Medicare for (what do you mean…)

Austin Frakt and Aaron Carroll at the New York Times Upshot lay out the ten different Medicare for (SOMETHING) plans that are floating out there. They illuminate the trade-offs. They show the choices that the different plans are making.

And then they bring in an expert panel of some of the best health policy and health economic voices to bring some more insight to the challenges. Finally, and best of all, they ask you for your opinions on the major choices.

Below is my preference set as compared to the Medicare for (Something) plans out there.  My big priority is universal coverage.  Everything else is a detail in my mind.  Different values and different judgement will produce different results.






101 replies
  1. 1
    JPL says:

    In a perfect world I’d like to see a medicare buy-in (public option) with the ability to have the supplemental paid for by employers or employees. I think there needs to be a slow but steady approach, i.e. open the door to under 34 first, because that could strengthen the existing program.
    Now I’m hoping to find out why approach is just bull, so weigh in.

  2. 2
    Princess says:

    Has Bernie said yet whether his plan will cover women’s reproductive health? Because I am betting it will not, based on the candidates he has been willing to endorse. And that’s not called Medicare for All, it’s called Medicare for Men.

  3. 3
    John S. says:

    It’s easy for Wilmer to shoot the moon and be in favor of all kinds of things that he has shown no ability to move legislatively, or any willingness to actually work with the party he caucuses with to get it done.

  4. 4
    HinTN says:

    I agree that universal coverage has to be the primary agenda item. Just as with the Military Industrial Complex, the Medical Insurance Complex is too inextricably baked into our socio-economic structures to just pull the plug. I’d like to hear a countervailing argument but I think for profit medicine and insurance have to be very slowly withdrawn from the public square or there will be chaos.

  5. 5
    JaySinWA says:

    The yellow box in the expert consensus row to end individual markets is a minus sign to indicate lack of consensus. I first thought it was itty bitty text and had to go to the article to find the answer. Probably due to lack of coffee.
    It is remarkable how much the expert consensus is tempered by a perception of the limits of politics. Thus the expert consensus is not so much what they think is the right thing, but the best they think the politics will allow.

  6. 6
    Procopius says:

    @JPL: I think it’s New Mexico that has a bill before their legislature now allowing people to buy in to Medicaid. I think that sounds like a good beginning. I’ve felt for some time that creating some kind of buy-in scheme first would be helpful. I’ve also seen comments that Medicaid is better suited for this than Medicare, but I’m amazed, looking at the graphic, that Bernie is the only one who does away with “cost sharing,” AKA co-pays, AKA paying more for what your insurance was supposed to cover. Whatever scheme is finally settled on it must lead to the elimination of all co-pays. What I want to see is a system where, when you are sick, you go to a place that provides medical care and a doctor examines you and provides whatever treatment you need, and you leave. And you don’t get a bill two weeks later. Everyone. No asking for a membership card or proof of citizenship. The way I’ve been told it used to be in England before the Tories demanded austerity and started cutting the National Health Service.

  7. 7
    HinTN says:

    @Procopius: Ah yes, austerity for thee but not for me. The modern conservative mantra.

  8. 8
    eclare says:

    @Procopius: When I worked in London in 1996, I fell and hurt my leg. Just made it to the nearest hospital. Admin asked my name, address, religion (I guess if I died?). In and out in under three hours.

  9. 9
    Paganbaby says:

    @Princess: Universal coverage means universal coverage for all with ANY medical need. The comment to the contrary is specious and unsubstantiated.

  10. 10
    Betty Cracker says:

    @HinTN: There’s already chaos. Millions live with acute anxiety about being a happenstance away from losing everything they’ve worked for if they have to be hospitalized. Untold numbers of people have died in the richest country in the world because they’re afraid to bankrupt themselves or their families by seeking needed medical treatment. You know this, of course — don’t mean to pick on you. It just seems like sometimes we lose sight of the horrible current reality in our understandable caution about disrupting the existing system.

  11. 11
    burnspbesq says:

    @Procopius:

    What I want to see is a system where, when you are sick, you go to a place that provides medical care and a doctor examines you and provides whatever treatment you need, and you leave. And you don’t get a bill two weeks later. Everyone. No asking for a membership card or proof of citizenship.

    And your funding mechanism is …?

  12. 12
    Nicole says:

    @burnspbesq:

    And your funding mechanism is …?

    Higher taxes, obv. The problem is that Americans separate money into “taxes” and “everything else,” instead of “money in” and “money out.” National health care would ultimately cost the average American less, but since it would be paid through taxes, and Americans are wired to hate taxes above all else, it’ll be just about impossible to get the Average American™ to understand.

  13. 13
    daveNYC says:

    @Procopius: Czech Republic has some cost sharing. Cost me less then $10 for an ambulance ride, ultrasound, crutches (that I get to keep), and some drugs when I tore my calf. The cost sharing that my plan in the US had could have run me a month’s rent for the same.

    Universal coverage doesn’t mean anything if you still can’t afford to pay for the care.

