Healthcare, health policy, cognitive science. , and the path to Universal Healthcare..
How Medicare Fails the Elderly – NYTimes.com:
“HERE is the dirty little secret of health care in America for the elderly, the one group we all assume has universal coverage thanks to the 1965 Medicare law: what Medicare paid for then is no longer what recipients need or want today. “
Goes on to delineate some of the problems with the Medicare payment system, that are not news if you’ve been paying attention, but always good to get it out there for further discussion.
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The Independent Payment Advisory Board — Congress’s “Good Deed” | Health Policy and Reform:
“Among the most important attributes of legislative statesmanship is self-abnegation — the willingness of legislators to abstain from meddling in matters they are poorly equipped to manage. The law creating the Federal Reserve embodied that virtue. Congress recognized the abiding temptation to use monetary policy for political ends and realized that it would, at times, prove irresistible. To save themselves from themselves, wise legislators created an organization whose funding and operations were largely beyond the reach of normal legislative controls. Short of repealing the law, Congress denied itself the power to do more than kibbitz about monetary policy.
“In establishing the Independent Payment Advisory Board (IPAB) in section 3403 of the Affordable Care Act (ACA), Congress may once again have shown such statesmanship. For several reasons, however, it is too early to be sure. The board must surmount major challenges — first to survive and then to function effectively. Harold Pollack has neatly summarized the problem, the solution, and the problem with that solution: “Every Democratic and Republican policy expert knows that we must reduce congressional micromanagement of Medicare policy. Unfortunately, every Democratic and Republican legislator knows that mechanisms such as IPAB that might do so would thereby constrain their own individual prerogatives.”1
“Medicare’s founding legislation stated that “Nothing in this title shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine.”2 Duly warned, Medicare administrators have largely forborne from using coverage policy or financial incentives to discourage ineffective or needlessly costly methods of care. Members of the legislative branch have not, however, displayed similar restraint. They have pressured those same administrators on coverage policies and passed laws to impose them.
“In the view of many observers, both executive inactivity and legislative intrusiveness have been unfortunate — the former because the leverage that the country’s largest single buyer of health care could wield to effect reforms has gone largely unused, the latter because few members of Congress are well enough informed to make such decisions wisely, and some are in thrall to campaign contributors and producers and suppliers of medical services.”
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Squandering Medicare’s Money – NYTimes.com:
“MEDICARE has suddenly taken center stage in American politics, with Democrats now trying to score an advantage from the unpopularity of the Republican plan to overhaul the government health insurance program. Apart from the politics, though, Medicare’s financing challenges are worsening: this month, Medicare’s trustees projected that the insurance program would become insolvent by 2024, five years earlier than previously estimated.
“Much has been said about the growing gap between the program’s spending and revenues — a gap that will widen as baby boomers retire — but little attention has been focused on a problem staring us in the face: Medicare spends a fortune each year on procedures that have no proven benefit and should not be covered. Examples abound:”
Go to the original piece for the rest!
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[Originally posted at Doctors for America’s Progress Notes Blog]
Andrew Sullivan’s tag line, via George Orwell, is that “It is a constant struggle to see what is past the end of one’s nose.” One of my favorite lines is from Upton Sinclair, “It is difficult to get a man to understand something if his livelihood depends upon his not understanding it.”
When I say “favorite,” I mean I like it because it says a lot about the human condition in general, and about our political struggles in particular. Unfortunately, in these times, this myopia in our world views has the potential to lead to human misery, and to continue America on the road to tragedy, as we already have passed farce. I consider myself an optimist, but recent events including our world class embarrassment of a debt ceiling “deal” have left me pessimistic for our short term prospects of reinvigorating our priorities as a nation and consequently our intermediate term prospects of leaving the nation better than we found it.
