If risk adjustment is gamed today, e.g., by Medicare Advantage plans, how will that be prevented under single payer?
For risk adjustment to work well under single payer, oversight and enforcement will need to be strong.
Risk adjustment works well when it’s applied fairly, removing 85-90% of differences in costs due to differing clinical severity. It has failed in the current US system due to lax enforcement. Specifically, for example, CMS has data quantifying upcoding practices, but lacks the political support to stop or adjust for this upcoding. Some single payer proponents worry that enforcement will always be problematic. Others believe that with properly empowered single payer administrators, enforcement can work well.
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