  14. 14
  15. 15
    JaySinWA says:

    @daveNYC: Low cost sharing schemes rarely collect more than the cost of administering them. I believe they are an attempt to limit overuse of medical care, on assumptions that free care would be abused by a large enough group that a small barrier to service can stop.
    I don’t know if there is sufficient public information to support the theory. I suspect it is as valid as the theory of wide spread in person voter fraud. There are implicit costs in getting medical care in lost time from work or other more pleasant activities.
    Abuse of care (drug seeking for example) might be better regulated by medical records and intervention than copays.

  16. 16
    Barbara says:

    Medicaid has almost no copays. In my view, copays are okay above a certain income level because “no pay” really does induce unnecessary utilization, or utilization of more expensive stuff. I think by and large people were okay with cost sharing levels before the emergence of high deductible plans, which have significantly undercut the value of being insured for many people.

    In addition to HDHPs, balance billing for out of network providers has imposed a lot of pain, either on individuals or their payers. Here, I think there really is potential for consumer protection laws similar to what Medicare and Medicaid have had in place, although probably not quite as draconian. This would also promote better payer networks because providers would have less of an incentive to adopt a business model that leverage out of network status to charge significantly higher rates.

  17. 17
    FlipYrWhig says:

    I don’t think I have ever seen any variation on my pet idea for reforming healthcare, which would be this: have the federal government take over the role of providing primary care to everyone. I would also suggest that in the name of public health there should be much cheaper and much less elitist training to become a healthcare provider of any sort. If the Army can make soldiers out of any able-bodied person, some agency should be able to make healthcare providers the same way. Then after however many years of training and service you can become a specialist in something and perhaps make your career more lucrative. Boom, access is solved.

    Of course I have no idea how much this would cost.

  18. 18
    tobie says:

    Kay asked yesterday whether providers would accept the Medicare pay scale or in the long run choose other professions. The question reminded me that we look at many things from the consumer angle — how.much does healthcare cost me — but pay less attention to the cost drivers. I don’t get why every aspect of healthcare from blood work to x-rays to aspirin in the hospital to a walker is so expensive. A fee for service system can’t be the only driver. Or am I completely off the mark?

  19. 19
    FlipYrWhig says:

    @Nicole: Good point. I have no idea how to combat American tax-phobia.

  20. 20
    Ohio Mom says:

    I just heard my heart throb Sherrod Brown has proposed a Medicare buy-in plan for people 50 and older. But maybe that was after this chart was pulled together.

  21. 21
    Barbara says:

    @JaySinWA: There is no point in speculating, because there is a lot of research on cost sharing and utilization of medical care. When it’s free the use of it goes up, regardless of whether you think the average person has better uses for their time and energy. CMS even has a a term for it: “induced utilization.” The problem with medical care in particular is that individuals often don’t decide on the level of utilization. Doctors and hospitals will order more or convince people they need more when they know they won’t face financial consequences. So the perfect system is one where patients don’t pay, but providers are penalized for inefficient utilization. That’s the theory behind capitated providers, which is to say, they get paid per person and so have an incentive not to overdo it. Unfortunately, they might have an incentive to do less than they should, and there are lots of other issues with providers taking risk.

  22. 22
    BC in Illinois says:

    @Nicole:
    Yes:

    National health care would ultimately cost the average American less, but since it would be paid through taxes, and Americans are wired to hate taxes above all else, it’ll be just about impossible to get the Average American™ to understand.

    Someone once made a presentation saying that our goal should be to reduce American taxes to the level of France or Sweden. And after people said, “wait, what?” he showed that, while the people of Europe pay, in one sense, higher taxes than we do, they get healthcare, college, and a number of other things from those taxes.

    When you add up what a US taxpayer pays in taxes, tuition, healthcare, etc — often with crappy results — and then compare that to what someone in France and Sweden pays, they have the better deal. It’s not automatic, you have to work to make the system work . . . but on the other hand, no one in a nation with universal health care is looking at the US and saying, “We ought to do what they’re doing.”

  23. 23

    @FlipYrWhig: Most Americans apparently have no problem with taxing the people who have money. The problem is the people with money are in charge.

  24. 24
    Barbara says:

    @tobie: Here is what I tell people: Yes, we pay more on a unit cost basis than anyone else in the world including rich countries. That will need to change. However, it doesn’t need to be as big of a shock that it might be because one of the other big problems with the way we do things is that there is so much “robbing Peter to pay Paul” that we don’t even really know how much stuff costs, or whether Medicare is underpaying or commercial insurance is overpaying, and there are a lot of costs that are simply attributable to the level of friction in the system of having to run through so many hoops for so many different payment programs. Think of every program as a river that requires you to get in your craft and row or paddle in order to navigate the rules and the complexities, some of which are like five class rapids. There are many systems that can work, but the most important step is to start placing everyone, or at least the non-elderly, in the same river. So if it’s Medicare (which I don’t favor for reasons I have articulated in the past) and the payscale is too low, we can correct for it, but we would need to correct for it honestly, rather than by assuming that providers will raise rates to someone else.

