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Americans are not stupid;  at least not the 48% of Americans living in New York’s 26^th Congressional District.  Polls show that the victory by Democratic candidate, Kathy Hochul, in this traditionally conservative district was a reaction against the Republican budget proposal approved by most House Republicans and calling for a radical transformation of Medicare.

Paul Ryan, the Budget Committee Chairman who concocted this most recent Republican idea to kill Medicare,  would have you believe that his plan would not hurt seniors, his plan to to end Medicare as we know it would not hurt seniors.

He thinks people who are 54 years old – the first ones who will fall under Ryan’s plan -aren’t thinking about needing Medicare.

He thinks those older than 54 won’t feel threatened by his voucher plan idea.

He thinks people will somehow fall for this “kick-the-can-down-the-road” ploy.

What goes around …

There is some delicious satisfaction to watching Republicans squirm as Democrats accuse them of “ending Medicare as we know it.”

Dana Millbank, writing in the Washington Post, described Ryan’s own demagoguery on Medicare and health care reform:

Speaking on the House floor in 2009, he said the Democrats’ health-care legislation would “take coverage away from seniors,” “raise premiums for families” and “cost us nearly 5.5 million jobs.” Later, he said the health plan would bring about government “rationing” of health care.

He also labeled the plan “a government takeover of our healthcare system,” claimed America was at a “tipping point” toward a “European social welfare state,” and gave a wink to the “death panel” allegations. His suggestion that the legislation would result in the IRS getting “16,000 agents” to police the health-care law was knocked down as “wildly inaccurate” by Factcheck.org.

But Paul Ryan and the Republicans are not backing away from their lies and their distortions.  They must feel  confident that with the corporate money faucet turned up, they can convince Americans of anything.

The Huffington Post quotes a spokesperson for Carl Rove’s American Crossroads groups:

The GOP can’t and won’t retreat from the Medicare valley it has occupied. “We know that bell can’t be un-rung, and we wouldn’t want to,” said a well-placed GOP aide. “We’re on the right side of history.”

Just the facts

I can’t speak to history yet, but they are clearly on the wrong side of the facts.

Paul Ryan lies when he says his plan won’t affect seniors.  It most definitely will affect  the seniors who will be voting just two short presidential elections from now.  Americans aren’t fooled by that little trick.

What does it mean to replace Medicare with a voucher system?

Imagine you had access to an almost free new car.   Someone comes along and says, “This car is costing us too much money.  So we are going to give you cash instead.  Oh, and if car prices go up, well our ‘voucher’ won’t increase.”

But it gets better than that.  The Ryan plan insists that you not buy direct; you must buy from a third party insurer. Continuing the car analogy, instead of getting that car direct from the factory, you now have to buy it through a middle man.   Everyone knows that middle men (and women) are not free.

The Ryan plan may keep a government program called Medicare solvent.  It will abandon Medicare’s goal of contributing to the financial security of our senior citizens by providing for their health security.  It will sacrifice the solvency of seniors for the solvency of Medicare.

Seniors , current seniors and will-be seniors, are and should be scared by the Ryan budget proposal

Photo Credit:  FLICKR  lucaohman

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Paul D. Ryan (R-WI)

Boy do I have a plan to fix Medicare.  Well, actually, it’s not my plan.  This guy, Paul Ryan, thought it up.  He’s some kind of chairman in Washington.

Medicare is the program that pays for health care for old people.  Also disabled people, but mostly old people.  It seems it is going broke.

That’s what this guy Paul Ryan says.  His logic is a bit hard to follow but it goes something like this.

Too many old people

There are too many old people.  The government spends too much on their health care.  The government isn’t smart enough to fix it, so it should turn the money over to those old people.

Of course, the old people can’t do it by themselves, so they have to buy insurance from insurance companies.

Since the insurance companies have lots of money and the government doesn’t this makes perfect sense.

But here is where it gets confusing.  The insurance companies have lots of money because they don’t pay for health care and the government doesn’t have money because it does pay for health care.  So won’t this situation just reverse itself in a few years?

