Sunday, October 4, 2009

Seniors and Medicare: Beware not simply "Scare Mongers" but lying hypocrites

Old age, at whatever chronologic age it happens to one, is not an easy time. The body loses its resilience, often strength, and resistance to disease. Seniors account for the bulk of medical spending because chronic disease is so much more common. It is a time of vulnerability, both physical and socioeconomic; most seniors are living on fixed incomes and, after children, they are the demographic group most likely to be living in poverty. So it is quite understandable that many seniors would be worried about threats to the few things that they feel that they can count on to support their lives, especially Medicare and Social Security. It is also understandable, and completely unconscionable, that reactionary politicians and blowhards in the media would play upon those fears for their own political ends, which are usually about supporting the greater amassment of wealth for the already rich and powerful.

We already know about “death panels”. Hopefully, most people know, by now, that they do not exist, they never existed, and nobody was proposing that they exist. It was a falsehood made up of whole cloth, an insidious perversion of the idea that our government (which supports most of the research as well as much of the care already) support research into what medical interventions work and what don’t, and assess the cost:benefit ratio for those procedures. All of us, seniors and non-seniors alike, want to have what will benefit us, and do not want, particularly when we are most vulnerable, interventions that will not help and only cause discomfort, false hope, and cost us money besides.

I, along with many others, have made fun of the comment, unfortunately often heard, “Keep the government’s hands off my Medicare!” This seems like a joke – doesn’t everyone know that Medicare is a government program? But I guess not. Medicare, in 1965, and Social Security, in the 1930s, were progressive programs that have become the most valued and hallowed institutions in our society. They help to ease the pain and insecurity of old age. And – and let me be absolutely clear on this – they were completely opposed, in the 1930s and 1960s, by the political ancestors of those who are opposing government health reform now.

Let me say this again. The McConnells, McCains, Grassleys, Boehners, and Cantors, the Limbaughs, O’Reillys, Becks, and Hannitys, the AMA and the AHA and manufacturers’ associations of those periods, absolutely opposed the government intervention that created Social Security and Medicare. Their ideological heirs today are charlatans, liars and cheats to pretend that they are defending it now.

The latest scare tactic is to imply that those receiving Medicare would have their coverage watered down because all these other people would now be covered. To even imply this is an immoral and egregious crime. The best system, as I have often advocated, is Medicare for All. The additional money it would cost would not be equivalent to multiplying the percent now receiving Medicare by everyone else, because those receiving Medicare, the aged, blind and disabled, are the population already requiring the most care. The savings, not simply on insurance company profits but on the huge administrative infrastructure both insurers and providers have to protect those profits, would be enormous. Even in the tepid, inadequate reforms being proposed by the Senate Finance Committee, the additional funds appropriated would address this need. Medicare recipients would not lose quality care; savings being proposed are those that would come from no longer paying for worthless but expensive procedures, and from eliminating Medicare fraud.[1]

Nonetheless, unsigned and unattributed inflammatory emails continue to arise unsolicited, as this one recently forwarded by a friend:

Subject: Info For Seniors

Congress vote themselves cost of living adjustments (hefty ones at that)....what's wrong with this picture?

For the first time in history, Congress will not allow an increase in
the social security COLA (cost of living adjustment). In fact, the
Henry J. Kaiser Family Foundation predicts there may not be any COLA
for the next three years. However, the per person monthly Medicare
insurance premium will be increased from the 2009 premium of $96.40 to
$104.20 in 2010 and to $ 120.20 for the year 2011.

Let's send this to all seniors that you know. Remind them not to vote
for the incumbent senators and congressmen in the 2010 and the 2012

Sounds pretty bad. But I strongly recommend looking at the actual website of the Kaiser foundation, which has a superb paper on the topic,

The reason there will be no cost of living adjustment (COLA) for 2 (not 3) years is that the Consumer Price Index (CPI), to which it is tied, went down. Remember the recession? Part B Medicare payments (this is what pays doctors, and is paid by individuals, not the Medicare trust fund; the latter, to which we contribute from every paycheck, funds only Part A, hospital costs) will still go up, because medical costs rose despite the recession.