  25. 25
    satby says:

    @BC in Illinois: I try to tell people that often. They don’t believe it. If they did we’d see some massive change in this country, for sure.

  26. 26

    @Princess: The last time I read through the Sanders bill, it fully repealed Hyde and was good on women’s health issues as far as I can tell.

  27. 27
    eclare says:

    @Dorothy A. Winsor: Very well put.

  28. 28
    Kathleen says:

    @HinTN: Yes. And provider contracts/compensation must be cared for in such a way to ensure patients will have providers. I have Medicare Advantage plan but many providers won’t accept Medicare patients.

  29. 29
    JPL says:

    @Procopius: Thank you and other for the comments.

  30. 30
    daveNYC says:

    @JaySinWA: There was an article a while ago about Australia’s implementation of fees for medical service. The problem they were having was that retired folks would head into the doctor for anything and everything, mostly because it got them out of the house or something I guess. So they started charging a really minor fee, $5 I think, and the problem basically went away.

    My key point is that Universal Coverage is a great goal, but also effectively empty of meaning. You could mandate that everyone in the US gets health insurance via the government or private industry or whatever, but if that insurance is has 10% co-insurance with a $10,000 deductible then there’s a large chunk of the population that effectively don’t have coverage because they can’t actually afford to use it unless they’re hit by a bus or something.

  31. 31
    satby says:

    @Princess: this.
    @John S.: and this
    @Betty Cracker: and most especially this.

  32. 32
    JaySinWA says:

    @Barbara: My experience is with a largely capitated system, so “induced utilization” by providers is not much of an issue for me. Defensive medicine was probably more of a problem, along with increased induced demand from advertising.
    Sure, reducing cost will increase utilization. Some but not all will be excess utilization, so the question is are co-pays the most effective way of regulating usage without damaging patient care.

  33. 33
    eclare says:

    @daveNYC: Exactly. For a while I paid $400 per month for a plan with around a $5,600 deductible. That’s around $10,000 out of pocket if you have bad luck/chronic conditions.

  34. 34
    ALF says:

    Interesting stuff! Good to know the details of various plans.

  35. 35
    Barbara says:

    @JaySinWA: If you have spent most of your time in a capitated system your experience isn’t typical. But I think you also need to consider that many sick and retired people actually do like going to the doctor.

  36. 36
    StringOnAStick says:

    @JaySinWA: I have a friend from Poland and this is her fear too because she’s watching her MIL who still lives there using the local doctors office as her biweekly social outlet, demanding appointments constantly. My response is there needs to be a social worker staffed system that people like this can be diverted into, with lower cost treatment provided for what are mental and social issues, not necessarily medical ones.

  37. 37
    low-tech cyclist says:

    I’d be satisfied with any system that was:

    a) universal,
    b) is simple to use: doesn’t come with complicated choices, burdensome paperwork, hoops to jump through (e.g. work requirements),
    c) subsidizes poor and lower-income people as the ACA does now, and
    d) total annual cost to any family doesn’t exceed 10% of after-tax income.

    Make it happen any which way, and call it whatever. I’ll vote for it.

  38. 38
    Barbara says:

    @StringOnAStick: This is why a lot of elderly people resist using the “convenience” of mail service pharmacies. At some point in your life, convenience means isolation.

  39. 39
    PST says:

    @Kathleen:

    I have Medicare Advantage plan but many providers won’t accept Medicare patients.

    I think that is a Medicare Advantage problem only. That involves a private insurer who negotiates contracts with providers, so some are in network and some are not. My experience with original Medicare is that practically everyone but the occasional “concierge” practice takes it.

  40. 40

    Stupid experts, what do they know?

    This and climate change are my two main issues. All I’m looking for in either is for a candidate to have a plan that’s at least somewhat realistic. My bar is low enough that I’m looking for a candidate who at least acknowledges that a plan has, like, trade-offs, and costs money. When it comes time to actually legislate, I mostly agree with @low-tech cyclist about outcomes.

    From what I’ve seen on Twitter, “free at point of use” is becoming a new purity test for these plans.

  41. 41
    JaySinWA says:

    @StringOnAStick: Social isolation is a significant health determinant. I’m seeing attempts to address it in my medical plan. It’s not fully functional yet, and may never be, but it is an attempt.

  42. 42

    @JaySinWA: I live in an over-55 community, and they try to make it easy for people to socialize. There’s free coffee in the cafe, for instance. At the last town hall, someone suggested other coffee machines be placed around the complex, but the person running the meeting said they had it in a central location so promote socializing.

  43. 43
    Villago Delenda Est says:

    Wilmer’s proposals aren’t plans; they’re ambitions, at best. He hasn’t the slightest clue how these will be implemented.

    All hat, no cattle. That’s our Wilmer.

  44. 44
    Villago Delenda Est says:

    @low-tech cyclist: Simple to use is VERY important. One of the most frustrating things about US health care is the endless array of hoops that are placed in front of a patient.

  45. 45
    JaySinWA says:

    @Dorothy A. Winsor: I am largely asocial, and will find it hard to adjust when the time comes. People have conflicting world views when it comes to aging, move to a more age friendly environment or facilitate aging in place. Aging in place is attractive in some ways but debilitating in others.