Old people aren’t too keen on this idea.  They think the insurance companies will continue to not pay for health care.  I’m not sure I get that. If the insurance companies have all this money, why wouldn’t they spend it on health care.  What else are they going to spend it on?  Themselves?   That’s stupid.

But hey, this is where this guy Ryan shows his smarts.  I mean the guy is no dummy.  You see his plan won’t take effect until 2022.  That means it won’t effect anyone older than 55.   I think he figures they aren’t paying attention.

Time to save

And here is the beauty of his plan.  They will have 10 years to save the extra $182,000 the plan will likely cost them in retirement.  Of course, they need to be paying attention to that part; otherwise they may forget to save that much.

Extra is the key word here.  Everyone knows it is going to cost them between $330,000 and $390,000 to pay for health care in retirement under the current plan.  Presumably, these under-55 year olds have that much stashed away already.  So they will just need to save about an extra $15,000 per year until they reach 65.  How difficult can that be?

But wait!  If it looks like you aren’t going to make it, you could try going out on social security disability before 2020.  Then maybe you can get into Medicare under the old rules.

Some people just don’t get it.  It’s all about Medicare.  It’s not about people.  Some people have this silly idea that government is supposed to be here for people in need.  Remember what John Kennedy said, “Ask not what your government can do for you.  Ask what you can do for your government.”

Well our government needs us to stop asking it to do things for us.  That way it will be able to do things for people who are not in need – the rich.

This is an idea whose time has come.  Its beauty is in its simplicity.  Those who need, pay; and those who don’t, get tax cuts.

The Republicans may be backing away form this Ryan fellow, because they think people are against the idea.  But they’re just kidding.  Elect them and find out.

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The Republicans have lined up behind the budget proposal of Congressman Paul D.Ryan (R-WI), chair of the House Budget Committee.

They have lined up against the American people.

During the health care debates, the Republicans dared to criticize health care reform because it cut Medicare.

What is the Republican proposal?  They don’t just want to cut access to Medicare.  They want to phase it out.  They want to replace it with a private health insurance.

Government forfeiture

Instead of what the Republicans call a “government takeover”; they propose a government forfeiture of responsibility to the elderly and the poor.

The Ryan proposal goes far beyond just outsourcing Medicare and Medicaid to private insurers.  The fact-challenged Republicans refuse to recognize what study after study has demonstrated.  Every single effort to turn over parts of Medicare to private insurers ends up costing the government more money.

And yet they want to replace Medicare and Medicaid with a voucher system to be used to purchase private insurance.

Let’s leave aside the obvious concern that private insurers will demand a profit, something that is not part of the current Medicare cost equation.  The concept of subsidizing the individual flawed.  As I pointed out last week, there is an inherent inefficiency in subsidizing individuals rather than subsidizing the system.

In addition, the concept of “skin in the game” is equally flawed.  For too many consumers of health care, increased out of pocket expenses means delaying routine care that ends up costing more down the road.  Unless, of course, they die.

Republican – death panel redux

In addition, the Ryan Republicans have re-opened their own back door to death panels.  But they will absolve themselves of responsibility and pass it off to individual choices.

Their approach can be likened to a feed the hungry program that gives someone 50 cents and invites them to buy all the food they need.  “What!” they say, “You can’t feed  yourself on 50 cents?  You must be an irresponsible consumer.”

But Ryan is sly enough not to propose this for today’s seniors, but for tomorrow’s.  The Republicans charge that failure to fund tax cuts now is just “kicking the can down the road.”

Actually they don’t quite say it that way.  They talk about reducing the “crushing burden of debt.”  The accuse the Democrats of “kicking the can down the road.”

Define “crushing debt”

The Republican solution?  Stuff America’s poor, working and middle class into the can and kick them down the road.  Instead of  a debt  owed by America, it will be a debt owed by Americans, specifically those least able to afford it.

I am reminded of someone who called me about a bill that was not getting paid.  She had retired to a poor rural area of the country.  She told me, “I don’t like to get bills.  These hillbillies down here wonder why I get so worked up.  The tell me just throw the bills into the trash can.”

