the dollar amount by which expenditures would need to be reduced or revenue increased to maintain the financial soundness of the program over a period of time. The Trustees estimate that the current value of funding needed to cover the expected difference between income to the HI trust fund and expenditures over the next 75 years is $3.60 trillion. The Trustees note that this financial imbalance could be addressed by immediately increasing payroll taxes to 3.7758% (from the current 2.9%) or by immediately decreasing expenditures by 19%. 15%. The Trustees' report also provides estimates of the present value of future SMI spending. Although SMI is automatically funded SMI is funded automatically and does not face a shortfall, the general revenue portion represents obligated federal spending. The present value of expected general revenues needed to pay for Medicare Parts B and D over the next 75 years is $24.78 trillion. Adding the HI unfunded obligation estimate and the present value of future SMI spending for the 75-year period yields a total of $28.3 trillion.2227.8 trillion.²¹ In other words, it would take about $28.327.8 trillion in current dollars to cover the cost of Medicare not funded through dedicated sources over the next 75 years. 22 The Trustees note that while SMI general revenue transfers represent formal budget commitments under current law, no provision exists for covering the HI trust fund once assets are depleted. c11173008 Congressional Research Service 10 Medicare Financial Status: In Brief . Table 2. Current Value of Estimated Medicare Unfunded Obligations and General Revenue Spending Present Value of SMI General Revenues Present Value of HI Deficit Part B Part D Total Unfunded obligations through 2088 $3.6 trillion General revenue contributions through 2088 $17.9 trillion $6.8 trillion $28.3 trillion Unfunded obligations through infinite horizon $1.9 trillion General revenue contributions through infinite horizon $31.5 trillion $14.2 trillion $47.6 trillion Source: 2014 Report of the Medicare Trustees, Tables V.G1, V.G3, V.G5. Comparison to 2013 Estimates In their 2014 report, the Medicare Trustees reported some improvement in Medicare’s financial outlook from projections in their 2013 report. For example, the expected depletion date of the HI trust fund (2030) is four years later than was projected in last year’s report (2026). Additionally, over the next 75 years, the estimated HI actuarial deficit (the amount that would need to be added to the payroll tax to maintain HI solvency for this period) decreased from 1.11% of taxable payroll in last year’s report, to 0.87% of taxable payroll in the 2014 report. The main reasons cited include (1) lower than expected spending in 2013 for most HI service categories, especially for inpatient hospital services; (2) lower projected utilization of inpatient hospital services; and (3) lower estimates of spending for skilled nursing facilities and home health agencies due to changes in assumptions of the case-mix of individuals receiving those services. Taxable HI earnings in 2013 were also slightly higher than expected. As noted earlier, the Medicare Trustees generally make their projections based on current law. However, in their 2014 report, the Trustees made an exception with regard to the sustainable growth rate (SGR) formula for physician payments under Part B. Although under current law, physician payments are scheduled to be reduced by close to 21% in April 2015, the Trustees recognized that in almost every year, Congress has overridden these reductions. The Trustees therefore used a “projected baseline” for Part B spending that assumed that physician payments would remain at their current levels through the end of 2015, and then would be increased by 0.6% annually through 2023.23 Due to the above change in projection method, the expected growth rate of Part B costs is 0.3 percentage points higher over the next 75 years than the estimate in the 2013 report that was based on current law (which assumed that the physician cuts would go into effect).24 However, compared to similar baseline projections contained in the last year’s report “alternative to SGR” scenario, the expected growth in Part B outlays projected in the 2014 report is slightly lower. This decrease is attributed to (1) lower than expected spending in 2012 and 2013 for most types of Part B services; (2) assumptions of reduced future volume and intensity for some types of services based on recent experience; and (3) lower CPI assumptions. Part B expenditure growth rates 23 This is equal to the average of the SGR overrides over the most recent 10 years. Under current law assumptions, projected 2023 Part B costs in the 2014 report are about 4% lower than projected in the 2013 report. 