  46. 46

    @JaySinWA: We decided we needed to be closer to our only child because, based on our experiences with our own parents, living 5 hours away wasn’t fair to him. We didn’t want to buy another house. So here we are.

  47. 47
    Jane2 says:

    @burnspbesq: It’s funded by taxes. Having said that, universal health coverage has to be rationed in some manner to make it affordable with those tax dollars. It’s my understanding that Medicare as it is now is unrationed, i.e., everything is covered. I’ve had experience with the Canadian and British systems – both have limits on coverage, and there is room for (very profitable) private supplemental coverage.

  48. 48
    JaySinWA says:

    @Barbara:

    If you have spent most of your time in a capitated system your experience isn’t typical

    Given that it is now a Kaiser system, it is not entirely atypical. We are talking about the realm of the possible, not strictly the status quo.

  49. 49
    Yarrow says:

    @JaySinWA: Things like “Silver Sneakers” programs at YMCAs are part of getting older people socializing. Some medical plans subsidize the costs for older folks.

    @Dorothy A. Winsor: This is typical for retirement communities. They have lots of activities but they also push socializing as part of their wellness. Or they should. Isolation in the older population is a big health risk. As people age the ability to be mobile can decrease and that can mean they can’t get out to their regular activities and end up dropping them. Little by little they become isolated and no one checks on them because they’re not expected anywhere.

  50. 50
    Jane2 says:

    @JaySinWA: The British NHS is implementing policies to combat social isolation, i.e. prescribing activities and covering the costs under health care. For many of us, it would be an attractive alternative to playing bingo in a seniors’ complex.

  51. 51
    Barbara says:

    @Dorothy A. Winsor: I live in a densely populated walkable suburb (not all neighborhoods are equal). Anytime I visit a Starbucks or McDonald’s there is a contingent of retirees hanging out. My dad used to go to Dunkin Donuts every day and hang out. All the employees knew him. Even though my mother was much more outgoing than he was, after her sisters died, she hardly ever ventured out, basically only for doctors’ appointments and grocery shopping. So setting aside real debilities that require you to move to a more supportive environment, it doesn’t take much time out of the house to prevent social isolation, but it does require some effort.

  52. 52
    Barbara says:

    @JaySinWA: Absolutely. But Kaiser is only typical in certain geographies. It should be typical in more because it has so many advantages, but that’s just a whole different subject.

  53. 53
    e julius drivingstorm says:

    Nowadays it seems everybody signs up for Medicare Part B at 65 yrs old, and almost all of those also for Part D. So that’s $135.50 per month for B and let’s say $27.00 per month for D for a nice round monthly premium of $162.50. This scheme pays roughly 80% of the bill less the $185.00 annual Part B deductible and whatever convoluted shifting plane associative out of pocket expenses incurred for the drugs in Part D. Now everybody of all ages buys both pro rata. Let’s see 162.50 divided by 65 equals $2.50. So an infant pays that much per month, a one-yr-old pays 5 bucks, a 2-yr-old $7.50 etc,…a 19-yr-old $50…at 39 you pay 100 and at 59 years old you pay 150 bucks a month. Somebody run the numbers and see how much money we got and get back to me.

    Maybe we can’t pay 80% for each age group but remember, we eliminate all that clerical legal and insurance related administrative costs that cause us to blow about 30% of our revenue on bean counters instead of the 1.5% estimated for Medicare to run.

  54. 54
    Barbara says:

    @e julius drivingstorm: How about you run the numbers and stop expecting everyone to prove your best case scenario for you.

  55. 55

    @Jane2: Medicare covers 80% of expenses. Most people buy a supplementary policy. Mine is a United Health Care policy through AARP. And of course, drug coverage costs extra. Mine has deductibles.:

    ETA: Medicare does cover some things completely, annual exam for instance.

  56. 56
    Juice Box says:

    I’m a retired primary care physician. I used to see patients who had lost insurance for $0-20 depending on their situations. They used to come in frequently, mostly to socialize. It was noticeable.

    @FlipYrWhig: Primary care is actually pretty tough. You do waste a lot of time on routine tasks like filling out forms and performing “annual physicals”, but there are a lot of complex tasks as well. Rather than giving primary care tasks to relatively untrained people, it makes more sense to increase primary care training and simplify specialty training more like the European model of training.

  57. 57
    Kelly says:

    We pay for the Fire Department entirely with taxes. The Fire Department does not send a bill after an incident. Republicans do not question this. This is how I want health care to work.

  58. 58

    @Jane2:

    It’s funded by taxes.

    Such as? These details are extremely important. ETA to me.

  59. 59
    Barbara says:

    @Kelly: Do you really not see the difference between the two in complexity of services and incidence of need?

  60. 60
    JaySinWA says:

    @Yarrow: The Medicare Advantage plan portion of my health system has had Silver Sneakers (now replaced by another plan because of issues) as well as a pioneering plan that was part of research projects in exercise as part of physical and mental health. They have new initiatives (largely around complex case management, I believe) that try to address social issues as well

  61. 61

    I had a heart attack in August, and I have to say I’m very happy with my Medicare plus AARP supplement coverage. My drug coverage not so much.