Is that the future for America?  Let hard working Americans be reduced to throwing bills into the trash can?

These Republicans claim to love America, but they don’t have any love for most Americans.  These Republicans seem to think that all Americans live to serve and enrich them.  No level of sacrifice is too great for poor, working and middle class Americans to endure if it fattens the coffers of the very rich.

Americans cannot afford the Ryan budget proposal.

America cannot afford the Ryan budget proposal.

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The single payer movement was not invited into the national health reform debate.

But they are not going away.

July 30, 2010 was the 45^th anniversary of Medicare.  Activists across the country took the opportunity to remind us that Medicare works for older Americans and it can work for the rest of us.

Click here to view the embedded video.

Medicare at 45

The Obama administration took the opportunity to tout improvements in Medicare as a result of the Patient Protection and Affordable Care Act (PPACA):

• More benefits, especially preventative benefits
• More tools to fight fraud and abuse
• Lower drug cots for seniors
• Improved quality of care through pilot programs that encourage more integrated and coordinated care delivery

CMS also issued a report that the savings from the PPACA would extend the life of the Medicare Trust Fund an additional 12 years.

The irony of touting Medicare while its Deficit Commission warns of the need to rein in entitlements seems lost on this administration.

Medicare for All

Meanwhile, three strong congressional proponents of a single payer health care system used Medicare’s birthday anniversary to remind their colleagues in Congress that “Medicare for All is inevitable in the United States.”

In their letter to “friends of health care for all”, Representatives Dennis Kucinich (D-OH), and John Conyers (D-MI) and Senator Bernie Sanders (I-VT) wrote, “We vow to continue to fight along side you for health care justice for all at both the federal and state level.”

States and single payer

It is at the state level that activists hope to make breakthroughs.  One of the more promising states appears to be Bernie Sanders’ own state of Vermont.  Governor Jim Douglas has allowed a bill to become law without his signature that could challenge the federal health reform law in a very positive direction.  Apparently he is passing on the opportunity to have the name Douglas permanently associated with single payer in both Canada and the United States.

The law will create a health reform commission, which has until Feb. 1, 2011, to propose to the governor and general assembly three design options for universal coverage in Vermont.  One of those options will be creating a single system of health care in the state.

California has twice passed single payer bills only to be vetoed by the Governor Schwarzenegger.

Other states are actively pushing their legislatures.  Maryland has two identical bills in both houses of the Maryland Legislature, called the Maryland Health Security Act”.  They have held hearings and have about ¼ of the legislators on board as sponsors.  Healthcare-NOW of Maryland is trying to raise money for an economic impact study.

Maryland and Pennsylvania

Across the Mason-Dixon line in Pennsylvania, Governor Rendell has promised to sign a single payer bill if it should reach his desk.  Since the Governor will be leaving office in January, that window of opportunity may be closing fast.  Nevertheless, activists in Pennsylvania are building a movement that is gathering momentum.  In response to grass roots pressure, The State Democratic Committee endorsed single payer and both Democratic candidates for governor and senator have said they would support single payer legislation.

The prospect of two border states enacting single payer health care offers an exciting vision of a regional single payer health care plan network.  But there are more than just local challenges that face these activists.  And the “Letter to friends of health care for all” certainly highlights that issue.

The PPACA gutted efforts to encourage state initiatives for health care reform.  Instead, the law puts up roadblocks for any creative state initiatives to resolve their own health care issues.

More on that topic next week.

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The Senate Dems are talking about expanding Medicare.  Well, expanding Medicare to people over 55.  Um, expanding Medicare to some people over 55.  Er, expanding Medicare to some people over 55 who can afford to pay the price.

Is this a good idea, or part of a good idea? What and Why?

What is it?

The details are sketchy at this point.   The so-called expansion of Medicare is tied to discussions about killing the public option because that insurance company lackey, Senator Joe Lieberman (I, CN), could otherwise kill health care reform demanded by the majority of Americans.

And those right wing nut cases think we lefties are jamming health care reform down their throats?

Expanding Medicare has some appeal, but the Senate solution, like so many Congressional fixes, manages to muck it up.

