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If you could make one change to Medicare, what would it be? Ask three former directors of the program and you鈥檒l get plenty of ideas.

Bruce Vladeck, who was head of what was then known as the Health Care Financing Administration, or HCFA, for former President Bill Clinton, wants more market-based competition and less pricing set by Congress.

鈥淚 would like to move all of Medicare drug purchasing, whether through Part D or Part B, all of [durable medical equipment] and related services 鈥� almost everything other than hospitals, docs and managed care plans 鈥� to a real market-based purchasing model,鈥� he said. 聽Give the聽 administrator of the Centers for Medicare & Medicaid Services the authority to negotiate prices 鈥渟tarting with the federal supply schedule for the 20 or 25 percent of Medicare outlays that are creating windfalls for various producers that we don鈥檛 talk about so much because it鈥檚 only 20 or 25 percent of outlays,鈥� he said.

Gail Wilensky, who ran HCFA for President George H.W. Bush, would urge lawmakers to adopt a聽competitively bid premium support model that includes the current traditional fee-for-service plan and the payments beneficiaries receive would vary by income and health risk.

Mark McClellan, who ran CMS for George W. Bush, wants to see Medicare make more progress on reducing the growth of costs. 聽The program, which serves 50 million elderly and disabled Americans, 鈥渋s nowhere near done with those kinds of steps, nowhere near the private sector鈥� on cost control. 聽聽鈥淩educing overall spending growth while still insuring access to care and improvements in innovation鈥� are key, he said.

The three experts want to see a permanent fix for the payment formula for doctors. That formula, called the , or SGR, has threatened large payment cuts nearly every year since being implemented and Congress has repeatedly stepped in to stop it. And all said it鈥檚 high time Congress confirms a CMS administrator. (President Barack Obama acting CMS chief Marilyn Tavenner for the post last year after his first choice, Dr. Donald Berwick, failed to gain Senate confirmation and served聽as a recess appointee.)

Vladeck, Wilensky and McClellan made their remarks as part of a panel discussion Wednesday sponsored by the Kaiser Family Foundation that was focused on Medicare鈥檚 role in the debate over debt reduction.聽 The foundation released a new 聽that examines a variety of proposals, such as gradually raising Medicare鈥檚 eligibility age from 65 to 67 or increasing beneficiary cost sharing, that have the potential to produce Medicare savings. (KHN is an editorially independent program of the foundation.)

鈥淎t 15 percent of the budget and a growing share of the economy, 聽Medicare is always a part of budget and deficit reduction discussions鈥�.,鈥� said Tricia Neuman, senior vice president and director of the foundation鈥檚 Program on Medicare Policy. 聽鈥淭his report is intended to frame the debate.鈥�

This article was produced by Kaiser Health News with support from .