  62. 62
    Barbara says:

    @Dorothy A. Winsor: Just FYI, if you have original Medicare plus a Medicare Supplement plus Part D, over the last five years or so, the standalone Part D plans have become noticeably skimpier than the integrated MAPD plans, mostly because they are not integrated with a provider network and the plan has fewer levers to temper utilization of more expensive drugs. You might look for a different plan, although you might have missed the deadline for this year.

  63. 63
    r€nato says:

    here is a radical idea. Government should manufacture insulin and distribute at cost and free to those below a certain income level. There is NO GOOD REASON for Big Pharma and its shareholders to profit from the sale of this vital medicine. BP did no research and development into insulin that could justify any argument that somehow the feds are expropriating private property. Besides, eminent domain will be and has been used to build the border wall/fence/slats. It’s been used to seize private lands for Keystone XL (which mainly would benefit a foreign corporation). Nobody with diabetes should be having to choose between insulin and the rent/mortgage/groceries.

  64. 64
    Villago Delenda Est says:

    @Major Major Major Major: Drive the Kochs, DeVoses, Mercers into penury. They’re all parasites.

  65. 65
    Another Scott says:

    @Kelly: I agree with your point, but lots of places now charge for fire department ambulances. IIRC, ~ $500 charges are not uncommon.

    Nickel-and-diming people rather than raising taxes on those who can afford it (and who have overwhelmingly benefitted from the last nearly 4 decades of “cutting taxes”) is a crime.

    Cheers,
    Scott.

  66. 66
    Yarrow says:

    @Kelly:

    The Fire Department does not send a bill after an incident.

    They do when their EMTs and their ambulance take you to the emergency room. That probably varies by city, county and state, but it’s certainly done.

  67. 67
    Kelly says:

    @Barbara: Yes, I do see the difference and should note the prevalence of volunteer firefighters and EMTs. The similarity with a fire is the way an overwhelming problem can hit with no warning.

  68. 68
    gene108 says:

    @John S.:

    It’s easy for Wilmer to shoot the moon and be in favor of all kinds of things that he has shown no ability to move legislatively, or any willingness to actually work with the party he caucuses with to get it done.

    More importantly, how much will our taxes would go up, in order to pay for his socialist utopia.

    As well ancillary issues such as how to get jobs for the thousands of insurance industry employees, who will be out of work, medical billing specialists at doctor’s offices, and will providers cut back services, as Medicare pays less than private insurance, and thus their overall income/revenue will fall?

    But it will all be worth it, because the socialist utopia, promised by Lenin and Marx, will finally be brought to us upon this Earth.

  69. 69

    @r€nato: If we fix our horribly broken drug-patenting and drug-manufacturing system, we’ll find that we have a new problem with underfunded drug research (according to the public health people I know). I think we should do those things, and then basically move the government into drug research too! But you have to do them all I guess.

  70. 70
    Barbara says:

    @Kelly: Right, and sometimes health problems are like that but mostly they aren’t. They are recurring, chronic, or the result of life events (having a baby) that are completely different from your house catching on fire. I mean, if you really like this analogy, you should consider that municipalities have building standards for the use of fire resistant material that adds to the cost of housing, and some insurers and municipalities require fire and smoke alarms or even sprinkler systems that impose costs that are not borne by taxes. IMO, making weak analogies that wash away the complexity of the task is less likely to result in reasonable solutions.

  71. 71
    satby says:

    @Yarrow: @Barbara: I see both sides of this at the Farmers Market, which was founded in 1928 so has had generations of both vendors and customers coming. For some elderly vendors, it’s their primary social outlet, so they continue to try to stay in business there even though they lose money or are physically challenged doing it. At least 3 vendors in their mid-eighties still trying to hang on; and several more in their seventies. And during the week the customer base is almost entirely retirees, just coming to get out of the house. Here’s the problem: South Bend has all sorts of programs for seniors, but none of them want to use them. The market is a large uninsulated building that gets too cold in winter and too warm in summer, has occasionally treacherous footing behind counters for people with limited eyesight or mobility, and as I mentioned, it costs money to maintain a booth there so these oldsters are all depleting their finances. I’ve tried to encourage the one oldest lady to call the aged services programs but she won’t. So the perennial problem is, how do you get people to use the resources that address their needs and not abuse resources like doctor’s offices for social rather than medical needs.

  72. 72
    satby says:

    @Yarrow: hell yeah they do.

  73. 73
    Sloane Ranger says:

    @StringOnAStick: This is being pushed in the UK.I am on the Committee of our local University of the 3rd Age and our National HQ is urging us to work with GP’s to advertise what we do in the expectation increased social interaction will reduce Doctor visits.

  74. 74
    FlipYrWhig says:

    @r€nato: IANA expert of any kind but that seems like a no-brainer to me. There has to be a way to have the feds crank out simple, effective treatments like that.