We turn to the New York Times

The New York Times offered a variety of perspectives on the issue.

From Stuart Butler, adjunct professor in public policy at Georgetown University, and  vice president for domestic policy at the Heritage Foundation.

One in ten  55- to 64-year-olds are uninsured and can face crippling health costs, which rise with age. So why not let them join Medicare?

One problem is the steep premium required if these new beneficiaries pay the full cost. Individual coverage would cost nearly $8,000 annually (including prescription coverage). And Medicare still has gaps requiring costly supplemental coverage. That would make it unaffordable to many eligible Americans….

A Medicare buy-in program would further unravel employer-sponsored retiree coverage, as firms nudged younger retirees into Medicare to cut their benefit costs. So the number of new enrollees, and total costs, could escalate.

From Robin Hanson, an associate professor of economics at George Mason University.

If we were to move everyone over 55 into Medicare, and raise worker premiums to match, that would be a big slip down the slope toward a European style state-run medical system, but at least it would be straightforward and workable. Medicare works now for folks 65 and over; it could similarly work for folks 55 and over.

Letting folks 55 and over opt in to Medicare from less generous plans, with no pre-existing condition penalties, risks disaster via adverse selection.

From Jonathan Oberlander,  associate professor of Social Medicine and Health Policy and Management at the University of North Carolina-Chapel Hill.

The U.S. health care system is fragmented and that produces fragmented solutions that try to build on our bizarre, complex mix of public and private programs.

This is an example of that, to be sure, but given the other policies being proposed, this at least has the virtue of building on a popular program. Moreover, the public plan in the Senate bill is so watered down that it is not clear that this, from liberals’ perspectives, (is) really a lesser option.

From Gerard Anderson, a professor of health policy and management and professor of medicine at Johns Hopkins University. His research focuses on comparative health care systems, health care payment reform, and technology diffusion.

It is disappointing that only people age 55 and above will be able to purchase Medicare coverage. However, it is a start. People age 54 will see it is a good deal and will start to argue for it in the coming years….

There is no reason why a Medicare beneficiary at age 55 should pay more than a Medicare beneficiary at age 65 for the same service, certainly not 20-30 percent more. In fact, they should pay less because they likely have fewer complications and are less costly to treat.

There are economies of scale associated with having them treated exactly like other Medicare beneficiaries. Setting up two parallel systems simply is not efficient or effective.

From J. Michael McWilliams, assistant professor of health care policy and medicine at Harvard Medical School and Brigham and Women’s Hospital.

A Medicare buy-in option for adults ages 55-64 could provide an important complement to other health care reforms being considered by the House and Senate….

Near-elderly adults may not cost as much as previously thought, because they would enter traditional Medicare at age 65 with lower risks of costly complications….

Indeed, growing evidence suggests that when older uninsured adults gain Medicare coverage at age 65, their use of effective health services increases, their health trends improve, and their risk of cardiovascular complications diminishes. Near-universal Medicare coverage is also associated with reduced death rates for hospitalized patients and reduced racial and socioeconomic disparities in control of blood pressure, blood sugar and cholesterol….

An effective buy-in may help control national spending because a greater fraction of care for the chronically ill would be affected by innovative changes to Medicare’s payment and delivery systems currently proposed by Congress.

From Steffie Woolhandler, professor of medicine, and David Himmelstein, associate professor of medicine, both at Harvard Medical School. They are co-founders of Physicians for a National Health Program.

Milk and lemon both taste good in tea. But mix them together and it’s a curdled mess. Similarly, the latest Senate health reform compromise combines two appetizing elements — a Medicare expansion and tighter insurance regulations –- to create a noxious brew….

The Senate plans to take some of these high-cost patients off private insurers’ books, and make them Medicare’s problem. Consequently, the costs of this Medicare buy-in will be high — both for patients and for the taxpayers who will subsidize the near-poor starting in 2014….

But even though it’s bad health policy, this new compromise is brilliant politics. For insurers, it offers a hidden subsidy. Meanwhile, it gives the appearance of responding to the vocal and growing legion of single payer supporters who want Medicare for All….

