Medicare’s 49th birthday: What is to be done?

At a crowded townhall meeting in 1959, an elderly woman stepped up to the microphone and spoke to a panel of senators. “I am not worried for my son’s time,” she began. “He is 35, and I am sure he will face a better future when his time comes to retire. But what is to be done for those of us who need help right now?”

This was one of a series of grassroots hearings held by a Senate subcommittee between 1959 and 1961. The senators visited 38 American cities in all, inviting the elderly to come and speak of the troubles they faced in their everyday lives. And come they did, tens of thousands of them, packing halls from San Francisco to Miami.

As the transcripts show, these men and women had much on their minds, with concerns ranging from housing, to unemployment, to pensions. But there was one topic that dominated the hearings: health care.

“Here are the doctor and hospital bills for my wife’s latest illness,” said one man brandishing a sheaf of papers. “They come to more than $2,000. I’ve paid them and my savings are all gone now. What shall we do the next time one of us gets sick?”

These stories and others like them galvanized the nation into action, and on this day in 1965, Lyndon B. Johnson signed Medicare into law. In 1965 only 46% of seniors had hospital insurance; in 1970, that number was 97%. In those five years, the death rate for seniors over 85 dropped by 20%. Subsequent modifications expanded eligibility to include Americans with certain chronic diseases, as well as those too disabled to work. With the benefit of hindsight, most Americans now agree that Medicare has been a massive success, and the program has withstood repeated attempts to abolish or curtail its benefits.

Yet Medicare, and its sister program Medicaid, did not completely solve the problem of health care finance, especially for those under 65. As costs have continued to rise, it has become more and more difficult for Americans to get the care they need. Before the Affordable Care Act (ACA), there were more than 47 million of us without any health insurance, including me.

I couldn’t afford private insurance, and as a healthy young man, I hoped I wouldn’t need it. When I injured my right hand, the pain was excruciating. For days I could barely move my fingers, and my forearm looked like a banana well past its expiration date. But worst of all was the uncertainty. Had I broken a bone, torn a tendon? In any case, I knew I couldn’t afford to see a doctor. Federal law requires emergency departments to treat all patients regardless of their ability to pay, but uninsured patients still get stuck with the bill. I bought a $10 splint at a drug store and hoped for the best.

Thankfully, my injury eventually healed. But now, as a fourth year medical student, I have already seen many patients who faced the same dilemma and were not so lucky. One, who had gashed his leg in a fall, came to the hospital only after he had developed a rampant wound infection that required surgical treatment and could easily have left him wheelchair-bound. A woman who came in to a clinic with near-critical high blood pressure told me she hadn’t been able to afford her medications, so she had been taking a pill a week to make them last.

Should I pay my rent, or should I buy my water pill? Do I fix my car, or do I see someone about my shortness of breath? These are decisions nobody should have to make — and yet, these are the decisions many face every day. Medicare, Medicaid, and now the ACA have all been steps in the right direction, but affordable and high-quality health care is still out of reach for millions of Americans.

It is time to finish the job. It is time to acknowledge that health care is a human right, that no man, woman, or child can engage in the pursuit of happiness while under the threat of illness or death. The time for half-measures and quick fixes has passed. We need universal health care, Medicare for all.

On this day, the 49th birthday of Medicare, let us reflect on how much we have accomplished, and what still remains to be done. In 1959 an old woman asked, “What is to be done for those of us who need help right now?” It is my fervent hope that we will soon have an answer to her question.

Danny Ash is a medical student.

Comments are moderated before they are published. Please read the comment policy.

  • NewMexicoRam

    Everyone wants the best.
    But no one wants to pay for it.
    We put off the truth for 49 years, and now the time is quickly coming when it will all fall down.

    • SarahJ89

      “Should I pay my rent, or should I buy my water pill? Do I fix my car, or do I see someone about my shortness of breath?”
      This is your idea of “the best?” This is pretty basic stuff.

  • QQQ

    “and now the ACA have all been steps in the right direction”

    I’m still wondering why any exemptions or delays were requested or
    granted for this law. After all, it’s the “AFFORDABLE CARE ACT”. Why
    would anyone, any business, any union, or any organization want to delay
    participation if it’s truly “AFFORDABLE CARE”? If it’s actually going
    to save people money, on average $2,500 per family, you would think
    everyone would be lining and celebrating, eager to participate, with no
    exemptions being requested by anyone or any entity.

    Unless, that is, it’s all smoke and mirrors, people are going to end up
    PAYING $2,500 more per family, and it’s going to add significant costs
    all across the board, with a necessary decline in quality of services.

    Strange that all these groups continue to want exemptions and delays. It
    couldn’t be because it’s all a big expensive fraud… naw… big daddy government
    wouldn’t do that.

    • Lisa

      The ACA is a step in the right direction. I have good private insurance; however, due to the ACA I will be able to obtain insurance if I loose my job. Previously, I would have been uninsurable due to my prior conditions.

      I know many people who have insurance because of the ACA. They generally self employed or work for small employers who don’t provide insurance. They are not paying more for insurance if they had insurance before. And the their maximum out of pocket is less than it was before.

      I think one of the major problems of the ACA is the governors of red states who won’t extend medicaid to the poor people in their state.

      I think if people had honest information, not information generated by Fox News and their ilk, the roll out of the ACA would have been smoother. I heard so many falsehoods during that time and I think your statement that people will be paying $2,500 more per family is another falsehood.

      • NewMexicoRam

        I’m sorry, but that sounds like fantasy thinking.
        Seriously.
        The ACA is crumbling due to it’s own deficiencies and the liberals think it’s the right wing’s fault.
        Really?

        • Lisa

          1) While the ACA has problems I don’t think it is crumbling.

          2) There was a hugh amount of dishonest propaganda about the ACA, generated about the right wing. It didn’t help the roll about a bit when people got inaccurate information.

          • NewMexicoRam

            I disagree entirely, but that’s what internet blogs are all about.

          • southerndoc1

            There are about 300 Republican amendments in the ACA, including the famous requirement that Congress and staff are forced to give up their employer-provided insurance and go on the exchanges

        • Danny Ash

          The ACA is hardly crumbling – millions have enrolled, and the majority of Americans are in favor of keeping the bill. Furthermore, HHS have had to deal with a minefield of unexpected changes to the legal landscape, including the effects of multiple legal challenges. Considering the circumstances, its performance to date has been most impressive.

      • Patient Kit

        I’m happy to hear that you know many people for whom the ACA exchange plans are working out well, Lisa. That gives me hope as I may have no choice myself soon but to try my luck with the exchange. And regardless of the problems, it beats having cancer and no healthcare options, which was true just seven months ago. CA and NY are two states that I’m hearing good things about. I agree with you that the relentless effort to dismantle and repeal the ACA by the right has been a big problem. Until we have something better to replace the ACA, we should be working together to try to fix it.

    • Danny Ash

      The ACA is an enormously complex law. In our legislative history, every instance of a comparably influential bill has required fixes, tweaks, and other emendations to be passed after the fact. The 2012 Supreme Court decision, and the refusal of certain elements in the Congress to permit changes to be made via the legislative route, have both made the implementation of the ACA even more challenging, and so executive orders have been necessary.

      We should remember the case of Medicare Part D. Even in the presence of a legislature willing to amend the bill, the administration – that would be the Bush administration, of course – found it necessary to issue executive orders to delay or modify various provisions of the bill. I don’t recall anybody having a problem with that at the time, and don’t understand the current hullabaloo either.