We have been at our best as a nation when we have had visionary leadership, from Teddy Roosevelt’s “Square Deal,” to Franklin Roosevelt’s “New Deal,” to LBJ’s “Great Society.” Even Eisenhower’s more mundane Interstate Highway System and JFK’s goal to put a man on the moon represent aspirational goals for America. (“We chose to do these things, and the others, not because they are easy, but precisely because they are hard!”) Now, our political will has been demeaned to the lowest common denominator: how will I keep more of my meager income for myself in the short term?
Paul Krugman, Robert Reich, and others have been banging this drum for over a decade now: investing in human capital is the way to grow the economy and keep us a great country. Many wish to continue the defunding of our societal investment in human capital: reducing investments in education and research, reducing money spent on the health of the population, demolishing our social welfare programs like Medicare, Medicaid, SCHIP and Social Security. This is short sighted and a recipe for disaster (with all the ingredients mise en place).
We now have plugged in a small group of Congress Persons in the wildly inappropriately named “Super Congress,” with the stated goal of resolving our budget stalemate. I am skeptical, to say the least, and two articles in this week’s New England Journal of Medicine reinforce my pessimism.
Jonathon Oberlander points out that “austerity politics” are now in force, and there are real potential dangers that Medicare and Medicaid funding could be cut substantially, including reduced payments to providers, reductions in federal funds for state Medicaid programs, increasing cost-sharing for enrollees, repealing the long term care insurance provisions in the ACA, and – per Paul Ryan’s plan – changing Medicare into a voucher plan.
While Oberlander doesn’t say it, I will: the “austerity politics” manufactured in Washington by power brokers with lots of money behind them are designed to take an axe to the programs that provide medical care to those who need it and prevent expansion to those who need it even more. We at DFA are all too aware of deficiencies in our current health care system and are not shy at all about pointing them out. But we also know that reforming health care requires a greater intellectual effort than unthinking cuts born out of myopic political calculations.
In the same NEJM issue, Christopher Jennings notes that many stakeholders in health care are coming to realize that there is almost no good that can come out of the work of the Super Committee. Because of the construction of the debt ceiling deal, if the Super Committee reaches no deal and the “automatic cuts” are enacted, Medicaid is exempt from cuts and Medicare would face “only” a two percent cut. As he explains, it is hard to imagine a deal crafted by the twelve that would so good to health care funding:
From the current vantage point of these stakeholders, the choice is therefore not a close call; the automatic cuts are by far the best poison to be forced to take, particularly in comparison to the concoction they fear the super committee could produce. It would meet the requirement of the law, protect against unknown and much larger cuts, and preserve resources and bargaining chips for the next big deal, which will probably take place in 2013 after the presidential election.
So, there is hope, if I ditch my own myopia and hope and pray and work for a new, better Congress in 2013, we may be able to get on the path to becoming a great country again, instead of the “dollar store” nation that so many seem to believe is our destiny!
FactCheck.org : Premium Nonsense On Medicare:
My sister-in-law sent me one of those BS right wing chain emails (they try to misinform while staying under the radar of actually informed people by sending it to their fellow in-the-Fox-bubble friends) about rising Medicare premiums because of the Affordable Care Act. Here is the original quote, in the hopes that people Googling for this nonsense will find the correct information, then the FactCheck response (the full response is at the link at the top):
The per person Medicare insurance premium will increase from the present monthly fee of $96.40, rising to: $104.20 in 2012; $120.20 in 2013; And $247.00 in 2014. These are provisions incorporated in the Obamacare legislation, purposely delayed so as not to ‘confuse’ the 2012 re-election campaigns. Send this to all seniors that you know, so they will know who’s throwing them under the bus.
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FACTCHECK.ORG
The Real Effect of the Health Care Law
That’s not to say that the health care law won’t have an effect on the premiums paid by some seniors. It will, but not in the way this bogus message claims. The change will affect only a small minority of upper-income Medicare beneficiaries.
Currently, about the top 5 percent of seniors pay an “income-related premium” that was enacted as part of the same 2003 law that created the new Medicare prescription-drug benefit. Upper-income seniors have been paying more than the standard premium since 2007. Currently those earning between $85,000 and $107,000 for individuals (between $170,000 and $214,000 for couples) pay a total of $161.50. The amounts grow larger for higher-income groups, reaching $369.10 per month for seniors making more than $214,000 (or $428,000 for couples).
