The Sunday Review in the NT Times this week contained an outstanding critique of Medicare. According to the critique by Jane Gross, the problem with Medicare is that its bloated spending is designed to benefit Big Pharma and pay-for-service doctors while doing essentially nothing to help individuals deal with end-of-life nursing needs. As Gross succinctly states about the universal medical coverage afforded by the 1965 Medicare law – “What Medicare paid for then is no longer what recipients need or want today.”
Medicare provides essentially unlimited coverage for any drug or treatment that Big Pharma or doctors can invent or create. In fact, much of Medicare’s supporting legislation specifically prohibits the agency from considering cost or cost-effectiveness in approving coverage for various drugs or treatments. Is it any wonder that America’s healthcare industry is thriving and that its share of America’s GDP and will soon reach 20%?
By contrast, Medicare provides almost no coverage for nursing care for frail or demented old people, and this absence of coverage is what prompted Gross to become an expert on this issue. According to Gross, her mother, who was incapacitated by a stroke, received neurosurgery of questionable benefits under Medicare, but had to pay for her own nursing care for a decade until she had depleted her $500,000 estate, at which time she became eligible for welfare-type nursing coverage under Medicaid. Her mother shamefully called herself “a welfare queen.”
Obviously, her mother should have used some of her estate to buy nursing-home coverage, but only a small percentage of Americans do. Most rely on the likelihood that they will die without lingering, but sadly that does not happen to millions of Americans:
- “By now, you may be wondering if your parents have a half million dollars for old age. Or if you or your children do. You may be counting on quick and easy deaths. Shoot me, so many people say. Alas, 70 percent of the elderly will need extended care before they die. Denial is powerful but doesn’t pay the bills.”
So there are two components to this issue. Assuming that we can’t change the amount of Medicare dollars available for the elderly, the optimal reform of Medicare should consist of equal amounts of (a) cuts to inefficient drugs and treatments, and (b) increases to efficient, desirable services.
Refusing to pay for inefficient drugs and treatments, however, is a concept that opponents can easily demagogue. Please recall Sarah Palin and the Republican Party wailing about Death Panels, i.e., anyone who refuses to pay for any drug or treatment that the patient and the doctor want. The reasoned response should be that the government will never come between a patient and the doctor, but don’t expect the government to give them an unlimited charge card to do whatever they want. That is economically crazy.
Demagogues will be difficult to defeat because people are fearful and the demagogues will leverage those fears. For example, I have a friend who is getting ready to go on Medicare, and his ortho has recommended to him that if he wants to have his knew replaced, he should have it done now with private insurance because coverage for it under Medicare might be taken away at any time. I thought this was an Urban Legend, but the Times critique actually listed joint replacement as the type of treatment that shouldn’t be covered by Medicare in certain situations – e.g., if the patient has dementia that will prevent him/her from receiving physical therapy.
Gross lists the following as examples of treatment that in the past year has been determined to be ineffective, but which remain fully covered by Medicare:
- Feeding tubes, which can cause infections, nausea and vomiting, rarely prolong life. People with dementia often react with agitation, including pulling out the tubes, and then are either sedated or restrained.
- Abdominal and gall bladder surgery and joint replacements, for those who rank poorly on a scale that measures frailty, lead to complications, repeat hospital stays and placement in nursing homes.
- Tight glycemic control for Type 2 diabetes, present in 1 of 4 people over 65, often requires 8 to 10 years before it helps prevent blindness, kidney disease or amputations. Without enough time to reap the benefits, the elderly endure needless dietary limits and needle sticks.
Reformers should explain that, for every dollar saved by eliminating ineffective drugs and services, the saved money will be redirected toward improved coverage for nursing care. This will force the demagogues to argue not only that the drug or treatment is effective, but that it is more beneficial than improved coverage for nursing care.
Two important aspects of this issue that were not addressed in the critique:
- The critique acknowledges that individuals, either reasonably or unreasonably, decline to buy coverage for nursing care when they are younger and the coverage would be affordable. But there is no discussion of possible tax reforms that might encourage more individuals to buy such coverage at that earlier time.
- Paul Ryan’s plan to reform Medicare relies heavily on the federal government issuing payment vouchers that would enable private insurers to develop flexible coverage options. Thus, we can hope that private insurers will take advantage of this flexibility to create affordable policies that provide enhanced coverage for nursing-home care and restricted coverage for state-of-the-art, cutting-edge drugs and treatment. If Jane Gross is correct (and I think she is), many Medicare beneficiaries will choose a policy with reduced coverage for neurosurgery and joint replacements and enhanced coverage for nursing care.