      • James O’Brien, M.D.

        Not true. Many people, both on the left and right, were ticked off at Bush’s obvious election year ploy to get senior votes. It was even more egregious because Part D was not funded by payroll tax increases. And many people on both sides of the spectrum were warning about executive overreach, which has only intensified under Obama.

  • QQQ

    “On this day, the 49th birthday of Medicare, let us reflect on how much we have accomplished, and what still remains to be done.”
    ————————————————————————————————————-

    The nine most terrifying words in the English language.
    “I’m from the government and I’m here to help.”

    Ronald Reagan

    • Patient Kit

      Ronald Reagan was the beginning of a lot of our current problems in this country. Taking care of the wealthy first has absolutely failed to trickle down. The gap between the few at the top economically and the rest of us has only gotten wider and wider and wider.

      • John C. Key MD

        Ah Kit! You have finally revealed yourself. Always wondered why your comments were so full of nonsense.

        • Patient Kit

          LOL! “Finally” revealed myself? I think I’ve been pretty much an open book on KMD, openly and painfully revealing myself and my life here to the point that sometimes I’m in tears while I’m posting here. I’m sure there is a whole list of docs who wish I would just go away. How I feel about Ronald Reagan should come as no surprise to anyone who has read a few of my comments. You might have missed that I’ve said here several times that I worked on President Obama’s first campaign (and yes, I am very disappointed in the ACA). If Hillary Clinton runs in 2016, I will work for her campaign. I’ve been pulling myself up by my bootstraps my whole life but sometimes we just need some help. And seriously, it’s been trickling up, not down.

    • Danny Ash

      You can say that the government is a problem, not a solution, but saying it doesn’t make it so. I believe, and could argue convincingly that the anti-government ethos ushered in under Reagan is the primary cause of many of the most serious economic and social problems in this country. That doesn’t mean I would convince you – I have no illusions to that effect. But it does mean that the situation is complex enough to sustain multiple distinct interpretations, and that we should be careful of falling back on dogma in situations that call for pragmatic solutions.

      • Dr. Drake Ramoray

        I see QQQs political quote and raise him one.

        “Of all tyrannies, a tyranny exercised for the good of its victims may be the most oppressive. It may be better to live under robber barons than under omnipotent moral busybodies. The robber baron’s cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end, for they do so with the approval of their consciences.”

        CS Lewis

        • Danny Ash

          In what sense would single-payer healthcare constitute tyranny? Also, I am not sure where CS Lewis got the idea that the cupidity of robber barons could be satiated, but that is certainly not my reading of history.

          • Dr. Drake Ramoray

            I believe I have already made my point with regards to the non-negotiation of rates through Medicare (see my posts about DEXA scans) and the at least preliminary discussions of seeing Medicaid as a condition of licensure. It would not be very hard in this process for the government to tell me what I will get paid (which they already do) and the also tell me who I will see. I understand your point that you don’t think that will happen and I have provided an example of where it has (DEXA and pay) and one where there has been very legitimate political discussion (taking Medicaid in some states).

          • Danny Ash

            I don’t agree that accepting the national plan will be made a condition of licensure. In any case, I can only tell you what I support and don’t support, and my opinion on any of the many possible future scenarios is not especially germane to this discussion.

          • Dr. Drake Ramoray

            I don’t believe your scenarios are germane (nor our mine certain to come to pass (ie being told where to work) to the discsusion however I am troubled by the lack of a specific of a specific concrete plan for physician reimbursement other than assurance that it will be equitable and not fee for service, whereas I have pointed out the near universality of fee for service in other payment systems as well as specific issues with capitation and pay for performance systems.

            I do not make this point to discount your position, and I see your vision I really do as I don’t take the idea of emigrating to a country with a universal system lightly, but the reimbursement system (and the lack of specifics) becomes a larger concern as you get older, have to pay back your debts, have more bills, and are supporting a family. I think you could potentially garner more support from a different generation (than your own gneneration) of docs if you worked out a concrete

          • William Viner

            Drake, you need to bite the bullet and move to NZ. Then you won’t have to spend so much time on this site. Not boasting, but I work 3.5 days a week in direct patient contact for the govt, 1in 4 calls with junior support, 0.5 days a week in private practice (by choice) and make as much as I did in the US working 4+ 12 hour days per week plus 1 in 3 calls. I don’t have the legal woes. My over head in private is 15% and not 60%. I arrive at 8ish and done by 430. I could do all private if I wanted, but only 30% of populace has insurance so I currently do need to stay in the system, but I love it anyway. I see maybe 20 patients daily instead of 40-60. Generous CME. Private insurance pays very well and you can actually bill whatever you want and the patient would pay the difference. Personally I just bill what the median reimbursement is and don’t bill patients anything additional. We have a union that protects us. You would have to do Internal Medicine stuff again though. Come check it out. There is an Endocrinologist here from Chicago that came long before me, so he could probably give you more info. Tax rate is maxed at 33%. You could at least ride out the storm.

          • Dr. Drake Ramoray

            Well if my life now was like it was 10 years ago when I originally looked I would already be there. My wife is very reluctant to move, has lots of family and very deep roots here We live very near where she grew up and in her hands down favorite part of the country (I’m pretty taken with it too myself).

            From a professional perspective the other hinderance is that I am seriously considering not recerting in general internal medicine. I don’t need it (if I stay here). It’s not worth it. And should I ever fall under the clutches of a hospital system I can use Endo certifcation only as my trump card, and then not be forced into corp med primary care without certification.

            While I plan on maintaining my Endo certification for now (see my recent posts on AACE is actually laying the groundwork for their own certification because of the ABIM), not maintaining certifcation here in the states for general internal medicine is very likely to complicate any emigration plans to NZ. As I have looked into it further it is looking to be less likely.

            That being said she is on board with my plans to slide out of the system in a direct pay practice and in a few years when the kids are older and if need be I can very much move to a part time and/or we as a family will be in a position to be much less reliant on me as the sole income. Also, I have made some very positive recent strides in longterm planning and consideration for a low cost direct pay practice.

            NZ isn’t off the table, but is looking to be far less likely. That being said NZ has all the facets of how a “universal” system can function well, although everyone here who wishes to pursue single payer and the like seem to ignore the specifics that make it work.

          • William Viner

            Sounds like you have some excellent alternatives. Moving away was more difficult than I thought, but well worth it in my line of work (ObGyn). I think you hit the nail on the head when you stated how NZ has a well functioning universal health system. I would really like our leaders in the US to take a look at this. Not perfect, but very good for the citizens and the docs.

      • SarahJ89

        I live in a small town. We have Town Meeting every second Tuesday in March. People drive from their homes, which are protected by government-paid police and firemen, over roads built and maintained by the government to our local school, also built and maintained by the government. They stand there and rail away about how evil government is and never see the utter irony of their words.

        All or nothing/black and white thinking is one of the 12 cognitive distortions. We seem to specialize in it in our culture. (And yes, I’m guilty of it too at times.)

      • James O’Brien, M.D.

        You could also claim that Calvin Coolidge is to blame for our problems and I wouldn’t believe that either.

    • SarahJ89

      QQQ,
      Let me know how that building your own roads and bridges thing works out for you.