75% of Medicare recipients will not see an increase in their Part B payments because the law contains a "hold harmless" provision that prevents the total from decreasing from one year to the next. That is, it prevents the increase in payment for Part B from exceeding the increase in income from Social Security. Of the other 25% of Medicare recipients, 17% are "dual-eligibles" who also get Medicaid because they are poor; their Part B premiums go up, but Medicaid already pays them and will continue to do so. 3% are folks who just retired this year and thus aren’t covered by the “hold harmless” provision because they payments can’t "go down" (they are receiving SS for the first time). The last 5% are higher income seniors -- those with a modified adjusted growth income of $85,000 for individuals and $170,000 for couples who are (absolutely correctly in my opinion) presumed to be able to pick up the few extra dollars a month. (Part D, the drug program, is not covered by the Hold Harmless Provision, so its premiums will go up.)[2]

Another target has been cuts to the Medicare Advantage (formerly Medicare-Plus-Choice) program (which is Medicare Part C.) I have criticized this program as one more give-away to the insurance companies in a previous blog. To understand the issue here, you need to understand the difference between fee-for-service and capitation (as in HMOs). In fee-for-service care, which is what most insured people, as well as most Medicare recipients have, providers (doctors, hospitals, equipment providers) are paid per-service or per-item. In an HMO, the provider (the HMO) receives money in advance and then provides all covered care to the beneficiary. Medicare Advantage plans have the same plusses and minuses as other HMOs – which is to say that they vary tremendously by HMO. Most provide (relatively low cost, but valued) “extra” services, such as glasses and hearing aids. They may or may not provide the actual services that one needs when one is sick. Remember – they already have the money, and anything they spend on you is loss of profit (the “medical loss ratio”). Unsurprisingly, the HMOs (and Medicare Advantage) programs that are owned by for-profit insurance companies are usually meaner (in the sense of “cheaper” and well as the more common definition) than are the few remaining “consumer cooperatives” such as Group Health of Puget Sound and HIP in NYC, or Kaiser Permanente (somewhat different in that it was initially founded by a corporation for its employees). Some recipients of Medicare Advantage are angry that it may be cut back, but the fact is that most of these programs restrict access to care more than traditional Medicare. Both of these points of view are expressed in letters to the editor of the New York Times, Sept 30, 2009; I commend especially the data-driven, rather than solely opinion, letters of Barbara Kennelly and Samuel Brooks.

These letters are in response to a New York Times editorial (“Medicare Scare Mongering”, Sept 27, 2009), which, among other things, calls for changes in this program. Acknowledging the extra benefits that Medicare Advantage offers, it correctly points out that it is unfair and unreasonable for Medicare to pay more to these insurers than it pays for other recipients. Some Medicare recipients pay additional money out of their own pockets to be covered by an HMO; this is their choice and if it is a good HMO, may well be a wise decision. But it is wrong for Medicare to subsidize, as it has, the insurance company providers by paying more for Medicare Part C (most of which goes to profit, not patient care, or, excuse me, “medical loss”!), and the Times is correct to call for such change.

The original Social Security, as we all know, was championed and pushed through by President Franklin D. Roosevelt -- against the opposition of conservatives who called him a “socialist”. All seniors, and all of the rest of us who will hopefully become seniors, owe him thanks. The following words are carved on his memorial:


We need to keep these words in mind, live by them and make policy by them. We must resolutely oppose those in Congress or the private sector whose goal is to “add more to the abundance of those who have much”, often because those who have much share some of it with them, especially when they deviously seek to achieve their ends through vicious scare tactics. They are immoral and wrong.

[1] As I have indicated, I believe that the government way overstates Medicare “fraud”. The regulations are complex and ever-changing, and the vast majority of this is not fraud at all, but simple mistakes. One can liken this to the IRS. But I am certain that there is some true Medicare fraud, just as there is income tax fraud.
[2] Also note that it is fine to call for voting out those in Congress, but, but the ones who voted this in are largely dead, as the linking of SS and Medicare to the CPI was done in 1973.

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