The new law doesn’t increase those premiums, but does ensure that more high-earning seniors will pay them. It does this by freezing the income brackets at 2010 levels through 2019, rather than allowing them to rise with inflation as originally enacted. The Kaiser Family Foundation released a report in December projecting that in 2019 the top 14 percent of seniors would be paying the income-related premiums — an additional 3.5 million seniors.
The law also established a separate set of income-related premiums for Medicare Part D — the prescription-drug benefit — which previously had charged only a standard premium for all. Taken together, these changes are expected to bring in an additional $36 billion over 10 years, Kaiser’s study said.
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Press Releases – Press – U.S. Congress Joint Economic Committee:
A new state-by-state analysis by the U.S. Congress Joint Economic Committee (JEC) finds that in each state in the country, out-of-pocket health care costs will more than double for residents turning 65 in 2022 under the Republican budget plan passed by House Republicans in April.
The non-partisan Congressional Budget Office has estimated that a typical 65-year-old Medicare beneficiary in 2022 would see their out-of-pocket health care costs increase from $6,154 to $12,513 under the Republican budget. Using that data along with cost-sharing data from the Centers for Medicare and Medicaid Services, the JEC has estimated out-of-pocket costs on a state-by-state basis. While the increase varies by state, residents in all states will see their out-of-pocket expenses more than double when they turn 65 in 2022. Residents in Florida face the largest increase –$7,383.
The report also shows that current Medicare beneficiaries will be harmed by the GOP budget, immediately losing preventive services such as mammograms and facing higher prescription drug costs.
“This new JEC analysis helps to fill in the picture on just how disastrous and costly the Republican Medicare plan is for our older Americans,” said Senator Bob Casey (D-PA), Chairman of the JEC. “If Republicans have their way, traditional Medicare will no longer exist in 2022. Instead, our elderly will get a voucher to purchase private insurance, but the voucher won’t keep pace with health care costs. The result would be a staggering increase in out-of-pocket costs beginning in 2022. In my state of Pennsylvania, someone turning 65 in 2022 would face a $6,300 increase in their health care expenses. Our elderly Americans cannot afford to have their health care expenses double, but that’s exactly what the Republican plan delivers.”
The increased out-of-pocket costs result from older Americans bearing a larger share of health care costs under the Republican plan and the increase in total health care costs that results from shifting from traditional Medicare to a less efficient, more expensive voucher program.
“The Republican Medicare plan doesn’t rein in health care costs,” continued Casey. “Instead, it simply shifts the costs onto the backs of our elderly. The Republican ‘solution’ is providing our elderly with dramatically higher costs and less care. Current beneficiaries will suffer and the next generation will face retirement without Medicare and without the peace of mind it offers.”
“This is an important hour for the Nation, for those of our citizens who have completed their tour of duty and have moved to the sidelines. These are the days that we are trying to celebrate for them. These people are our prideful responsibility and they are entitled, among other benefits, to the best medical protection available.
“Not one of these, our citizens, should ever be abandoned to the indignity of charity. Charity is indignity when you have to have it. But we don’t want these people to have anything to do with charity and we don’t want them to have any idea of hopeless despair.”
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“Many men can make many proposals. Many men can draft many laws. But few have the piercing and humane eye which can see beyond the words to the people that they touch. Few can see past the speeches and the political battles to the doctor over there that is tending the infirm, and to the hospital that is receiving those in anguish, or feel in their heart painful wrath at the injustice which denies the miracle of healing to the old and to the poor. And fewer still have the courage to stake reputation, and position, and the effort of a lifetime upon such a cause when there are so few that share it.
“But it is just such men who illuminate the life and the history of a nation. And so, President Harry Truman, it is in tribute not to you, but to the America that you represent, that we have come here to pay our love and our respects to you today. For a country can be known by the quality of the men it honors. By praising you, and by carrying forward your dreams, we really reaffirm the greatness of America.