24 c11173008 Congressional Research Service 11 Medicare Financial Status: In Brief . projections for 2013 through 2024 are also affected by the 2% sequestration of Medicare benefit expenditures under current law.25 Additionally, the 2014 report projected slightly lower Part D outlays compared to last year’s report due primary to (1) lower projected cost trends over the next 10 years, and (2) higher expected rebates from drug manufacturers reflecting recent experience. Certain Part D expenditures are also affected by the 2% sequestration of Medicare benefit expenditures through 2024.26 The Trustees, however, expect that per capita Part D spending will increase more quickly that other types of medical spending due to a slowing in the growth in generic drug utilization and an increase in the use and price of specialty drugs. Even after accounting for the change in methodology used to determine the projected baseline for Part B spending, this year’s total Medicare spending projections to year 2055 are lower than equivalent projections in the 2013 report, primary due to lower recent spending and slower expected growth rates in payments to Part A and Part B providers and Part D plans. Alternative Projections Throughout the 2014 report, the Medicare Trustees caution that actual costs are likely to be higher than their intermediate projections. For example, because the Trustees are required to base their estimates on current law, their assumptions assume that the ACA-required Medicare plan and provider payment reductions are maintained,27 and that Independent Payment Advisory Board (IPAB) proposals to reduce Medicare costs will go into effect.28 (As noted above, unlike in previous years, the Trustees assumed that future scheduled physician payment reductions under the sustainable growth rate system (SGR) will be overridden.) Because of concerns about the accuracy of these projections, the Medicare Trustees asked the CMS Office of the Actuary to prepare an alternative projection based on the assumptions that some of the ACA provider payment adjustments would be phased out beginning in 2020, and that some reductions proposed by the IPAB would not occur.29 Under this alternative scenario, long25 The Budget Control Act of 2011 (BCA; P.L. 112-25) provided for increases in the debt limit and established procedures designed to reduce the federal budget deficit, including the creation of a Joint Select Committee on Deficit Reduction. The failure of the Joint Committee to propose deficit reduction legislation by its mandated deadline triggered automatic spending reductions (“sequestration” of mandatory spending and reductions in discretionary spending) in fiscal years 2013 through 2021. The American Taxpayer Relief Act of 2012 (ATRA, P.L. 112-240) delayed the automatic reductions by two months, while the Bipartisan Budget Act of 2013 (BBA, P.L. 113-67) extended sequestration for mandatory spending for an additional two years—through FY2023. On February 15, 2014, the President signed into law an amended version of S. 25 (P.L. 113-82), which, among other things, included a provision to extend BCA’s sequester of mandatory spending through FY2024. Also see CRS Report R41965, The Budget Control Act of 2011, by Bill Heniff Jr., Elizabeth Rybicki, and Shannon M. Mahan, and CRS Report R43411, The Budget Control Act of 2011: Legislative Changes to the Law and Their Budgetary Effects, by Mindy R. Levit. 26 See CRS Report R42050, Budget “Sequestration” and Selected Program Exemptions and Special Rules, coordinated by Karen Spar. 27 See CRS Report R41196, Medicare Provisions in the Patient Protection and Affordable Care Act (PPACA): Summary and Timeline, coordinated by Patricia A. Davis for more information. 28 For information on the IPAB, see CRS Report R41511, The Independent Payment Advisory Board, by Jim Hahn and Christopher M. Davis. 29 John D. Shatto and M. Kent Clemens, “Projected Medicare Expenditures under Current Law, the Projected Baseline, and an Illustrative Alternative Scenario,” August 28, 2014, http://www.cms.gov/Research-Statistics-Data-and-Systems/ Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/2014TRAlternativeScenario.pdf. c11173008 Congressional Research Service 12 Medicare Financial Status: In Brief . term Medicare costs are projected to reach 8.8% of GDP in 2080, instead of 6.8% under the Trustees’ baseline projections. Additionally, under the alternative scenario, the HI actuarial deficit would be 1.92% of taxable payroll (compared to 0.87% under the projected baseline), which could be addressed by immediately increasing payroll taxes to 4.82% or by immediately decreasing expenditures by 33% (compared to 3.77% and 19% respectively under current law). The alternative scenario also projects that HI insolvency would occur one year earlier, in 2029. Author Contact Information Patricia A. Davis Specialist in Health Care Financing pdavis@crs.loc.gov, 7-7362 c11173008 Congressional Research Service 13 Revenue Spending

