I’ve thought long and hard about this. It makes sense even with all the risks to simply expand Medicare to cover all Americans. If you have a better idea that accomplishes all the desired goals, let’s hear it.
The current health crisis again demonstrates once again we need to do something about our healthcare system, and soon.
As I see it our primary goals should be:
1. Coverage for all Americans
2. Manage costs with the least possible third-party intervention in our health care.
3. Allow as much freedom of choice as possible.
This can best be accomplished through a public/private partnership with reasonable patient financial responsibility.
I have been enrolled in Medicare for ten years. My wife has used it many times; in-patient, outpatient, emergency room, trauma center, etc. Along with supplemental coverage, it works. If we have bills, our out-of-pocket costs are capped at $1,750 through an employer supplemental plan. Medigap plans provide more coverage.
Medicare currently covers 18% of the US population, over 60 million Americans. Currently 10,000 Americans a day enroll in Medicare. It’s hard so see a strong argument against expanding this system for all Americans.
Those of us on Medicare can use virtually any health care provider in the USA, we can enroll in private sector supplemental plans that pay some of our out of pocket costs, or we can use the Medicare Advantage option to virtually eliminate out of pocket costs in exchange for a more limited choice of health care providers.
The great majority of physicians participate in Medicare. If we happen to use the services of one of the relatively few doctors who do not accept Medicare assignment, we are protected because what they can bill is limited by law. Even if we use one of the very few doctors who has opted out of Medicare, that doesn’t mean a huge bill, it means they don’t want to file a Medicare claim. They can charge at will which the patient can determine in advance and negotiate. That’s a choice.
Medicare uses modest deductibles and co-pays. There is nothing wrong with that. Creating the illusion that health care must be free by eliminating all out of pocket costs is counterproductive. Everyone, based on their income, should expect to pay a portion of their health care bills. Such bills are no different than other bills we pay every day. A modest co-pay for an office visit does not prevent the great majority of Americans from seeing a doctor, it’s a matter of spending priorities.
While health care providers do not like Medicare reimbursement levels which are 20% or so less than private insurance (Medicaid is even less), Medicare does virtually no concurrent review or pre-approval; something doctors dislike about health insurance.
Let’s consider the positives of expanding current Medicare:
1. The quickest route to cover all Americans
2. A known system to both health care providers and Americans
3. Few limitations on when and where services can be provided or by whom.
4. A payment system in place and familiar to most health care providers.
5. Continuation of choice beyond baseline coverage
6. An ongoing optional role for health savings accounts (HSA).
7. Uniform, but regional and other factor adjusted reimbursement rates.
8. Premiums that are income based.
9. Consolidation of programs; Medicaid, CHIPS, TRICARE and VA benefits, except for those with military service-related healthcare needs, would be eliminated.
10. An ongoing role for private health insurance.
Now the issues:
1. Cost. Given there is a known system with known coverage, estimating the costs would not be that difficult. The starting point is current Medicare. Adjustments would be made reflecting the needs of all ages. Modifying the system for added benefits would come after gaining experience.
2. Paying for the system. That’s easy, a combination of payroll taxes, premiums and out of pocket costs. Employers would pay a flat 8% of payroll which is generally the average they pay today. The payroll tax percentage for workers would be less, but higher than the current Medicare tax. Premiums would remain income based as would be some out-of-pocket costs. Premiums would be based on the total cost, not just the cost of Part B.
3. How will ongoing costs be managed? This question is generally ignored, but one that we should seriously consider. Either we manage costs or we continuously raise the cost of funding the system. In my view, managing costs requires questioning and maybe limiting some health care services, it may mean doing cost benefit calculations for certain procedures, it means managing resources. How else shall we manage costs?
4. Current provider reimbursement levels are inadequate. Medicare payments to health care providers are significantly less than private insurance. It is unlikely this can continue without harming health care services. We must find a fair level between today’s market prices and Medicare. And, we must encourage health care providers to maximize efficiency to help with their profits. There is minimal incentive for that today.
5. Loss of control. Yes, there will be more federal control over the payment of healthcare, and eventually perhaps over some of the the care we receive. However, studies show there is substantial unnecessary health care. The reality is that you cannot have an affordable system without some controls. Our current system demonstrates that. Even the strategies employed by insurance companies and employers have had a limited effect. Remember, it’s not always the unit prices of healthcare services that primarily drive costs, it’s the use of those services.
6. Expansion of current Medicare covered services only implemented as costs develop. Adding dental or other new coverage must be delayed and when added, all costs must built into the funding structure immediately. However, coverage would be immediately adjusted for all age groups and obstetrics.
7. There should be a national healthcare data base for individuals for efficiency, for better care and to avoid duplication and unnecessary care. You enter the system, present your card and your medical and treatment history is instantly available to your provider.