B2 · Pillar B · Spending Efficiency
Medicare site-neutral payment
Pay the same Medicare rate for the same service whether delivered in a hospital outpatient department or an independent clinic or ambulatory surgical center, with rural-hospital protections and corresponding physician-payment adjustments. Site-neutral savings remain positive under Version 2 but shrink by approximately $30–$40 billion over ten years because universal primary care (D1) modestly increases utilization.
- 10-year fiscal
- −$750BSavings
- Implementation
- Years 2–6
- Middle class
- Positive
- Planetary
- Neutral
$500B–$900B · Medium-High confidence
Lower Medicare premiums and out-of-pocket costs as program unit costs fall.
No material climate effect.
Global precedent
Most OECD systems, including Germany, France, and the Netherlands, do not embed U.S.-scale site-of-service differentials. MedPAC has repeatedly recommended site-neutral payment.
Lead mechanism
CMS; House Ways and Means Subcommittee on Health; Senate Finance Subcommittee on Health Care.
Bipartisan framing
Conservative case
Eliminates a subsidy for hospital consolidation and supports independent physician practices.
Progressive case
Addresses documented overpayment without affecting beneficiary access.
Figures in this framework are illustrative directional estimates derived from publicly available data and conventional Congressional Budget Office budget-window logic. They are not official CBO scores. Any provision adopted from this framework would require formal CBO scoring before legislative consideration. This document is a policy white paper, not an introduced bill.