  75. 75
    r€nato says:

    @Major Major Major Major: that is certainly something to consider, but I am not talking about that. I am not talking about The People’s Republic of the USA swooping in and expropriating drug patents and manufacturing them for free distribution under Medicare for All. I am talking about insulin, period. It’s a special case because no drug company did research for it. It is literally a case of ‘your money or your life’. It’s not cheap and those with diabetes shouldn’t have to play all sorts of games and jump through all sorts of hoops to get it at something approaching a reasonable price.

    As for the issue you raised it is a valid one but perhaps Big Pharma will have to content itself with not making blockbuster profits. Maybe they will need to tighten their belts a bit like the rest of us are supposed to do. BP constantly raises this spectre of “we won’t be able to afford taking risks on new drugs if we can’t anally rape Americans for their medications.” It’s the worst sort of fearmongering, a white collar kind of hostage taking rhetoric.

  76. 76
    Kathleen says:

    @PST: Interesting. Will have to check that out

  77. 77

    @satby: I got thwacked by a five-year-old ambulance bill collection notice the other day. They’d billed BCBS of Connecticut, not California, and then decided it was my problem to the tune of a few thousand dollars. Needless to say this has been disputed!

  78. 78
    chris says:

    @Major Major Major Major: Taxman: How much you got?//

    In Canada single payer is the law and is administered by the provinces.

    In the mid 80s Ontario went from mandatory payment, about $30/month for a single person, to a tax. They raised the provincial income tax by, IIRC, 1.5%. Except for the usual bloviating suspects no one noticed and now all provinces are the same.

  79. 79
    Kelly says:

    @Barbara: I’ve been kinda attached to the Fire Department/Police Department analogy ever since some campfire discussions with a couple Republican cop whitewater buddies way back when the Clinton Administration tried health care reform. It was a very effective analogy in that context.

  80. 80

    @r€nato: Insulin, epinephrine, there are all sorts of drugs in that category. I’m not saying we expropriate all the patents, just that our IP system is too abusable. Fixing it may indeed affect research profits, which will decrease research unless we force them to do it. We can just do it ourselves.

  81. 81
    gene108 says:

    @tobie:

    Kay asked yesterday whether providers would accept the Medicare pay scale or in the long run choose other professions. The question reminded me that we look at many things from the consumer angle — how.much does healthcare cost me — but pay less attention to the cost drivers. I don’t get why every aspect of healthcare from blood work to x-rays to aspirin in the hospital to a walker is so expensive. A fee for service system can’t be the only driver. Or am I completely off the mark?

    No one really knows, because how hospitals generate revenue for procedures is utterly arbitrary. They agree to get paid ‘a, by Medicare, agree to get paid ‘b’ by BCBS, agree to get paid ‘c’ by United Health Care, etc. Other than Medicare, the basis of how much private insurance pays is entirely dependent on how good the hospital’s negotiating team is versus the insurance company’s negotiating team.

    When I was on dialysis, the dialysis center would bill about $5k per treatment, Medicare would pay something like $300, my secondary insurance, after I hit my deductible, would pick up the 20% of the Medicare reimbursement amount not paid.

    There’s no logical connection between what providers charge, what they get paid, and how they arrive at these figures.

    Until this gets sorted out, I am not sure we can make any headway in truly reforming our healthcare system. The revenue generation and associated costs are utterly opaque.

  82. 82
    Yarrow says:

    @satby: The issue that isn’t being addressed is that the seniors both want socializing events and don’t want to admit they’re getting older and have more limitations. They want to keep doing what they’ve been doing, just like they always have. And it’s understandable. No one likes admitting they’re getting older and losing the ability to do things they used to do. They will go to doctors for socializing because “going to the doctor” is an acceptable activity that they’ve always done. They don’t have to admit they’re old just because they go to the doctor. No one will say, “Oh, you’re old. You go to the senior group.”

    When they join a senior program it’s obvious they’re getting older. Some of the people in the program may be way worse off than they are and that’s depressing. I see this in retirement communities where people move in and many other residents are in bad shape and it gets the younger, newer residents down. “This is what I have to look forward to.”

    I’m not too sure how to fix that problem but making it fun and making it an adjunct to their daily lives has to be part of it. The Silver Sneakers program at my Y is very active so whatever they’re doing must be working.

  83. 83
    Fair Economist says:

    @r€nato:

    here is a radical idea. Government should manufacture insulin and distribute at cost and free to those below a certain income level. There is NO GOOD REASON for Big Pharma and its shareholders to profit from the sale of this vital medicine.

    Agreed! This is a no brainer. Insulin is almost 100 years old; there is absolutely not the faintest excuse for extortionate profits (and there is with insulin formulations.) Considering how essential it is for treating a common chronic and serious disease, that’s just nuts.

  84. 84
    gene108 says:

    @Major Major Major Major:

    Did the provider send you the bill or was it from a collection agency? There’s a cottage industry of companies that buy up outstanding bills from providers, which the providers have basically written off, and send out collection notices for whatever the cash price the provider charged.