Present Value of HI Deficit

Present Value of SMI General Revenues

Total

   

Part B

Part D

 

Unfunded obligations through 2089

$3.0 trillion

General revenue contributions through 2089

$17.5 trillion

$7.3 trillion

$27.8 trillion

Unfunded obligations through infinite horizon

$0.4 trillion

General revenue contributions through infinite horizon

$28.3 trillion

$15.0 trillion

$43.7 trillion

Source: 2015 Report of the Medicare Trustees, Tables V.G1, V.G3, V.G5.

Comparison to Prior Year Estimates Over the short term, projections of Medicare's total spending in the 2015 Trustees' report are slightly higher compared with last year's report, mainly due to higher recent actual experience for Parts B and D. However, over the longer range, spending estimates are substantially lower, primarily due to a methodological change²² and to provisions in the recently enacted Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; P.L. 114-10) that changed the way Medicare physician payment rates are determined.²³ (See Figure 5.)

The short-term financial outlook for the HI trust fund is similar to that in last year's report. The estimated depletion date of the HI trust fund is 2030, the same as in the 2014 report. Over the next 75 years, the estimated HI actuarial deficit (the amount that would need to be added to the payroll tax to maintain HI solvency for this period) decreased from 0.87% of taxable payroll in last year's report to 0.68% of taxable payroll in the 2015 report. The change is primarily due to the methodological change mentioned above, and to certain Part A provider payment reductions under MACRA.²⁴ Partially offsetting these lower estimates is the assumption that a higher proportion of Medicare beneficiaries will enroll in MA plans, where benefits may be more costly.

For both Parts B and D, projected short-term costs are higher in this year's report. For Part B, the increased estimates are mainly due to (1) higher than expected actual 2014 spending for most types of services; (2) higher assumed volume and intensity growth for some types of services based on recent experience; and (3) provisions in MACRA that increased Part B spending for certain services. For Part D, the expected higher spending is mainly due to higher projected drug-cost trends, primarily due to the introduction of high-cost specialty drugs used to treat hepatitis C. Over the long term, Part B projections are lower than in the prior report due to lower physician fee updates under MACRA and lower assumptions for long-range health care cost growth for other Part B services. Part D long-term projections also are slightly lower than in last year's report, mainly due to lower assumptions regarding growth in the cost of long-term health care.

Figure 5. Comparison of 2014 and 2015 Medicare Expenditure Projections

(expenditures as a percentage of GDP)

Sources: 2014 and 2015 Medicare Trustees' Reports, Supplementary Tables.

Notes: In the 2014 report, the Trustees provided two separate estimates. One was based on current law at the time, which assumed that physician payments would be reduced under the sustainable growth rate formula, and the second was based on the assumption that Congress would override the reductions and payments would increase in most years. The 2015 estimate assumes current law, which includes physician payment rate changes made by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; P.L. 114-10).

Alternative Projections

Throughout the 2015 report, the Medicare Trustees caution that actual costs are likely to be higher than their intermediate projections. For example, because the Trustees are required to base their estimates on current law, their assumptions assume that physician payments will be updated according to levels set forth in MACRA, that the full ACA-required Medicare plan and provider payment reductions will be maintained, and that Independent Payment Advisory Board (IPAB) proposals to reduce Medicare costs will go into effect.²⁵

Because of concerns about the accuracy of these projections, the Medicare Trustees asked the CMS Office of the Actuary to prepare an alternative projection based on the assumptions that annual physician payment updates will transition beginning in 2024 from 0.0% to 2.3% by 2039, that ACA provider payment adjustments will be partially phased out beginning in 2020, and that reductions proposed by the IPAB will not occur.²⁶ Under this alternative scenario, long-term Medicare costs are projected to reach 8.5% of GDP in 2080, instead of 6.0% under the Trustees' current-law projections. Additionally, under the alternative scenario, the HI actuarial deficit would be 1.70% of taxable payroll (compared with 0.68% under the current-law projection), which could be addressed by immediately increasing payroll taxes to 4.60% or by immediately decreasing expenditures by 31% (compared with 3.58% and 15%, respectively, under current law). The alternative scenario also projects that HI insolvency would occur one year earlier, in 2029.

Figure 6. Comparison of Medicare Expenditure Projections Based on Current Law and Alternative Scenarios

(expenditures as a percentage of GDP)

Source: 2015 Report of the Medicare Trustees, Supplementary Tables.

Note: The alternative scenario assumes phasing out certain MACRA and ACA provider payment reductions.

Author Contact Information

[author name scrubbed], Specialist in Health Care Financing ([email address scrubbed], [phone number scrubbed])

Footnotes

1.

For additional information on the Medicare program, see CRS Report R40425, Medicare Primer, coordinated by [author name scrubbed] and [author name scrubbed]. More detailed information on Medicare's financial status may be found in CRS Report R41436, Medicare Financing, and CRS Report RS20946, Medicare: Insolvency Projections, both by [author name scrubbed].

2.

For a brief history of changes to the Medicare program, see CRS Report R40425, Medicare Primer, coordinated by [author name scrubbed] and [author name scrubbed], and the Medicare chapter of the House of Representatives, Committee on Ways and Means, Greenbook, at http://greenbook.waysandmeans.house.gov/2014-green-book/chapter-2-medicare.

3.

For details on individual Medicare provisions in the Patient Protection and Affordable Care Act (ACA; 111-148, as amended), see CRS Report R41196, Medicare Provisions in the Patient Protection and Affordable Care Act (PPACA): Summary and Timeline, coordinated by [author name scrubbed].

4.

Beneficiaries enrolled in a Medicare Advantage (MA; Part C) plan must pay Part B premiums as well as any additional premium required by the MA plan.

5.