Medicare for All won’t grow from the Senate compromise, but from its ashes.

Not exactly a ringing endorsement from any part of the political spectrum.

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Seven dollars and forty cents hardly seems like an amount that should erect a barrier to health care.

In fact, when Mr. Koch (all names are fictitious) called to complain about this bill for seven dollars and forty cents, my first reaction was, “You should appreciate how lucky you are that you have a health care plan that pays most of your bills. Why are you quibbling over $7.40?”
Of course, that is not an appropriate customer service response.

But listen to Mr. Koch. “This bill is for two pain pills that were given to me when I was admitted to the hospital for an emergency surgery.   Medicare won’t pay for the pills because they were “self-administered.”

Our insurance plan won’t pay, because Medicare won’t allow payment. (a common Medicare complementary policy). The hospital wants its $7.40. I must have been semi conscious when they gave me the pills, because I do not remember it at all.  Why should I pay for pills that some nurse made me swallow when I was semi-conscious?”
Mr. Koch’s total pharmacy bill for this hospital stay was over $8,000  Who is the one who is quibbling over $7.40?  And the issue has little to do with whether the two pills cost $7.40.
In fact, it is more likely that the hospital knows full well that the two pills only cost $0.20  But they calculate that it will take at least an additional $7.20 of bureaucratic labor to collect that $0.20.  The bureaucracy needs to be fed.
Think about the effort to maintain these bureaucracies.   Somewhere in the bowels of the CMS (Center for Medicare and Medicaid Services) someone has crafted regulations that stipulate that Medicare will not pay for certain medications that are self administered.
The logic is apparent  Before Medicare Part D, CMS did not pay for prescriptions outside the hospital or physician office. “Self administered” appears to fairly delineate the boundary between those drugs that can only be administered in a hospital or physician office setting, from those dispensed by a pharmacist.

By making that distinction, CMS avoids paying for a supply of drugs dispensed in a hospital that the patient can “self-administer” at home.   That is the silo mentality.

In addition, the insurance carriers offering complementary Medicare policies have to develop claim adjudication policies and payment procedures to deal with these and similar situations.

Let’s not forget the customer service departments that have to be trained and paid to respond appropriately and effectively to complaints from other $7.40 claims.

Our office was able to determine that Mr. Koch did not need to pay the $7.40  The hospital is satisfied, because they got confirmation that they could write off the $7.40. Medicare never notices that they didn’t pay the $7.40.
So where is the $7.40?   What is the price of aggravation? Seven dollars and forty cents?

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Amazing seems a most appropriate word to describe the financing and delivery of health care services in the United States of America.

According to Merriam-Webster’s Collegiate Dictionary, 9th Edition (OK, I have an old dictionary) amazing is derived from a French word meaning “to confuse”.  Obsolete meanings include consternation, bewilderment and perplexing.

Yes, health care in the US is truly amazing.  Rube Goldberg could not have invented a more illogical maze of non-systems.  Lewis Carroll’s might have added an additional chapter on Alice’s efforts to get those pills that made her big and small.  Kafka might imagine a special Penal Colony for those responsible for this maze.

I should be careful on this last point, since I am part of that system.  I administer the benefit plan for approximately 25,000 participants.  I like to think that we do our best to help our members navigate what is all to often a daunting and perplexing maze.

Take for example a retired woman who called our office recently.  She was turning 65 and wanted to know if she had to sign up for Medicare Part B.  Her concern?  She was starting cancer treatments.  But her doctor did not participate with Medicare.  The payments were too low.  So now, just as she was starting a physically and emotionally draining process, she was being compelled to leave a doctor she trusted, because she would not be able to afford her.  Because the doctor could not earn enough by treating her. Because our plan could only afford to cover Medicare eligible retirees as long as they were enrolled in Medicare.

Amazing!

 Most critics of health care in the US focus on the uninsured, or on the high cost of health care, or the poor outcomes.  This blog will tell stories that highlight the inherent waste and inefficiencies that are built into the system.  They are the combined result of a free market ideology that does not work for health care, and a focus on solving only one part of the problem at a time.

More later!

James L. McGee