“It was a generation ago that Harry Truman said, and I quote him: “Millions of our citizens do not now have a full measure of opportunity to achieve and to enjoy good health. Millions do not now have protection or security against the economic effects of sickness. And the time has now arrived for action to help them attain that opportunity and to help them get that protection.”
“Well, today, Mr. President, and my fellow Americans, we are taking such action–20 years later.”
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“And through this new law, Mr. President, every citizen will be able, in his productive years when he is earning, to insure himself against the ravages of illness in his old age.”
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“I said to Senator Smathers, the whip of the Democrats in the Senate, who worked with us in the Finance Committee on this legislation–I said, the highest traditions of the medical profession are really directed to the ends that we are trying to serve. And it was only yesterday, at the request of some of my friends, I met with the leaders of the American Medical Association to seek their assistance in advancing the cause of one of the greatest professions of all–the medical profession–in helping us to maintain and to improve the health of all Americans.
“And this is not just our tradition–or the tradition of the Democratic Party–or even the tradition of the Nation. It is as old as the day it was first commanded: “Thou shalt open thine hand wide unto thy brother, to thy poor, to thy needy, in thy land.”
“And just think, Mr. President, because of this document–and the long years of struggle which so many have put into creating it–in this town, and a thousand other towns like it, there are men and women in pain who will now find ease. There are those, alone in suffering who will now hear the sound of some approaching footsteps coming to help. There are those fearing the terrible darkness of despairing poverty–despite their long years of labor and expectation–who will now look up to see the light of hope and realization.
“There just can be no satisfaction, nor any act of leadership, that gives greater satisfaction than this.”
Just looking up a little SGR history.
It was part of the 1997 Balanced Budget Act passed under Congress controlled by Republicans and Clinton signed. It was designed to save $115 billion over ten years to avoid making any other painful, politically unpopular changes to Medicare.
In 1998, all the interested parties were pushing back:
“Everybody who got a tuck and a trim in 1997 wants more money,” said Ari Fleischer, spokesman for the House Ways and Means Committee, which oversees the nation’s health care program for the elderly and disabled. “If everybody . . . gets more money, Medicare will go broke even faster.
And here we are, gearing up again…
(Trying to cross post this at Huffington Post for this piece:
http://www.huffingtonpost.com/johnny-benjamin/beware-cut-medicare-fees_b_435283.html )
Sorry, nice try.
1. The projected cost of Medicare will bankrupt the United States.
Only if we do nothing to bend the curve and reduce unnecessary procedures and increase preventive care and care coordination. I suggest you read some Gawande and then come on back here. And “This American Life”:
http://cmhmd.blogspot.com/2009/10/this-american-life-hc-reform-part-2.html
2. There remains tens of millions of US citizens that do not have adequate policies or means to pay for health care coverage.
Yet none of them are over 65.
3. The cost of adequate health care coverage for those citizens still fortunate enough to be able to pay is rising at an unsustainable rate.
See number 1.
4. Systemic waste remains.
See number 1 again.
5.Doctors are compelled to practice expensive defensive medicine due to fears of almost infinite liability and costs associated with litigation.
Really? When was the last time you saw a physician bankrupted by medical liability? That is why we have insurance. Patients, on the other hand are bankrupted routinely by health care costs.Defensive medicine varies inversely with the time you are willing to put in with the patient explaining what you are doing. The big problem with defensive medicine is that we are reimbursed well, in many cases to practice it, and rewarded very poorly for explaining why a patient does not need a CT scan or antibiotics or whatever.
I will acknowledge a frightening trend against science, however:
http://cmh
Yes, we’re all against fraud and we all SAY we are for universal access to prevent pain and suffering, but there are different views of that. For example, is going to a Remote Access Medical clinic good enough? Some would say that, yes, as long as there is a free clinic somewhere, that’s good enough. I disagree.