  • Patient Kit

    Thank you. I agree with you completely. I’m amazed when I hear people — doctors especially — refer to the years before Medicare/Medicaid as the “good old days”. They weren’t the good old days for many elderly and poor Americans. Medicare definitely made my parents’ life better. And this year, Medicaid saved my life when I was diagnosed with ovarian cancer after I was laid off from a job I held for 18 years and lost my Blue Cross insurance. The ACA has a lot of problems but an exchange plan may give me access to the medical care I need until I can afford better health insurance.

    But there are no guarantees that I won’t fall through the cracks and again become an American with cancer who is unable to access medical care. I spent the first six months after my GYN found my probable cancer uninsured and with no access to medical care until I qualified for Medicaid. It was the most terrifying six months of my life. I felt like a human ticking bomb. And millions of Americans like me are still falling off that tightrope without a net — to their deaths.

    I agree with you that healthcare is a human right and that it is beyond time that we find a way to implement universal healthcare in this country. It’s great to see a young almost doctor just starting his career feeling this way. I hope there are a lot of current med students and residents who feel the same way about universal healthcare. Please tell me that there are a lot of you. Best of luck to you in your career. We need docs like you.

    • Danny Ash

      Thank you very much for the kind words! Here at OSU, we are working on building a chapter of Students for a National Health Program, the student arm of Physicians for a National Health Program. We are still learning and growing, and we are doing our best to bring this cause to the attention of ever-wider audiences.

      I’m sorry you had such a terrible experience with the healthcare system, and I hope you were able to get the care you deserve. I do believe that change happens from the bottom up, and by having the courage to tell your story and advocate for healthcare for all, you are becoming part of that change. Thank you, be well, and keep up the good work!

      • Patient Kit

        Thank you. I’m hellbent on rebuilding my life. My mantra this year is “Phoenix rising!” This past year, I had started referring to myself as a’”pet albatross” to all who helped me while I was struggling. Friends, family and, yes, my government are what saved me from ending up a cancer patient living on the street. It was a rough couple of life-changing years for me. I learned a lot firsthand that I only knew intellectually before. I’m a lifelong grassroots activist and I agree with you about working for change from the bottom up.

        I’ve long cared about changing our healthcare system but now it’s my #1 priority. I’m very lucky that my cancer was found at the earliest stage and that I live in NYC where I found excellent care at one of the many good academic medical centers here. I spent years working in the nonprofit sector working on social justice issues and advocating for other people’s rights. So, I had that experience to draw on as I had to quickly learn how to advocate for myself in a scary healthcare system. But millions of Americans are not as lucky as I’ve been. There is something terribly wrong when our healthcare system is scarier than cancer!

        It’s very exciting to hear about Students for National Healthcare popping up and growing at medical schools throughout the country and that many young doctors believe in and want that kind of change. I think we need to build a strong doctor-patient movement together and young docs are a very important part of that movement. Don’t let the system beat you into submission. Hang on tight to what you believe in and what you envision!

    • querywoman

      In your uninsured emergency spell, didn’t you have access to a public hospital? Cancer is something they are happy to train on. Medical students need to see a certain amount of each procedure.
      Also, and your ovarian cancer is a done deal now, the religious hospitals will take on the uninsured for heavy

      • Patient Kit

        Actually, I was never treated at a public hospital, although you are right that NYC does have a large public hospital system that is an important safety net for many people. I really had no clue what to do when I was initially diagnosed by a private practice doctor just before my COBRA’d Blue Cross policy ended. I had had a BCBS very comprehensive PPO policy for a couple of decades. I had no idea what to do when I was suddenly uninsured for the first time and in shock with a new pre-existing cancer condition, which made it impossible to buy new insurance. It would have been nice if that private practice doc had given me a clue about where to look for help — or at least wished me luck. But her only advice was that I had to find the money for surgery somewhere without delay. It was a real learning experience. But my survival instinct kicked in, I scrambled and learned fast.

        Once I was approved for Medicaid, my surgery was done at a teaching hospital in the NY Presbyterian Hospital
        System and there I have remained for my follow up
        surveillance. Even though we caught it and did successful surgery at an early stage (for which I am eternally thankful), I still need to be monitored for recurrence every 3 months for 2 years and then every 6 months for 3 years and then annually. So, it’s hard for me to think of the cancer as a completely “done deal”. It probably wouldn’t be wise to not see any doctors for a while, especially my GYN ONC. Now, I’m working on transitioning off of Medicaid and on to some other insurance. Luckily, the hospital system I’m in takes a lot of different insurances, including about 8 of the exchange plans. I’ll give that a shot if I keep working without an iemployee-provided insurance benefit. But I’m working on finding that. One way or the other, I’m determined to make everything work out ok.

        In summary, I have better options going forward with the ACA than I would have had without it. In the meantime, I’ve gotten very used to and comfortable with being treated by hospital-based docs. In my case, my hospital-based GYN ONC has been awesome and my previous private practice GYN was awful.

        • querywoman

          Sure, lots of people don’t know what to do. The uninsured upper middle class are over the income limits for the public stuff, but they can get procedures at religious hospitals with a down payment and payment plans.
          Those people should be able to buy into ACA plans now.
          At least you finally got whatever you needed.

    • querywoman

      Your private gyn should have helped you find treatment. The cancer societies can spend some of that money they collect on patient care.
      I have chronic skin disease, which is a low priority everywhere. Lots of providers know nothing about skin disease.
      Cancer has a well-established industry and many treatments are known. If a medical school treats your cancer, which they will, it helps train medical school students and residents working for board certification.

      • Patient Kit

        Agreed. She could have given me some suggestions about where I could seek help after unloading such a serious dx on me. She was extremely cold. She was clearly in a very bad mood and not in control of her personal emotions. It was Election Day and I think she couldn’t keep her ACA hate out of the exam room. Very unprofessional, but what I really can’t forgive her for is not even wishing me good luck when she sent me alone out into the world with that new scary dx.
        Because of this night and day experience with doctors — awful private practice doc and awesome teaching hospital-based attending doc — I don’t think anybody will ever convince me that private practice docs are always automatically better docs than hospital-based docs. There are good and bad docs in both practice models and I no longer think of private practice as the default place to find a good doc.

        • querywoman

          Where I live, the good docs know where the public hospitals and church hospitals are. From my welfare years, I know that the church hospitals work with the upper middle class uninsured.
          I had a home health nurse, an LVN, who is married to an RN. Income maybe $80,000 a year, no insurance. Their teenage son got injured in HS football. The school referred him somewhere for surgery that took $1000 down and made a payment plan.
          He dislocated his shoulder three times playing football. Like a good mother, she told him she was going to break his other arm if he didn’t quit.
          I need to text her and see how that kid is doing.
          Before she made arrangements, she was pleased I cared when I told her the church hospitals would work with them.

          • Patient Kit

            I’m not sure we have many — if any — “church hospitals” left here in NYC. Most of the hospitals with “Saint” in their name have either closed or been acquired, including Saint Vincent’s Catholic Medical Center in Greenwich Village, which closed in 2010 after being an important part of the community for 160 years, including during the early days of the AIDS/HIV crisis and on 9/11. Gone.

          • querywoman

            Most hospitals still claim to be “nonprofit,” even though they are really not. And they have to give a certain amount of charity care.