    Had an issue with this at work years ago. One of our employees had premature triplets. Then a few years later we got a bill for $500,000 for fees not paid to the hospital or something that we were liable for, for some reason. Their whole game is to send out thousands of these notices, and if a few people negotiate to pay some percentage on the outstanding, they still take in a good bit of money.

  85. 85
    smintheus says:

    @daveNYC: I think there is or was almost the opposite problem in Italy. A few decades ago I had a friend who was a doctor there who said she was trying to develop ways to get older patients to see her when they had medical issues and to be willing to say exactly what the issues were. Instead they would often deflect or minimize or talk about some other less urgent issue. She thought they were reticent because Italian culture has a long tradition with comic stereotypes, one of the most common being the old person who complains endlessly about nothing. A lot of elderly don’t want to be that stereotype.

  86. 86
    Fair Economist says:

    @satby: I think part of the problem for seniors is that non-seniors are kept too busy to socialize themselves. Lots of people like things like dancing, light games, walking, and movies, but they have to work 50+ hours, often irregular hours even, just to pay the rent.

  87. 87

    @gene108: It was from the collection agency because the original bill had also gone to the wrong address lol

  88. 88
    StringOnAStick says:

    @Barbara: Excellent point. For me, mail order pharmacy is convenient and cheaper, but I can still drive, have living friends, etc.

  89. 89
    Barbara says:

    @Kelly: It’s good as far as it goes in opening up discussion, it just doesn’t go very far in suggesting a solution to the problem. That’s my main point.

  90. 90
    StringOnAStick says:

    @gene108: I met a young investment banker this fall and as the alcohol worked it’s social lubricant magic I got him to admit that this is one of his profit centers. Buy up the past due claims for pennies, then sic an aggressive collection agency on them with his company splitting the profits with the collection agency. He said it’s good for 5 to 10% above what it costs him to buy the past due claims. And her I thought being an investment banker on the prowl for profits was looking for promising companies to invest in, not dig up loop holes and exploit the poor/unlucky who happen to get caught in them. He’s also starting to look into buying up drug patents and then jacking up the price, “but not a crazy amount like that idiot pharmabro”. Nice. The guy isn’t that smart but he’s ruthless and quite wealthy because of it so he thinks he’s smart; looks a bit pathological to me.

  91. 91
    Brachiator says:

    @BC in Illinois:

    Someone once made a presentation saying that our goal should be to reduce American taxes to the level of France or Sweden. And after people said, “wait, what?” he showed that, while the people of Europe pay, in one sense, higher taxes than we do, they get healthcare, college, and a number of other things from those taxes.

    And in France, people are taking to the streets for lower taxes and more benefits. Crazy French!

  92. 92
    Brachiator says:

    @e julius drivingstorm:

    Nowadays it seems everybody signs up for Medicare Part B at 65 yrs old, and almost all of those also for Part D. So that’s $135.50 per month for B and let’s say $27.00 per month for D for a nice round monthly premium of $162.50. This scheme pays roughly 80% of the bill less the $185.00 annual Part B deductible and whatever convoluted shifting plane associative out of pocket expenses incurred for the drugs in Part D.

    Isn’t there also a Medicare Part A? What does that do?

    Does Medicare Part B or D include dental and vision care? I have not noticed much discussion about that here or whenever the subject of Medicare for All comes up.

    I also read or hear stuff about Medigap? I think.

    I also hear radio commercials in the morning for various supplemental or alternative? Medicare Advantage plans. So I get the impression that no matter how comprehensive Medicare is supposed to be, there is a substantial market for supplemental plans. Why is that if Medicare is the complete solution?

    And says, I am a dope who does not clearly know what the difference in between Medicare and Medicaid. And also, here in California, Medi-Cal.

    I favor universal coverage. There are a boatload of programs in Europe, Australia and New Zealand, Japan, Canada, Mexico, all over the place. Do we know how to adapt the best these countries already provide, or do we really need to reinvent the wheel because, American Exceptionalism?

  93. 93
    tobie says:

    @gene108: Thanks for this. It gives me some handle on why everything is so insanely murky. I didn’t know the pricing system for care was so arbitrary.

    @Fair Economist: @r€nato: I joked yesterday that I was sure that just about any Democratic candidate could be awoken at 4 am in the morning and say something well-informed about patent law. And I meant it, because one thing that irritates me to no end is the sale of patents for chemical compounds discovered with NIH funding to pharmaceutical companies. These compounds belong to the taxpayers. I gather the one thing that the NIH won’t sponsor is the transformation of compounds into actual medication and maybe that should change. I’d also be happy to have the FDA responsible for drug testing.

  94. 94
    Michael Cain says:

    @PST:

    I have Medicare Advantage plan but many providers won’t accept Medicare patients.

    I think that is a Medicare Advantage problem only.

    Nope. When we went to Medicare this past year, none of my wife’s GP and two specialists would take traditional Medicare. Each would take exactly one Medicare Advantage plan, but no two of them accepted the same Advantage plan.