At the risk of starting a food fight, I think if we totally revamped what Medicare pays for (quality, not quantity; counseling over procedures), we could absorb that 20% OVER THE LONG TERM without too much trouble. When specialists make 3 or more times what a PCP makes, something is wrong with the paymenty system (I’m an intensivist, BTW).
I’ll stop there, and not take the bait on teachers. I hope you have some in your life and they read this!
Medicare Expansion Won’t Get Us There « Health Policy Blog:
A very disappointing post from the Mayo Health Policy Center:
Proposal Would Not Increase Access to Health Care Services or Control Costs
The current Medicare payment system is financially unsustainable. Any plan to expand Medicare, which is the government’s largest public plan, beyond its current scope does not solve the nation’s health care crisis, but compounds it. We need to fix Medicare by moving it to a system that pays for value – quality health outcomes that are affordable over time – and ensure its success, before bringing more people into a broken system.
Expanding this system to persons 55 to 64 years old would ultimately hurt patients by accelerating the financial ruin of hospitals and doctors across the country. A majority of Medicare providers currently suffer great financial loss under the program. Mayo Clinic alone lost $840 million last year under Medicare. As a result of these types of losses, a growing number of providers have begun to limit the number of Medicare patients in their practices. Despite these provider losses, Medicare has not curbed overall spending, especially after adjusting for benefits covered and the cost shift from Medicare to private insurance. This is clearly an unsustainable model, and one that would be disastrous for our nation’s hospitals, doctors and eventually our patients if expanded to even more beneficiaries.”
I simply have to call BS on the figure of how much money Mayo loses to Medicare. We know Mayo is one of the high performing providers and so should be doing far better.
From Ezra Klein:
On March 17th, Glenn Hackbarth, the chairman of MedPAC, testified before the House Ways and Means Committee on this very issue. Hospitals, Hackbarth argued, are inefficient. Their costs are too high. And this was backed up in the data. “MedPAC analysis has identified a set of low-cost hospitals that consistently out-perform other hospitals on a series of quality measures, including mortality and readmissions,” Hackbarth explained. “Among this set of hospitals, we found that Medicare payments on average roughly equaled the hospitals’ costs.” In less “efficient” hospitals, Medicare’s payments were below costs.
…
Among the major differences between “efficient” and “non-efficient” hospitals was that the less-efficient hospitals were not under financial pressure: They made a lot more money from other sources. As such, they spent a lot more money on things like capital expansion. As example, compare the amount a young journalist spends to the amount a young investment banker spends. The banker requires more income to break even on that lifestyle. His “cost” is higher. But he doesn’t need that lifestyle. He doesn’t need that “cost.” And if that banker is being paid on taxpayer dollars, I don’t want him to have that lifestyle. I want him to have what he needs, rather than what he wants. Because I’m paying for it.
And so too with Medicare payments. Indeed, what MedPAC found was that hospitals under “financial pressure” — hospitals that made less money, in other words — managed to control their “cost” better. Medicare’s payments sufficed for them. And their quality outcomes weren’t any worse.
This is a remarkably “retro” viewpoint from Mayo, which has taken progressive stands on cost containment, reducing over utilization of procedures and testing, chronic care management and the like. To hear them call Medicare unsustainable is surprising. While I agree that Medicare payment has to be radically changed in some areas, the only thing unsustainable is our current course!
And, regardless of what Mayo “believes” about government run entities (which they disparage in their piece), government run or strictly regulated systems consistently outperform the US system in France, Germany in many other places. The ACP Policy Committee has recognized this for years and has advocated for a single payer system like France or a hybrid system like Germany’s for many years.
And one more thing, wouldn’t you rather get paid by those expensive 55-65 year olds who don’t have insurance instead of eating it (or eating part of it, and bankrupting families)? I realize the Mayo’s catchment area has few uninsured, but consider the rest of the country in making pronouncements!
And the Mayo release has been picked up by Fox News for goodness sake! In a fair and balanced piece on Medicare expansion, of course.