Under a prospective payment system (PPS), Medicare payments are made using a predetermined, fixed amount based on the classification system for a particular service. The Centers for Medicare & Medicaid Services (CMS) uses separate PPSs to reimburse acute inpatient hospitals, home health agencies, hospice, hospital outpatient departments, inpatient psychiatric facilities, inpatient rehabilitation facilities, long-term care hospitals, and skilled nursing facilities. A fee schedule is a listing of fees used by Medicare to pay doctors or other providers/suppliers. Fee schedules are used to pay for physician services; ambulance services; clinical laboratory services; and durable medical equipment, prosthetics, orthotics, and supplies in certain locations.

6.

Many government programs are financed through trust funds. Despite the name, federal trust funds are not the same as private-sector trust funds. A trust in the private sector is "a fiduciary relationship in which one person (the trustee) holds property for the benefit of another (the beneficiary)." The trustee must follow the express terms of the trust instrument and administer the trust for the benefit of the beneficiary. Most federal trust funds are not based on a legal fiduciary relationship. Congress creates trust funds that involve a commitment to use monies for a specific purpose, but it can alter the terms (e.g., receipts, outlays, or purpose) of the trust fund at any time. For additional information, see CRS Report R41328, Federal Trust Funds and the Budget.

7.

These reports may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/index.html.

8.

See archived CRS Report R41128, Health-Related Revenue Provisions in the Patient Protection and Affordable Care Act (ACA), for more detail.

9.

Unlike marketable securities, special issues can be redeemed at any time at face value. Investment in special issues gives the trust funds the same flexibility as holding cash.

10.

From time to time, it is reported that Medicare is on the verge of bankruptcy; however, in the context of federal trust funds, this term is not meaningful. While a federal trust fund's spending can be greater than its income and trust funds can have a zero balance, unlike private businesses, the federal government is not in danger of "going out of business" or having its assets seized by creditors.

11.

There have been reports that Medicare beneficiaries receive more from the program than what they have paid throughout their working years in payroll taxes; however, as noted, unlike Part A, the costs of Medicare Parts B and D were designed in the original statute to be subsidized by the government and not through dedicated taxes.

12.

For additional information, see CRS Report R40082, Medicare: Part B Premiums, by [author name scrubbed].

13. This revenue source is included in "Interest and Other" for Part B in Figure 1. For additional detail, see archived CRS Report R41128, Health-Related Revenue Provisions in the Patient Protection and Affordable Care Act (ACA). 14.

Data is from the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, The 2015 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, July 22, 2015.

15.

This amount reflects Medicare total spending regardless of revenue source; it does not net out nonfederal income (e.g., premiums, state transfers). By law, the Medicare Trustees' report focuses on the financial status of the program's trust funds and does not examine the impact of Medicare spending on the overall federal budget.

16.

In years in which income exceeds expenditures, the surplus amount(s) would be added to this balance.

17.

The Trustees attribute this expected period of surplus to ACA provisions that are expected to reduce Part A spending, to an assumed strengthening economy, and to the sequestration of 2% of Medicare benefit spending.

18.

The Trustees are uncertain whether this slowing is of limited duration (e.g., due to recent economic downturns) or whether it may be a longer-term trend due to structural changes in the health care industry.

19.

When Medicare first began, there were about 19 million beneficiaries. This number has grown to about 54 million enrollees in 2014 and is expected to increase to about 87 million in 2035 and to 118 million in 2085.

20.

Total Part B outlays were 1.5% of GDP in 2014, and the Trustees project that they will grow to just over 2.4% of GDP by 2089. The Trustees also estimate that total Part D outlays will increase from 0.5% of GDP in 2014 to about 1.4% of GDP in 2089.

21.

The Trustees note that while SMI general revenue transfers represent formal budget commitments under current law, no provision exists for covering the HI trust fund once assets are depleted.

22.

The 2015 report changed some assumptions about the effect of increases in income, technology, and health care prices on health care spending.

23.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; P.L. 114-10) repealed the sustainable growth rate (SGR) formula that was used to determine physician payment rates. The 2015 report projects that after 20 years, physician payments will be much lower compared with the 2014 projections.

24.

These Part A providers include inpatient hospitals, skilled nursing facilities, inpatient rehabilitation facilities, long-term care hospitals, hospices, and home health agencies.

25.

For information on the Independent Payment Advisory Board, see CRS Report R44075, The Independent Payment Advisory Board (IPAB): Frequently Asked Questions, by [author name scrubbed], [author name scrubbed], and [author name scrubbed].

26.

John D. Shatto and M. Kent Clemens, "Projected Medicare Expenditures under an Illustrative Scenario with Alternative Payment Updates to Medicare Providers," July 22, 2015, at http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/2015TRAlternativeScenario.pdf.