By John Ballard
The Age Rating Game: Will Older Americans Pay More Under Health Reform? by Maggie Mahar at The Health Care Blog last week has drawn some sixty-five comments which together with the original essay now runs to well over ten thousand words. The usual spirited arguments play out (typically more about politics than health care) for anyone who enjoys that sort of thing.
So down toward the end someone got around to advancing the notion of Medicare for all, paid for by progressive taxes, a suggestion that has been made before and sounds like a good idea. Maggie's nuanced response is typically more than most readers bargain for, but thanks to years of attention to the issue she spells out the pros and cons in easy to understand language.
Yes, progressive taxes are the best way to finance health care. Ideally, when forging reform legislation, Congress would have called for a �tax� rather than a �penalty� for those who didn�t buy insurance. But for political reasons, they were afraid to use the word �tax� during the worst recession since The Great Depression.
The problem with expanding Medicare is that it is so wasteful and inefficient. The best medical research shows that 1 in 3 Medicare dollars are squandered on ineffective treatments, unnecessary tests, and over-priced drugs and devices that are no better than the older products that they are trying to replace. Because Congress has served has Medicare�s Board of Directors for all of these years, Medicare covers what lobbyists want it to cover: expensive back surgery for low back pain that back surgeons want covered (even though medical evidence show that in most cases back surgery for this particular problem does no good) PSA testing (which then leads to pricey prostate treatments which create more risks than benefits, and save very few lives�if any) that urologists want covered. (They�re still lobbying for PSA testing even though the Preventive Services Task Force has finally come out and recommended against it.)
Drug-makers want exorbitanty expensive cancer drugs covered, even though they may give the average patient onlly an extra three weeks of poor quality life. GE and other equipment makers want certain tests and treatments covered� even when there is no evidence that we�re getting value for our dollars. Academic medical centers want Medicare to pour more money into medical education even though we really don�t (and won�t) need more specialists in most areas. We need more primary care docs and nurse practioners. Meanwhie academic medical centers are throwing billions into over-build� new wings, more marble, more hotel-like amentities.
At the same time, Medicare doesn�t cover some things that it should cover: regular eye exams, for instance, hospice care that begins before the patient�s last few days, and adequate payment for palliative care that woudl encourage hospitals to hire more palliative care teams and more medical students would go into palliative care. The vast majority of people on Medicare have some form of supplemental private insurance (MediGap or Medicare Advantage) because there is so much that Medicare doesn�t cover which older patients truly need� while simultaneouslly wasting 1/3 of Medicare�s dollars on unneeded care. This is why I think it would be foolish to expand Medicare at this time.We don�t want to throw more people into a system that needs much repair. The Affordable Care Act sets out to repair Medicare by changing how we pay for care and how it is delivered, focusing on �evidence-based medicine.� Medical science�not lobbyists� should determine what we cover. Under the ACA, the Secretary of HHS has the power to lower payments for treatments that are overvalued while raising payments for treatments that are undervalued. And she doesn�t have to go through Congress� this is huge.
In additioin, if a pilot program is successful, HHS can roll it out nation wide� without going through Congress. (In the past, Congress blocked national roll-out of successful programs because they cut into someone�s income stream.) It will take time for the ACA to reform Medicare, but I�m hopeful that, by 2020, it might make sense to talk about opening up Medicare to more people.
In the meantime, non-profit insurers like Kaiser and Peugot Sound are helping to build data bases that show which treatments work for which patients. They have also made great strides in improving primary care, and in Kaiser�s case, reducing mortallities as a result of heart disease.,
Even Aetna has done better than Medicare in some areas� figuring out that it�s better to pay for more hospice care, even though patients in hospice care live longer, their care is less expensive than (and more humane than) the care they would receive in an ICU where they are undergoing futile treatments. (Unlike Congress, Aetna�s board of directors doesn�t worry about �death panels� and is not adverse to letting people the way they choose to die.)
Finally, with good IT systems, it won�t be that hard to verify who is eligible for subsidies. The Federal government has already given 5 or 6 states the funding they need to set up these systems, and they will serve as models for the verifiying eligibility in the other states.
It now looks as if the Federal govenrment will partner with most states in running the Exchanges, and most likely the Federal government will be verifying eligibility. Pollitically, it will be difficult to cut the subsidies: they�re built into the ACA, which is the law of the land. Moreover, all of the interests in the health care industry (insurers, drug-makers, hospitals) are strongly in favor of the subsidies because the subsidies will bring them more customers. I agree that we need to try to do a better job of letting low-income and middle-income know that they will be eligibe for subsidies which are, inf act, quite generous. They also need to understand that the insurance they will be buying will be much better than the insurance that most individiuals and small groups have today�it will cover the �essential benefits� �many of which are not covered today�, and there will be no co-pays or deductibles for preventive care.
The couple earning $68,000 aren�t eligible for subsidies because, if you look at income numbers, they�re upper-middle class. They earn more than median income for two people. As a practical matter, a couple who lives in New York City on $68,000 is middle-class (not uppper-middle-class) in terms of the life-style they can afford. But a couple who lives in Winston Salem, North Carolina (where my son lives) on that amount is quite affluent. (Everything from houses to wedding cakes are extraordinarily inexpensive in Winston Salem�and it�s a nice town! )
I suspect we may need to adjust the subsidies upward in some geographic areas and also raise subsidies for older Americans in states where their premiums are triple what a younger person pays.
Most importantly, we need to stop over-paying for many products and treatments. (My guess is that ultimately Medicare will begin negotiating for discounts with Pharma and device-makers, and private insurers will then demand lower prices as well). We need to stop over-paying for some specialists� services, stop over-paying hospitals for preventable errors and readmissions, and start paying bonuses to doctors who keep their patients out of hospitals!
Finally, funding reform through progressive taxes would have been cleaner and seemingly easier. But we never could have gotten reform through Congress if we tried to fund it solely through taxes.
As I have said from the beginning, reform will be a process not an event. Over the next 10 years we will continue to tweak and revise the ACA. One can only hope that American voters elect wise representatives�wiser that the majority who are in Congress today. We will get the government� and the health care system� that we deserve.