          • Patient Kit

            I found the academic medical centers/teaching hospitals in NYC to be my best bet here. And the good news going forward is that almost all NYC hospitals, including some very good hospitals, are accepting some, if not most, of the exchange plans. The hospital where I’m currently being treated is accepting 7 of the 9 plans that are an option for me. And my awesome doc is accepting at least some of those exchange plans too. So, as it was meant to be, the exchange seems to be functioning as a real safety net. I’ve always loved my NYC home but I’m especially thankful to be living in a state where they are actually trying to make this ACA/exchange thing work. I may not end up needing it, but I’m glad it’s there if I do.

  • Dr. Drake Ramoray

    I would have to second QQQ’s comments with regarding the ACA. I will also state as I have suggested in the past that I am not even opposed to a single payer system (provided we close our borders in a way commensurate with other nations who have single payer, and that doctors are allowed to collectively bargain (also like other nation’s who have single payer).

    I will focus on the collectively bargaining and healthcare being a right part. By suggesting that healthcare is a right, you are in essence saying that somone else is entitled to your labor as a future physician. And the absence of the ability to collectively bargain is my bugaboo with the concept of Medicare as it currently exists or Medicare for all. As I posted months back Medicare unilaterally reduced the reimbursement for thyroid biopsies by almost 50%. Given the time spent we actually lose money by doing them in comparison to what could be done during the time spent performing a biopsy (ie just see patients instead) although we still are in the black actually performing the procedure).

    CMS has now listed a diagnostic ultrasound as one of it’s over valued codes for 2015 and we are likely going to see a similar cut in reimbursment for that service. Depending on the cut in reimbursement we may no longer offer that service, and then patients will have that testing at the hospital (which is more expensive and not done as well).
    If you don’t believe that would become reality just take a look at DEXA scans. In 2001 reimbursement for DEXA scans was about $150. Medicare in my area now reimburses about $40 for a DEXA scan. My practice is unlikely to continue obtaining DEXA’s in office after 2015 because our service contract runs out and we are currently losing money on bone density testing. The hospital is able to charge a $150 facility fee on top of the $40 for the exact same test. If my practice consisted of nothing but osteoporosis and doing DEXA’s at the CURRENT CMS rate for DEXA scans I would not be able to keep the lights on and would have to close my practice. (or go work for a hospital, which is the real goal of the ACA, but I again digress).

    Only the government can do this. None of the private insurance companies can just unilaterally reduce reimbursement for services. Sure they can tell us they want to renogiate their rates, or require a prior authorization, or require different testing first in some cases (I could make the case that they shouldn’t be able to do this either but that would go beyond the scope of my point), but none of them can just one day decide yeah were gonna pay you 50% less for that service. If so they have to negotiate with us, and we can very easiliy drop them from network. It is very very hard to get out of Medicare.

    To suggest healthcare is a right means that someone else is entitled to the product of your years of training, dedication, labor, and that you witholding them from any particular individual person is illegal. If healthcare is a right, and the government has been established to protect that right, such as life, liberty, and the pursuit of happiness, then you are also suggesting that the government can tell you where you should practice medicine. Why should my community that lacks several specialties (even under represented by my own speciatly) be denied the right to healthcare while there is a glut of physicians in the affluent suburbs? Don’t those rural individuals or inner city individuals have the same right to healthcare? Do you want the government telling you where to practice medicine?

    • SarahJ89

      I totally agree you should have collective bargaining rights. I’m not clear on the part where AMA, which I thought was supposed to be your union, somehow forgot that part of things.

  • Thomas D Guastavino

    In 1965 treatments that we now consider routine (and to some consider a right) were science fiction. Because of this the cost estimates for Medicare conservatively were off by more then a factor of ten. Ironically, one the reasons the years from the late 1960s to the early 1990s were called the “golden age of medicine” was that with every advance Medicare paid without question, stopping only when costs increases were occurring at an alarming rate. Medicare costs continue to go up because of a rapidly expanding geriatric population and new procedures, drugs, etc continue to be introduced, but the reimbursement per procedure has been steadily dropping, in some cases dramatically. Today, adjusted for inflation, some procedures get paid less then 20% of what they were 25 years ago and there is no end in sight.

    • Dr. Drake Ramoray

      Isaac Asimov had thyroid cancer. He had surgery for this thyroid cancer in 1972 and wrote an article about the experience.

      “Doctor, Doctor, Cut My Throat” Isaac Asimov.

      “The operation gave me occasion to prove how delightful it was to be a writer. Carl charged me $1500 for the operation (well worth it) and I later wrote up a funny article about it (including my little verse) and charged $2000 for the piece. Ha, ha, and how do you like that, you old medical profession, you? (I was
      happier than ever that I hadn’t been accepted by any medical school.)”

      http://home.earthlink.net/~sweetwind7/thyca/asimov.html

      $1500 in 1972 is $8500 in 2014.

      http://www.bls.gov/data/inflation_calculator.htm

      CMS for a total thyroidectomy with neck dissection and 30 days of after surgery care in 2013. $1600 (for the actual surgery Asimov had probably $940 as I doubt he had a radical neck dissection)

      http://www.clinicalexpertise.com/sites/default/files/13-0028_2013_Reimb_Thyroidectomy.pdf

      • Thomas D Guastavino

        Ahh, another Asimov Fan. Im sure Isaac would approve the “Three Laws of Doctonics”
        Law #1: A Doctor must never harm a patient
        Law #2: A Doctor must do whatever a patient wants, unless it violates the first law.
        Law #3: A doctor must protect themselves unless that protection violates the first two laws.

  • Patient Kit

    Universal healthcare could be funded in this country with tax money. What we spend our tax money on is a matter of prioritizing. We could start by re-directing the huge amount of money spent on ridiculous pork items and by refraining from starting any more unnecessary wars. Every American should have access to healthcare just as every American has access to an education. I don’t have any children and I don’t flap my wings and squawk about my taxes being used to pay for other people’s kids’ educations. So, it really upsets me when the healthier-than-thou balk at the idea of taxes paying for medical care for those sicker than them. I wish people could grasp that a bad injury or diagnosis could happen to anyone at any moment and see the value — and the human decency — in covering every American for healthcare. But people love to hang onto their illusions (that nothing will happen to them and they will stay healthy) and people also love to gamble.

    • Dr. Drake Ramoray

      It is not as simple as raising taxes to fund universal healthcare. Moving to a single payer system that is viable in the United States would require a complete overhaul of our legal, immigration, and medical education infrastructure.

      As I have said, if you want a healthcare system like New Zealands, Switzerland, Australia, Germany, or Belgium (relatively high functioning systems that don’t get bad press to the level of Canada or the UK) then get you need to completely overhaul the education, and tort system.

      This would be in addition to closing our borders, deporting illegals, and even consider deporting people with green cards when they are unhealthy. Most of the cited countries have an immigration score to even consider allowing you to immigrate in the first place (speak the language, have a skill, etc.), but then they can deport you later for health reasons if they so choose.

      http://www.dailymail.co.uk/news/article-2380021/Albert-Buitenhuis-New-Zealand-kicks-obese-man-country-290lbs-heavy.html

      Universal healthcare is incompatible with the current structure of the remainder of the American government, laws, and system. To suggest that merely raising taxes will make it a sustainable reality is pure fantasy.

