Medicare: A lifeline, not a Ponzi scheme

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In an earlier post (Medicare: We need to expand it, not cut it!, July 1, 2011), I commented on the proposals from politicians such as Wisconsin representative Paul Ryan and Connecticut Senator Joseph Lieberman to limit Medicare.  I quoted economists Austin Frakt and Aaron Carroll (as cited by Paul Krugman (“Medicare saves money”, NY Times June 12, 2011), from their post on the Incidental Economist, that  “…right now Americans in their early 60s without health insurance routinely delay needed care, only to become very expensive Medicare recipients once they reach 65. This pattern would be even stronger and more destructive if Medicare eligibility were delayed.” It is a stupid idea, more designed to engender the political support of people who do not think the issue through than to practically save money.

There are other similar proposals to “fix” Medicare that fit the same pattern: they superficially seem to make sense, but are actually nonsense. One of the most popular is the idea that we exclude “wealthy” seniors from Medicare, or, at least, require them to make a significant financial contribution. This contribution could consist of premiums paid to Medicare that were tied to income (or wealth, more relevant for retired people but much harder to assess accurately) or co-payments for services, again tiered to income. This seems to make sense – why not? There are many well-to-do elderly; why should currently-working people, who are struggling to make ends meet, have to pay for their care?

One reason is that the reason that Medicare is an “entitlement” because these people have paid for it in advance by their taxes during their working lives. Some of this is from the specific Medicare deduction that comes from each of our paychecks, which supports only “Part A” (coverage for hospital care), as well as from the general income tax revenue that pays for “Part B” (doctors) and “Part D” (drugs). People pay into these plans during their working lives, and draw the benefits when they need it when they are older. This is, in principle, what “saving” is about, but it goes beyond an individual retirement plan to cover everyone. This is the nature of social insurance.

Governor Perry of Texas, a Republican candidate for the presidential nomination (perhaps, if we are lucky, soon to be former candidate), called Medicare (and Social Security, vide infra) “Ponzi schemes”. : “Perry: I think every program needs to stand the sunshine of righteous scrutiny. Whether it’s Social Security, whether it’s Medicaid, whether it’s Medicare. You’ve got $115 trillion worth of unfunded liability in those three. They’re bankrupt. They’re a Ponzi scheme.” They are not. A “Ponzi” scheme involves taking one person’s property (money), and using it to pay off previous investors, who are seeking to make money on their investments. Medicare (and Social Security) are social insurance programs where the benefit is understood to be care (in the case of Medicare) or [minimal] income (in the case of Social Security). The entire beauty of both of these programs is that they involve everyone. Thus the well-to-do as well as the poor and the people in the middle have a stake in keeping the program running and effective.

If we were to exclude certain sectors of the population from receiving benefits from either of these programs, it would undermine the collective investment that we as a society have in each other. The better off, better educated, more empowered now fight for these programs because they are beneficiaries, and results in their being in place for those who are not so privileged. It is probably this very sense of mutual interdependence that makes ideological conservatives oppose them, but such opposition is short-sighted. The reason for having social insurance programs that make us interdependent is that – we are interdependent. The society, in the US (and, arguably worldwide) requires not only healthy, educated, productive workers but also consumers who are able to purchase goods and services. Billionaires like Warren Buffett call for higher taxes on the wealthy (an idea picked up on by President Obama) because they understand that a prosperous society requires contributions from everyone. We ARE in it together.

If we were to exclude only the very wealthy from benefits under these programs (say the top 1%), it would not hurt them financially, but it would hurt the rest of us because these very powerful people would no longer have a personal stake in supporting such programs. And, of course, it would save essentially no money; the corollary of the enormous concentration of wealth in a small number of people is that there are not very many of them. Thus, if they never drew a single dollar of benefit from Medicare (or Social Security) the programs would not be any better off. In order to save money, we would have to exclude a lot of people beyond the very wealthy (10%? 20%? 30%? of the population), and this would be then excluding a large section of the population, and truly reduce support.

More recently, Jane Gross writes in the NY Times about “How Medicare fails the elderly” (October 16, 2011). Her emphasis is not on excluding people from coverage, but rather on not covering services that do not enhance, and often decrease, recipients’ quality of life. Medicare pays for many services that fall into this area, and the reason has rarely to do with the desires of the patients themselves. “Of course, some may actually want everything medical science has to offer. But overwhelmingly, I’ve concluded in a decade of studying America’s elderly, it is fee-for-service doctors and Big Pharma who stand to gain the most, and adult children, with too much emotion and too little information, driving those decisions.” Among the treatments that she notes that Medicare pays for but are usually not medically indicated (especially in the old, debilitated, and demented) are feeding tubes, many forms of surgery (particularly abdominal and joint replacement) and “tight” control of Type II diabetes. All of these treatments have high risks and rarely prolong life while significantly decreasing its quality.

