Medicare For None
"Medicare For All" is a theme promoted by advocates of a single payer system designed to extend affordable healthcare to all Americans. Less ambitious proposals include either a public option or a set of non-profit cooperatives to compete with private insurers, but healthcare reform opponents have denounced these proposals as stealth attempts designed ultimately to achieve Medicare For All.
They are mistaken. Regardless of whether a single payer system, a public option, or a non-profit cooperative arrangement is enacted, or no option at all, the most probable outcome we face is Medicare For None. An equally probable accompaniment will be a private insurance network that is affordable by none.
Despite the prevailing rhetoric, insurance reform is only one facet of a far more daunting challenge. Insurance inequities aside, healthcare itself is broken and is hurtling towards bankruptcy. The culprit is an unmanaged and chaotic system of duplicate or unnecessary facilities, tests, and procedures driven by a fee for service paradigm that encourages excess. As technology has advanced to offer an ever increasing choice of these various services, some quite expensive, healthcare costs have escalated to levels that devour more and more of our nation's total economy.
However desirable it might be to curtail unjustifiable costs imposed by private insurers, these are not responsible for the escalation. The evidence for this conclusion resides in the observation that the cost of public insurance - Medicare and Medicaid - is rising faster than overall health system costs. In small part, this disproportion reflects changing demographics, but a more important reason is that Medicare (and Medicaid in most states) are very good insurance programs that offer extensive benefits. Medicare beneficiaries thus enjoy access to a widening array of services, some useful, some useless, and some harmful - the good, the bad, and the ugly. An ineluctable principle arises from this observation - in the absence of system reform, insurance reform might make healthcare more equitable, but it will also drive it closer to economic ruin.
The sobering data can be found at
Those data, I believe, should be scrutinized, digested, and then confronted with unsparing honesty. Current reform proposals have failed that test in that they include only vague half measures and pilot programs aimed at system change, involving comparative medicine, fee for value rather than fee for service, bundling, and the like, but these are small-scale, and lack authority to mandate any needed changes. They are only a tiny step forward while the entire system is racing backward toward oblivion.
In the current debate atmosphere, reform opponents have warned seniors that they may be about to lose Medicare benefits. Reform advocates have denounced the warnings as scare tactics. It is the wrong message for advocates to send. Rather, they should be telling seniors and everyone else something very different - "Be afraid. Be very afraid."
What's sobering to me, Fred, is that rational discourse on this topic has become virtually impossible. Seems to me Obama has talked about reforming the "fee for service" approach and has run into cries of "rationing" and worse. At this point, nothing will get done and reform of any sort will be dead until the next wave appears.
August 11, 2009 3:45 PM | Reply | Permalink
I'm worried that you may be right in predicting no reform at all, but what I see happening is insurance reform that rectifies part of the problem (inequities in coverage) while exacerbating the other part (increased demand for wasteful or inefficient services). We need to fix both.
The problem goes beyond merely inefficiency, as objective analysts have pointed out. In a recent journal article, the question was raised as to the value of spending $400,000 for a cancer treatment shown to extend the patient's survival by a matter of some months, but with no change in the ultimate outcome. The data are fairly conclusive; there is indeed a survival benefit, and so the intervention is not worthless. Is it worth it for an insurer, including Medicare, to pay $400,000 per patient?
Without wandering into the more ambiguous circumstances, we can ask whether it is worth $400,000 for, let us say, an 84 year old patient to extend his or her lifetime by what might amount to a one percent or so increase. The answer would certainly be yes if resources were unlimited, but in a world of limited resources, a decision to give something to one person is inevitablly a decision to deny it to someone else. One can well argue, therefore, that $400,000 could buy a great deal more health if spent in other ways than on that 84 year old. Of course, he or she could still buy the extended lifespan out of pocket, but would not be able to ask someone else to pay for it.
As many have pointed out, this type of "rationing" - limitation of insurance coverage - is far worse and far more inequitable now than it would be under a reformed system, but it would be a denial of reality to pretend that health care can remain affordable if its costs are covered for everyone in every circumstance. As you point out, it is the political backlash from suggesting that not everyone can have everything that makes it hard to do what's necessary, with politicians excusing themselves on the grounds that at least they're making an effort.
However, as Winston Churchill once said, "It's not enough that we do our best, sometimes we have to do what's required."
August 11, 2009 5:18 PM | Reply | Permalink
Based on the Medicare Trustees own report, I would say this needs to be next on the list if it doesn't get addressed as part of this initial reform package.
It is encouraging that the president has spoken of this as being a priority and appears to be as fiscally conservative as the situation will allow.
I wish the HR 676 advocates had instead pushed for Medicare as the public option. Combine all existing public plans into one system. Call it Americare and use the love of Medicare to sell it. Offer it to the uninsured and those who don't have access to group coverage rates.
That would change all the numbers for the public system by bringing in a whole new set of experience data. Combine that with the fixes from the other reforms of the private health insurance system and medical providers and this package could have been very complete with very little resistance.
I have to believe someone thought of this idea. I just don't understand why they wouldn't pursue it as a way of closing the left-right divide on this issue almost immediately.
August 11, 2009 5:22 PM | Reply | Permalink
Could this have anything to do with the fact that Medicare and Medicaid patients are older and sicker THAN EVERYONE ELSE IN THE ENTIRE EFFING USA? Sorry for the all caps, but I just get all riled up when you pretend that all groups are the same. The only time when we will get to all risk groups equal is with Single Payer.
Fred. Please don't respond to the single - payer thing. You and your minions have already won. In fact, I'm happy for you not ro respond at all; it is preferable to you professorial, "I am so much smarter than you" answer. Especially since I don't accept the basic premise.
August 12, 2009 9:16 PM | Reply | Permalink
No, it is not primarily related to the fact that Medicare patients are older and sicker. They have always been older and sicker, and so that can't explain the disproportionate rate at which costs are rising. A more important reason is that Medicare/Medicaid are good insurance programs that cover a wide array of benefits (although there has been some recent retrenchment). Because what they cover includes not only valuable services, but also all the excessive, duplicative, and wasteful services, their coverage results in very large expenditures.
One of the whole points of emphasizing the need for healthcare reform as well as insurance reform is that insurance reform will increase demands on the system, and hence expenditures, by extending the number of individuals covered. This will actually accelerate the collapse of American healthcare unless the waste is dramatically curtailed.
In that sense, health insurance reform alone is not only inadequate, but dangerous.
August 13, 2009 11:35 AM | Reply | Permalink
The costs are rising because these are the only programs that reliably pay!
August 13, 2009 11:37 AM | Reply | Permalink
Absolutely, TheraP. Private insurers can mitigate rising costs by reducing benefits and cherry-picking subscribers. Medicare has refrained from the former and is prohibited from the latter. Very recently, Medicare seems to be cutting back on some of its coverage as well in the face of the looming bankruptcy threat.
My point about Medicare/Medicaid was not so much that their costs have been rising at disproportionate rates, but rather that skyrocketing costs for medical care as a whole can't simply be dismissed as the fault of the private health insurance industry.
August 13, 2009 1:43 PM | Reply | Permalink