      • Patient Kit

        I did not mean to suggest that it would be easy — but I do believe that we can find a way to fund universal healthcare and I am open to any number of forms that universal healthcare might take. I just want all Americans to have access to good medical care when they need it. I have seen way to much truly awful inhumane stuff when people do not have that. I also support tort reform, subsidizing medical education and collective-bargaining for doctors, during which you would negotiate not only your salaries and benefits but also your terms of employment so that, for example, you can’t be forced to work where you don’t want to work.

        I know that it’s not simple. But what’s the alternative? Let our current healthcare system just get worse and worse for doctors and patients and better and better for the businesses that control healthcare? Do we want a healthcare system that works fine for people with lots of money but doesn’t work for the rest of us? We have to find a way to make universal healthcare work.

      • Lisa

        I fail to see how closing the borders and deporting anyone who who is not here legally has anything to do with universal healthcare. I will remind you that many European countries have immigration problems (people coming from Africa) and they still manage to have universal health care for their citizens.

        To say that universal heatlhcare is incompatible with the our laws and system ignors the fact that our laws and system can be changed. We have a form of universal healthcare in place for people over 65; medicare. You may not like the reimbursement rates, the rules may be stupid, but it is in place. That system can be improved and expanded, but that would mean increasing taxes.

        • Dr. Drake Ramoray

          You can’t have an endless stream of illegals (and not deporting the ones here (just like Reagan didn’t in 1987) just encourages more to come) and have “free” healthcare for everyone. Taxpayers can’t pay for the healthcare of an endless stream of illegal immigrants. Why have borders at all. Perhaps I should just show up in Canada illegally with my chronic health problems and expect them to fund it. I already gave a real world example in New Zealand where deportation occurs directly because of health reasons.

          As for changing the laws, you are just reaffirming my actual point. Funding a universal healthcare system is the easy part (not necessarily palatable to raise taxes). Making the other changes to the system to make it even remotely sustainable is the hard part. Far from ignoring that the laws would need to be changed, that was actually my point to patient Kit. It’s much harder than simply funding it.

          Single payer or other forms of universal healthcare can work reasonably well in a small relatively homogeneous population with relatively closed borders, and a sane malpractice climate (none of which are present in the US). That is why things like emigrating to New Zealand are on the backburner.

          • Lisa

            I never said universal health care should be free or available to people who are not here legally. People should pay for it, either through taxes or directly and people who poor should be subsidized.

            I think the hardest part of creating universal health care in this country will be dealing with the insurance companies who do not want to give up their profits.

          • Dr. Drake Ramoray

            “I fail to see how closing the borders and deporting anybody who is here illegally has anything to do with universal healthcare?”

          • SarahJ89

            There are also plenty of people living here illegally who pay taxes and SS which will never benefit them.

          • SarahJ89

            “Perhaps I should just show up in Canada illegally with my chronic health problems and expect them to fund it.” Actually, I live near the Canadian border. More than one of my friends and acquaintances have gotten excellent free medical care while traveling up there, some quite extensive. I got care in Northern Ireland when I lived there. When I asked about payment I was told “You’re not in the United States any more, lassie. We take care of our people here.”

            So yes, you probably could get treated in Canada.

          • Dr. Drake Ramoray

            On vacation as a visitor yes. As a person living their long term illegally no. That is the context in which that statement is intended.

          • SarahJ89

            Yeah. I was being snarky. Sorry.

            I was, however, living in NI when I was treated (rather extensively) for a non-emergency problem. No one asked anything about my legal status so living there illegally would not have been an issue. I lived in the Republic for two years, had a regular PCP and again, no questions about my status. At the time Ireland was a very poor country, almost third world. My friends with little kids were all living four to a room and lucky to have housing. My roommate and I both worked but could barely pay the rent. And yet… the culture viewed health care as a right and made the choice to put their money where their beliefs were.

          • Danny Ash

            The people you call “illegals” do jobs Americans don’t want to do at any wage. They work hard, pay taxes, and get nothing in return except hatred and the threat of separation from their new lives and their families. If healthcare is a human right, then it follows that these humans have the same right to healthcare as you and I.

            I should note that within the European states, there is enough variation in healthcare quality that, other things being equal, one might expect migration to occur. And far from having closed borders, citizens of EU states have the right to visa-free travel anywhere within the EU. Yet we do not see the collapse of European health systems, nor migration in excess of what would be expected on economic grounds.

      • SarahJ89

        You are correct. And wouldn’t it be nice to toss mitigation of rampant corruption and collusion between corporate America and politicians into the pot whilst we’re at it? The endless kick backs are what would really make single payer difficult in the US.

    • SarahJ89

      Kit,
      I believe the correct term is “richer than thou.”

  • NewMexicoRam

    Of couse it’s grown more slowly. Medicare has increased it’s payments to doctors only 8% over the last 14 years–significantly below inflation.

    • southerndoc1

      Many private insurers are now forcing contracts at 50-75% of Medicare on physicians, if not dropping them from their networks completely. If Medicare’s chronic care management payments really happen, it’s going to be the insurer of choice for primary care docs.

  • QQQ

    “The time for half-measures and quick fixes has passed. We need universal health care, Medicare for all.”

    Oh really Danny?
    —————————————————————————————————-

    Dallas, Texas_ Parkland Memorial Hospital — the same iconic institution
    where doctors tried to save John F. Kennedy in 1963 — is today where
    tens of thousands of illegal immigrants receive taxpayer subsidized
    care.

    The most common patients here are expectant mothers. Each year about
    16,000 babies are born at Parkland. The hospital estimates about 70
    percent of them are delivered by undocumented mothers.

    Among the new mothers is a woman who didn’t want to be identified — an
    illegal immigrant from Mexico. Her medical bills will run more than
    $6,000.

    But with no insurance, Parkland — a public hospital — is forced to cover the cost.

    “We have to figure out how to continue to deal with this because it’s
    very difficult to fund it,” says Parkland President Dr. Ron Anderson
    says the cost of treating undocumented immigrants — millions of dollars
    each year — is unsustainable.

    • Danny Ash

      The cost of treating people without health insurance is unsustainable under the current system, because the current system relies on implicit cost-shifting rather than an explicit and therefore efficient allocation of scarce resources.

    • querywoman

      The chances of Parkland having to pay for the delivery out of county and state funds are miniscule. They will bully the woman into applying for Medicaid, which will probably cover the labor, an emergency condition.

      Luckily, Ron Anderson is no longer in control and shooting his mouth off.
      He would never admit that he liked having all those deliveries. Why? It helped him train and sustain large obstetrics and pediatrics departments.
      He loved to say that Parkland delivered more babies than any other hospital in the country. What that meant was that babies were being closer to their parents’ homes in the rest of the country.

  • QQQ

    “Dr. Michael Savage Ph.D: Obamacare Disaster FAKED To Bring In Obama’s Single Payer Socialist Dream

    https://www.youtube.com/watch?v=A1kQnDLcn3s

    • Danny Ash

      Nice, a conspiracy theory.

  • Dr. Drake Ramoray

    Life expectancy is an overhyped statistic ( I agree with the over hype to a degree of the Canadian and British system which is why I chose other countries (whether it be true in Britain and Canada or not but thus removing them from the conversation.)

    Life expectancy is a realtively meaningless statistic for comparison of health systems. The US has more fire arms and automobiles than any other nation both of which have a habit of ending a young otherwise healthy persons life rather early and unexpectedly. This skews life expectancy data very much downward. Furthermore, we also have the highest rate of obesity and the most sedentary population, again something that is at least somewhat outside the purview of our healthcare system. Unless you think any length of appointment with a primary care doctor is going to change the super size and tailgating culture of America.