Gross notes that when these complications arise patients often need long-term, very expensive (she cites costs for her mother 8 years ago of $14,000 a month!) care in nursing homes, which Medicare does NOT pay for. Medicaid will, but only after the senior has exhausted all their resources (including savings house, etc., and then only in some nursing homes which are willing to take Medicaid reimbursement, and these are often not those of highest quality). Thus, by paying for the performance of procedures that do not help, Medicare leads patients into worse quality of life at high cost.

Clearly, the motivations of the drug and device makers, hospitals and physicians and nursing homes are often (in some cases usually or always) financial, but this is not the case for the family members, who mostly want to “do the best” for their parent or relative. However, given unclear guidance by their physicians, or incorrect information from any source, they may associate “doing something” with “doing the best thing”; often “doing the best thing” is not doing “something”. If Medicare did not pay for unnecessary and potentially harmful procedures, there would be little motivation among providers to do them, and it would not only save money but more important improve the health care and preserve the dignity and quality of life of people in their last years.

There is a solution to the potential bankrupting of Medicare. One: Pay for only medically necessary and indicated services. Two: revise the Medicare fee schedule to maintain the payment for primary care services but decrease excessive payment for high cost specialty services. Three: Expand Medicare to include everyone. Then we all have a stake, right now.

Medicare: We need to expand it, not cut it!

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Medicare is big news lately. Saving Medicare, cutting Medicare, reforming Medicare. Medicare has become a part of the political right’s effort to roll back all programs that were implemented in the 20^th century to help provide any safety net for Americans. I was going to say “most vulnerable Americans”, but actually many of these are programs for all Americans. The prime examples, of course, are Medicare and Social Security, often seen as the “third rail” of American politics which cannot be touched because they are so wildly popular. They are particularly popular with those who most benefit, primarily seniors who vote in very high proportions. These “entitlements” (a word that is often used by those who oppose them as a negative, but it is not) are considered so core by their recipients that they “forget” they are government programs (as in “keep the government’s hands off my Medicare!”).

So the proposal of Paul Ryan, the chair of the House Budget Committee, to essentially privatize Medicare by giving out vouchers for recipients to purchase private insurance, was heralded as “bold” by many commentators. Perhaps it was, although Ryan himself is backing away from this “bold” stand, as are most other Republicans.  Sure, sometimes “bold” is stupid, leading a charge into impossible odds (“into the valley of death rode the 600[1], but it has the implication of “heroic”, doing the right thing even in the face of certain defeat. Ryan’s plan wasn’t heroic. It was mean and callous and another part of the effort to make sure that our national policies benefit only the wealthiest among us.

The Ryan plan is terrible because it does not ensure health care but (and only in its most positive formulation) insurance coverage – it would provide vouchers to purchase private insurance. But the vouchers won’t cover any reasonable health insurance plan (remember, all health insurance is not good health insurance), certainly nothing compared to the current benefits covered by Medicare. And as any health insurance purchaser (employer or individual) knows, the cost of health insurance keeps going up. When Medicare was passed in 1965, it was because our society finally recoiled in horror at the reality of older Americans, who had worked all their lives, finishing out those lives in sickness and indignity and bankruptcy without health coverage. That need has not changed.

But Rep. Ryan’s plan, designed to gut Medicare, isn’t the only bad one. Senator Joseph Lieberman of Connecticut has proposed raising the age of eligibility for Medicare from 65 to 67, again to save money. This plan was debunked by Paul Krugman (“Medicare saves money”, NY Times June 12, 2011), who cites the work of “… the health economists Austin Frakt and Aaron Carroll [who] document, right now Americans in their early 60s without health insurance routinely delay needed care, only to become very expensive Medicare recipients once they reach 65. This pattern would be even stronger and more destructive if Medicare eligibility were delayed. As a result, Mr. Frakt and Mr. Carroll suggest, Medicare spending might actually go up, not down, under Mr. Lieberman’s proposal.” This is exactly the point I made in the recent blog “The real face of lack of access to health care”, June 19, 2011; not covering people for a period of time doesn’t save money because those people “save up” their health problems for when they are covered, and often need more expensive care.