  95. 95
    Don K says:

    @Ohio Mom:

    That’s the one identified here as Stabenow-Peters. I looked on Stabenow’s web page to see what their proposal is, and it’s a Medicare buy-in for 50-64, and it lists the co-sponsors, among whom is Brown. https://www.stabenow.senate.gov/news/senator-stabenow-introduces-medicare-at-50-act

  96. 96
    Princess says:

    @David Anderson: Thanks David. I fully expect this would be the first thing he’d sacrifice in negotiations, based on his past statements and actions. I’d be happy to be proven wrong.

  97. 97
    J R in WV says:

    Have a neighborhood health care scare going on. A friend and neighbor, we can call him Chuck, is seriously ill. Chuck is a very eccentric hermit (in a neighborhood full of eccentric people) artist with a single kidney. He now has a reoccurring urinary tract infection.

    Chuck lives in a small cottage that he heats with wood, and ran out of wood. He was staying with our next door neighbor, who has taken him to the hospital in the beginning, when they learned he has the UTI. Neighbor took Chuck in, then to the hospital, took him in when he was discharged, then to the doctor this morning, who sent them back to the hospital.

    Chuck apparently will not be recovering to the point where he can cut firewood all summer to stock up for next winter. He doesn’t go to bed, he sits up over night with all the lights on. He won’t tell a doctor what’s wrong with him, where it hurts, etc. That’s too private or something.

    I told my neighbor to tell the hospital that Chuck will need to go to a rehab center when the hospital feels he is ready to be discharged, and that the social workers need to provide Chuck with everything. He should actually also tell them that Chuck is dammed strange past eccentric and needs medication for that PLUS his infection issues!

    But neighbors can only do so much to help each other out… and Chuck has no one else who cares at all.

  98. 98
    Monala says:

    @Procopius: SCHIP currently has a buy-in option, which my husband and I used to cover our daughter the year we were both working a series of part-time jobs. SCHIP is basically a pre-ACA Medicaid buy-in for children whose parents were above poverty (I don’t know if it still exists in the ACA era).

    There were 3 premium levels based on income: $20, $45, or $70 per month. We paid the $45 monthly premium, which was very affordable even as tight as our finances were then. No copays or deductibles at time of service.

  99. 99
    jl says:

    Shouldn’t ‘Bernie Sanders’ be ‘Warren-Sanders’?
    I wanted Warren to run in 2016, and in terms of policy proposals, and understanding the why and how of policies proposals, I Warren is my favorite. Only question is how well she does at electoral politics. But I am contributing to her campaign.

    I think David is wrong when he says all except universal coverage are details. We also need to deal with outrageous corporate price gouging, from not only drug companies, but also corporate hospital chains, labs, and large medical groups and insurers.

    In terms of economics, the US could continue to strengthen Obamacare and Go Swiss! or Go Dutch!. But going that route would require adopting much stronger market regulation of insurance companies and large corporate providers than the US apparently can tolerate politically. I am skeptical of centrist Democrats who talk about going in the direction of strengthening Obamacare, not because it is an inherently bad idea economically, but because they are consistently very vague about how to deal with the outrageous price gouging. And powerful corporate interests apparently still have enough political clout, and legal leverage in the US system to prevent meaningful strengthening of Obamacare in some critical and necessary areas.

    So, OK, let the ‘Medicare for X’ people have a shot at it. Been there and done that on Go Swiss! or Go Dutch! No sign that can happen in an acceptable time frame in US. So, go Australia! Why not give it a shot. A lot of legal obstacles will be swept away with that approach, though IANAL

    Maybe if ‘Medicare of X’ gets close enough, it will scare corporate interests enough to realize that they risk losing most of their power. They might realize better to settle for half a loaf rather than risk losing most of their power, and they will let meaningful reform of Obamacare proceed.

    I don’t think we know until we try as hard as we can on both fronts.

  100. 100
    Brachiator says:

    @jl:

    I am skeptical of centrist Democrats who talk about going in the direction of strengthening Obamacare, not because it is an inherently bad idea economically, but because they are consistently very vague about how to deal with the outrageous price gouging. And powerful corporate interests apparently still have enough political clout, and legal leverage in the US system to prevent meaningful strengthening of Obamacare in some critical and necessary areas.

    Obamacare has been working fairly well. I think a recent post here indicated that next year, prices in some states would actually decrease.

    People who claim to be progressive seem to want radical change simply because they think they see an opportunity to realize their single payer fantasies.

  101. 101
    jl says:

    @Brachiator: You make good points, for people who could not get insurance at all before Obamacare, or who could be easily financially wrecked when they lost insurance.

    But from a macroeconomic point of view, too much GDP in the US continues to be funneled through the health insurance and health provider sectors: over 17 percent for US compared to Switzerland (Obamacare done right, 12 percent) and Netherlands (Obamacare done better, 10 percent) or Australia (best model for Medicare for All, IMHO, 10 percent, when adjusted to be comparable to other countries).

    That causes macroeconomic problems, potential future national debt problems (even from reasonable Keynesian perspective) and even with Obamacare, affordability problems for average worker.

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