    When you look at actual specific health outcomes as your yardstick for the quality of healthcare, say cancer survival rates the US compares very well if not the best across many metrics.

    The US beats almost every other country on survival metrics for almost every listed cancer diagnosis. We certainly aren’t at the bottom like the “life expectancy” statistics suggest.

    See Table 5 on page 7.

    http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-027766.pdf
    There is no disputing it’s very expensive here, although again I to a degree cite the rate of obesity and DM in this country.

  • Dr. Drake Ramoray

    “In practice, such a system would almost certainly involve a move away from fee-for-service in favor of capitation or a similar population-based system, which would imply (but not mandate) that physicians would receive a steady salary unrelated to the number and type of procedures performed……..would provide a strong economic incentives for those physicians willing to serve as arbitrageurs across inhomogeneities in distribution.”

    Pay for performance or capitation payment schemes (pay for performance is really capitation on steroids, placing the financial responsibility on the physician for caring for the patient) is bad for underserved patients and the doctors who choose to take care of them

    I practice in a relatively rural, relatively poor underserved area. I have some patients with limited education and even some with transportation issues. There is no way that you can compare the outcomes of my patients and compare them to the patient’s of a physician in the affluent suburbs with less complicated, and more wealthy patients.

    Yet that is exactly what is happening. The best thing a doc can do for themselves in a pay for performance or capitation system is move to the affluent suburbs. This payment method will exacerbate not improve the difference in healthcare between the haves and have nots as doctors are further encouraged to gravitate to affluent areas.

    http://www.nytimes.com/2014/04/28/us/politics/health-laws-pay-policy-is-skewed-panel-finds.html?_r=3

    • Danny Ash

      I totally agree that pay-for-performance is at best extremely problematic. The current pay-for-performance regime not only fails as an incentive scheme, but is demonstrably harmful for patient care, as shown by Fenton et al. 2012 in which higher patient satisfaction rates were found to be correlated with increased mortality. Until and unless measures can be found to align physician pay with appropriate aspects of performance – and I am not at all sure such a thing is possible – I would be in favor of doing away with pay-for-performance, both in our current system and in any single-payer system.

      • Dr. Drake Ramoray

        Actually if you look at other industrialized nations with universal healthcare they almost universally have a fee for service system that is negotiated by the docs and the government through collective bargaining. Only the US is looking for capitation/salary/pay for performance schemes he national level.

        The insurance companies are tired of holding the financial bag, largely placed upon them by the government, and the government is tired of paying the ever increasing rates for healthcare. The music has stopped and the only one left standing are the docs. The financial responsibility is moved from the patient then to the insurance company/government and now lastly to the doc. (This doesn’t even take into account the primary care docs (at least) will be replaced by PA/NPs as fast as corp med can do it).

        Single payer healthcare without fee for service and without collective bargaining is exactly what my immigration to New Zealand paper work is for (assuming my no monthly fee, low cost direct pay specialty practice is either non-viable or illegal).

        • Danny Ash

          I’m mostly familiar with the Canadian and British cases, but the UK system is dominated by salaried positions, and the Canadian system is pretty much evenly split between FFS and other models, of which salary is the most common.

          I’m not going to say that the health insurance sector in this country performs no useful services at all, but it is probably several tens of times larger than it ought to be. The purpose of any healthcare system is to perform efficient resource allocation. There are many reasons this does not happen (which may be a topic for a post on market failure), but a big one is that insurance companies have an incentive to remove as much from the payment stream as possible. The portion of the payment stream removed as profit for insurance companies performs no useful function for society aside from increasing the income of already wealthy investors and providing clerical jobs.

          Re: increasing health costs: one of the biggest reasons for the increase in health costs is the astonishing proliferation of administrative positions in hospitals and physician’s practices. If you suggested to HR managers in any other field that they would require one administrator for every customer, you’d be laughed out of the office, but indeed these are some of the administrator to bed ratios we are seeing. This is due almost entirely to the ridiculous complexity of billing, which is a consequence of the fact that insurance companies have an incentive to make billing as difficult as possible. Get rid of the insurance companies, get rid of the glut of unnecessary administrative roles, and let the government negotiate with the pharmaceutical companies, and you will see healthcare costs drop to manageable levels.

          Physicians currently have, and will doubtless retain multiple avenues for negotiation with the government. I do not know of any specific prohibition on collective bargaining in HR 676, but I can check for you.

          Sources:

          https://secure.cihi.ca/free_products/physicians_payment_aib_2010_e.pdf

          http://www.nhscareers.nhs.uk/explore-by-career/doctors/pay-for-doctors/

          • Dr. Drake Ramoray

            Collective bargaining is currently illegal. Future legislation that doesn’t bar it is insufficient as it is already not allowed. I will not support any legislation for a single payer system that does not include the development of a collective bargaining system.

          • Danny Ash

            Can you explain to me what you mean when you say collective bargaining is currently illegal? I obviously don’t have firsthand experience, but see http://www.aafp.org/practice-management/payment/collective-bargaining.html among others.

          • Dr. Drake Ramoray

            Physicians can with their employer. They cannot with CMS. I have no power, nor do physicians as a group have power over the reimbursement that CMS dictate. Yes there is an RUC committee which recommends fees to CMS.

            I take Medicare’s $40 at a loss, stop performing DEXAs, or stop seeing Medicare. If this lack of options were to be continued under a single payer system or just say Medicare for all, then I can be either forced out of business or work for a hospital.

            I have no intention of working for a hospital in the US (again my emigration plans if need be)

          • Danny Ash

            Ah, I see what you’re saying. I’m sure you will see that Medicare compensation levels in a single-payer scenario would be very different from the status quo. The relative decline in Medicare reimbursements is, like many of the problems in American medicine, primarily a result of the fee-for-service model. FFS, simply put, is a poor way to map physician’s work onto monetary value, and imposes many biases and distortions across the multifarious landscape of practice types. Under single-payer, it is likely physician pay would be more uniformly distributed, but whatever mechanism would be used to set physician compensation would certainly involve input from physicians. And of course, nobody can take away your right to vote with your feet, though I think this is not something most people would consider lightly.

          • Dr. Drake Ramoray

            “Ah, I see what you’re saying. I’m sure you will see that Medicare compensation levels in a single-payer scenario would be very different from the status quo. The relative decline in Medicare reimbursements is, like many of the problems in American medicine, primarily a result of the fee-for-service model.”

            More vague reassurances and continued inappropriate bashing of fee for service that exists in functioning systmes in other countries. See the post by William Viner contained in this thread on the subject. NZ has all the things required for physicians to be happy practicing medicine, even balanced billing which is also illegal in the US.

            I have enjoyed this conversation but I do not see you accounting for the issues that I have raised in this thread with further discussion. It has been a pleasure.

          • Danny Ash

            Dr. Ramoray, it has been a pleasure for me as well. I wish to respond as follows: I have a certain policy proposal. You are raising concerns about policies that

            1. are not part of my proposal, and

            2. I have said I do not support.

            It seems like you are saying that you intend to move to New Zealand if your state should mandate acceptance of Medicare patients as a condition for licensure. I cannot say for sure whether or not this will happen, but I can say that my proposal does not make any reference to such a policy. So it’s not clear to me what this has to do with single-payer healthcare.