Needless to say, Senator Lieberman took umbrage and responded with a letter to the Times which did not effectively address any of Krugman’s criticisms. His position was supported by a letter from the Executive Vice President of America’s Health Insurance Plans, the health insurance company trade group. Krugman’s criticism was supported by all the other letter-writers, including Harvard Medical School Professor and former New England Journal of Medicine editor-in-chief Marcia Angell, MD. More recently, in the Times’ “Opinionator” blog, Notre Dame philosopher Gary Gutting (“Medicare facts and convictions”, June 22, 2011) analyzes the method of argument (rhetoric) being used by the “two” sides of the debate, Ryan’s and President Obama’s (accepting Ryan’s concept that these are the only two sides). He decides that the key difference between them is one of beliefs, not data; that is, what you believe is the right thing or the way to do things determine how the problem should be addressed, not the facts, which seem to Gutting not to be really where the disagreement lies. “We can and should argue about convictions,” he says, “but this can seldom be done fruitfully in the context of specific policy disputes.  Once we’ve pushed the debate on Medicare or any other policy matter to the point where convictions become the sole basis of disagreement, it is time to vote.”

I agree that the issue is one of convictions, or belief systems. It is about whether we want to live in a society where there is come collective social responsibility or a society in which everyone is on their own.  Republicans tend to state their convictions in the language of “big government is bad”. As an abstract concept, this can resonate with working people who are struggling to support their families and feel that their taxes are too high. But this misses the fact that only through the action of government can the collective interests of the vast majority of us begin to have any weight against the vast wealth of those who fund Ryan and his colleagues (well, for some of us there are unions, but there is a nationwide campaign, well-funded by a few billionaires such as the Koch brothers, to gut any strength they have; “exhibit one” being in Rep. Ryan’s home state of Wisconsin). The Supreme Court has been a huge enabler of this movement through its decisions in Citizens United, making corporations “people” with unlimited ability to use their money to influence the political process, and the recent Walmart sex-discrimination suit in which they have severely restricted the ability of regular people to join cause to oppose those big corporations through class-action lawsuits.

The critical flaw in all of these discussions is that the core issue for Medicare is financial: that it costs too much and those costs need to be controlled by some means – whether privatization (Ryan), increasing the age eligibility (Lieberman), finding fraud (whether real, as the organized crime groups stealing billions of dollars for completely fake claims, or inadvertent minor mistakes made by doctors and hospitals “uncovered” by bounty hunters), or some other plan. Yes, it is true that the costs of Medicare are rising, maybe too high (depends on your “convictions”), and it is likely, under its current funding mechanism, to go bankrupt. This, however, is not a problem with Medicare but rather with health-care costs overall. They are rising, in this country and all over the world, as the availability of new technologies allow us to do many more things – very expensively.

 As Krugman points out, relative to other forms of health coverage Medicare is cost-effective, with much less overhead than the private sector. Cuts to Medicare alone only limit the access of those non-high-income seniors who are dependent upon it and skirt the need to address rising medical care costs. Indeed, the ways to do that (having boards that can evaluate the evidence to permit Medicare to pay only for effective procedures; limiting insurance company and drug and device maker profit; reducing the enormous payments to the highest-income medical specialists and to many specialty hospitals) have been opposed by those same colleagues-of-Ryan who propose cutting benefits to the elderly.

Rather than raising the eligible age for Medicare, or providing vouchers to buy private insurance, the right answer, fiscally as well as morally, is to expand Medicare to include everyone. It would decrease costs as people no longer put off early diagnosis, prevention and treatment. It would allow, through a single insurer, regulation of the excessive costs addressed in the paragraph above. Sure, it would cost the government more, but most of that would be covered by the money currently going to buy private insurance, and the waste engendered by the administrative structures of providers seeking to get paid and insurers seeking to avoid paying (see A Modest Proposal: Bribe the Insurance Companies, August 23, 2009). And a rise in taxes, not for most people but for those wealthiest who saw their taxes cut in the Bush years by trillions of dollars so that now the top tier and biggest corporations pay less than 15% in taxes, way lower than the middle class.

If someone complains that they do not have enough money to feed and house their children, most of us would at least feel sorry for them. But if we then find out that the reason is because they are spending almost all of a good income on alcohol, drugs, and gambling, that sympathy pretty much disappears. As a society we have done the same thing. We have dropped tax rates, especially on profits from stocks (capital gains) and bailed out the financial industry so their titans would not lose much on their gambling debts. This has led to millions of job losses and home foreclosure – people not having enough money to feed their food and children. We need to fix it, and use that money to provide health care for our people rather than profits for the gamblers.

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[1] Tennyson, “The charge of the light brigade”, 1854.