            You also have concerns about collective bargaining, however you feel that under the status quo physicians already do not have sufficient negotiating power. I have said that PNHP’s proposal has provision for physician involvement in compensation scheduling, but since you asked for specifics, I quote from HR 676 §202(a)(2):

            “The global budget of a provider shall be set through negotiations between providers, State directors, and regional directors, but are subject to the approval of the Director. The budget shall be negotiated annually, based on past expenditures, projected changes in levels of services, wages and input, costs, a provider’s maximum capacity to provide care, and proposed new and innovative programs.”

            So under my proposal, physicians have a seat at the table, which would seem to address your concerns.

            As a side note, I have posted elsewhere that American physicians have considerably more purchasing power than those in New Zealand.

          • James O’Brien, M.D.

            Why do you think physicians have a seat or will have a seat at the table? During ACA negotiations, the AMA was told to shut up and sit down. Physicians are always the suckers in the room. Especially young idealistic physicians.

          • querywoman

            Ah, semantics!
            In Texas, teachers may not legally join a union. So they have an association, which collective bargains all the time, whether it is legal or not.
            I don’t know if the American Medical Association has ever been equal to an informal union. It had more of a social power and prestige, which it doesn’t have now.
            Doctors used to have a kind of social power, which has eroded as insurance companies stepped into health care. Now, with the internet, there are very few secrets left to the professions, like law and medicine.
            Less than half the doctors in this country belong to the AMA.
            If two or more doctors write a letter to an insurance company or the government, I call that collective bargaining.

          • Danny Ash

            I agree. Under any single-payer system it is inconceivable that physicians would not retain significant influence over their compensation, regardless of whether this influence were exerted through the formalized mechanism of collective bargaining or through lobbying, protest, or other channel.

          • querywoman

            Yup! Britain and Canada utilize their government as a third party payer paid for through taxes.
            I think the US system is an abominable mess, and that the wildly divergent pricing is insane.
            Yes, in socialized med, you might have to bribe to be treated first, but every system is corrupt!

          • querywoman

            Cute that you bring this up. The health insurance business is the only American business that charges wildly differing prices to different classes of people.
            This practice would be illegal in any other business.
            Research Teapot Dome!

          • Dr. Drake Ramoray

            Actually the banks largely charge differently based on income/class as well. I have notes in the past that a lot of te changes in healthcare mirror the changes of big banks. Don’t see many community banks anymore, just like you don’t see many independent doc practices anymore, for many of the same reasons. The beuracracy never favors the little guy.

          • querywoman

            You are right, like 22 percent interest as opposed to 12 percent. But, the hospitals can charge 600 percent more. Hospitals have been sued for charging the uninsured more than the insured. They are supposed to bill the uninsured an average of the contracted rates, but that may be unique to one state.
            The hospitals really don’t have a snowball’s chance in Hades of getting a huge bill out of most uninsured. So, they either get to write off a huge inflated bill or patients end up owing forever.
            In Texas, we can’t get our wages garnished for medical bills, but it happens in other states.
            I read of a very low income getting garnished over a miscarriages, which Medicaid would have covered.

          • querywoman

            Side note, banks are required to invest so much in their communities. You can request the Community Reinvestment Act or whatever at any bank.
            I did once. A lot of it goes in car loans, some in mortgages.
            Of course, it’s a miniscule section of most banking business.
            My credit unions are always trying to get me to take out a car loan, and I no longer drive.
            Car loans must be bread and butter to the credit unions.

          • Danny Ash

            Despite the supposed inadequacy of Medicare reimbursements, American physicians remain the best-paid in the world (by far) in terms of purchasing power.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Something has changed though since 1959. There is no elderly woman who can stand up today and say that she is “sure” that her son will “face a better future when his time comes to retire”. Quite the opposite.

    In just the last decade, median household wealth dropped by over 30% in this country (http://www.nytimes.com/2014/07/27/business/the-typical-household-now-worth-a-third-less.html ). The next generation and the one after that will become progressively poorer than those retiring today, unless we do something other than periodic complaining.

    If 1965 was the year when America looked back and decided to help the elderly, perhaps this is the year when we ought to look ahead and decide to help our children and their children.

    The ACA, and its rippling secondary effects are just a more efficient way to squeeze a little more money from the working middle class turnip, while throwing a few glittery but inconsequential benefits in the air, to distract the masses from business conducted as usual. Enough is enough.

    Government is where we all come together to care for each other. And if we have an ineffective and corrupt government, the solution is not to revert to survival of the fittest, which was not the original intent, and even if it was, times have changed. We need to fix this, and providing medical care to all our citizens is as good a place as any to start the process. Back in 2008, President Obama was given the mandate and the prerequisite majorities to do just that. He squandered the opportunity. We’ll just have to try again, and again, and again. There is no other option.

    • Dr. Drake Ramoray

      “And if we have an ineffective and corrupt government, the solution is not to give that government even more power over it’s citizens”

      This would be my interpretation of where we stand. I think a government run single payer system can work reasonably well. I honestly admit I don’t think the US government can run a single payer system at all.

      I’d say we could replace that government but that would probably just put me on an NSA watch list.

      I do say physicians should join the AAPS, although I believe their leanings and solutions are not what Margalit has in mind (although I do enjoy the points we agree on as well as those we disagree on). We certainly agree it does not look like my children will be better off with the direction we are heading.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Unfortunately, I don’t think we are in a position to give anything. It is being taken away, whether we like it or not.
        So let me say it for you (hello NSA), we must replace this government, and I don’t mean this or that party or person. I mean the system that allows and actively encourages them all to be corrupt and ineffective.
        If we can’t do that, we will never “fix” health care, and fixing health care will be the least of our problems. I think we can field a government that can run the financial side of health care rather well. Medicare FFS is not half bad compared to everything else we have floating around. We just don’t have the will (or foresight) to stand up to the pillaging perpetrated by corporations and financiers.

        As to AAPS, I have a hunch that as time goes on, the ultra liberal left and the libertarian right are going to have more in common than we can now imagine. Perhaps another shift in the identity of our major parties (not the first one, if you recall) is already in motion… Sooner or later the grassroots tea party will come to realize that they are poor, and the populist democrats will begin objecting to being treated like cattle… One can hope…. :-)

    • Danny Ash

      Margalit, I also found that quote poignant, and for the same reasons. Due to constraints on length I was unable to include a discussion of wealth inequality and class (im)mobility, but I hoped that the optimistic note the woman sounded would seem sufficiently dissonant against the current background to be noticed.

      I agree with all that you said. We must try again, and again, and again, until we get it right. Perhaps we can take solace in Churchill’s observation that “you can always count on Americans to do the right thing – after they’ve tried everything else.”

  • Danny Ash

    Good spotting, Dennis – in pre-Medicare parlance, hospital insurance was a subset of health insurance.

    Also, if you care to read some of the testimony from the 1959-1963 hearings of the Subcommittee on Problems of the Aged and Aging, I think you may have to surrender your assertion that “health insurance was no big deal.” The individuals I quoted in the article are only 2 of the more than 3,000 witnesses who gave testimony during the hearings. Many of them did not have health insurance or were underinsured, and this was quite a serious concern for them indeed. Then as now, many told of seeing their savings evaporate after an illness.

    Medicare has largely (but not completely) solved this problem for senior citizens, but one needs only glance at the bankruptcy statistics to see the dimensions of the problem. Last year, I think something like 70% of bankruptcies involved healthcare costs.

  • James O’Brien, M.D.

    Here’s the future of the US because of the 70 trillion unfunded debt of Medicare:

    http://www.bloomberg.com/news/2014-07-30/argentina-defaults-according-to-s-p-as-debt-meetings-continue.html

    So you Medicare Ponzi supporters can talk about how wonderful it all is, a wealth transfer program from the young and poor to the old and rich, but math doesn’t lie and national insolvency will result.

  • querywoman

    Supposedly, seniors still pay the same percentage of their incomes for medical care as before.
    Medical care gets more expensive all the time, which I’ve written about before, with rising longevity and new therapies. I’m a beneficiary of new diabetes treatment. My life would be much lower quality and much shorter without the new treatments.
    The glucometer is a wonderful invention. I recently read about the first guy who used a home glucometer. He was a Type 1 who was weak and skinny. He was able to reduce his insulin use by two-thirds with the glucometer and gain weight.
    The American government allowed an insanely varying pricing scheme to evolve in the medical arena.
    Insurance was supposed tor reduce costs and spread the risk. Instead, it’s become a game. The providers want more money, and insurance wants less.
    When we compare ourselves to countries with socialized medicine, those other countries still have insurance. It’s government insurance, and they charge taxes to everyone. It’s not direct pay. Most people will need some type of medical care. Some more, some less!

  • Danny Ash

    Dennis, as I do not find appeals to authority particularly persuasive, I read as little into your title as you read into mine ;)

    You assert that the hearings were highly choreographed, but you don’t provide any evidence. It is true that many committee hearings are staged. However, I reject your assertion in this case on the following grounds:

    1. This was not your modern Congressional hearing. The Subcommittee on Problems of the Aged and Aging collected hundreds of thousands of pages of testimony from over 3,000 witnesses. It is implausible to suggest that such a vast quantity of material could be contrived through the usual means.

    2. I have examined only a tiny fraction of the testimony offered, but what I have read gives a strong impression of spontaneity. The format seemed to be that each witness was allocated 2 minutes to say his or her piece. If additional time was left after the scheduled order, witnesses could return to the microphone for a second period, which they were often eager to do. Many of the statements given by witnesses seem to be prepared in advance, as one would expect, but the witnesses seem to cover the entire range of the political spectrum. There is none of the narrowness of views one finds among the preselected witnesses in modern political theater.

    So unless you have specific evidence to the contrary, I see no reason to accept on faith that the hearings were staged.

    I don’t dispute that the percentage of uninsured was similar across age cohorts, but we all know that medical utilization and costs increase with age. A lack of insurance coverage might not be a problem for a young woman, where it would be a serious issue for an older man.

    Medicare is not perfect. In fact, I specifically noted in my piece that “Medicare … did not completely solve the problem of healthcare finance.” A full discussion of the specific deficiencies of Medicare and the modern landscape of Medi-medi and Medigap plans was beyond the scope of this piece. Since you bring it up, I acknowledge that Medicare’s coinsurance policy is one of its most serious defects. The Medicare-for-all envisioned in HR 676 would eliminate coinsurance.

    You say that Medicare is bad, but compared to what? If you are going to take Medicare to task, you should acknowledge that its coverage is very generous by comparison with private plans. Even for those fortunate enough to have employer-provided insurance, it is increasingly common to find coinsurance, high premiums, and high deductibles, all of which profoundly undermine the ability of these policies to cushion the beneficiary from financial ruin in the event of a situation requiring acute or chronic care.

    • http://byrondennis.typepad.com/theabcsofmedicare/ Dennis Byron

      Most important, I want to address your last paragraph but first, the point of my making up a title for myself was simply to say that I am old. You are young and surely have no personal knowledge or even studied knowledge of the Truman (where I started but I am sure there even older examples), McCarthy, Kefauver, Watergate, CIA, Irancontra, Hillarycare, etc. hearings so you do not understand how the “hearings” system works. Basing your knowledge on just reading the transcripts is about as accurate intellectually as accepting the Bible literally.

      As to your statement that Medicare is “very generous” compared to private insurance, unfortunately I also question your knowledge of health insurance. That’s OK for a future doctor. I don’t expect my fire brigade to know how my homeowners policy works either. But it is an extremely ignorant statement. On average, Medicare pays less than half of a beneficiary’s health care costs. Compared to the PPACA Bronze/Silver/Gold/Platinum grading system for insurance, Medicare is a Balsa Plan. I can pretty accurately tell you that — pre PPACA — there was no employer sponsored insurance for full time employees that both had no annual out of pocket spending limit and also failed to protect you against catastrophe because of its lifetime limits. But that’s the basic description of Medicare as insurance, both of the worst two aspects any insurance could possibly have: no upside protection and high costs on the downside. (Post PPACA, both are outlawed for everyone in the country… unless you are on fee for service Medicare.)

      If you want to go down the single-payer route (I do not philosophically oppose single payer but just can’t figure out how we could pay for it), think Medicaid for All, not Medicare for All.

      • Danny Ash

        Whoah there – how about some sources, my friend? A Kaiser Foundation analysis [1] contradicts your claim that Medicare’s actuarial value is less than 50%. Their figure is 80%. The KFF compares this to a large employer PPO plan, which would have covered 86%, but of course only 57% of Americans are fortunate enough to be covered under such plans. Many Americans have no employer-provided insurance or work for smaller companies whose policies have much lower AVs. [2]

        This also means your comparison of Medicare to PPACA “metal” plans is inaccurate. HHS have defined the AVs of platinum/gold/silver/bronze plans as 90%/80%/70%/60% respectively. Using the KFF’s estimate of 80% for Medicare’s AV, Medicare is superior to bronze and silver plans, comparable to gold, and inferior only to platinum plans.

        Despite the lack of a OOP spending cap, in some cases beneficiaries with catastrophic costs will end up paying less than under private insurance due to the general prohibition on balance billing with Medicare. I have a friend who was left with an $87k hospital bill after being taken to an out-of-network hospital after a motorcycle accident. Had he been a Medicare beneficiary he would have simply paid his usual premiums plus deductible, as his hospital stay was far less than 60 days. The lack of a cap is still undesirable, and of course there are various programs to limit cost-sharing for beneficiaries unable to afford supplemental insurance. The “expanded and improved Medicare for all” under HR 676 would eliminate coinsurance and prohibit balance billing.

        I won’t respond to baseless ad hominems.

        [1] http://kff.org/health-reform/issue-brief/how-does-the-benefit-value-of-medicare/

        [2] http://kff.org/report-section/2013-summary-of-findings/

        • http://byrondennis.typepad.com/theabcsofmedicare/ Dennis Byron

          To see that Medicare beneficiaries pay more than 50% out of pocket for their health care costs on average, see any MedPAC annual databook for the last decade.I can’t imagine what you are reading into the Kaiser report you cite because its second sentence reads “For individuals ages 65 and older, the study finds that Medicare remains less generous on average than typical large employer health plans, even after recent improvements in the program’s drug coverage.”

          But it is interesting the way you keep dodging my initial question with debating tricks. Key point: If Medicare is so good, why do about 95% of the people for whom it was intended as financial protection, make other — mostly private — arrangements to provide their financial protection?

          (And if you consider being called young and “not an insurance agent” an ad-hominem attack, what can I say?)

Most Popular