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View Diary: What I Keep Not Hearing About Medicare (182 comments)

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  •  If they raised the eligibility age to 70 from 65 (15+ / 0-)

    Then the total cost of Medicare would go down because their would be fewer people covered.  Average cost per person would go up, but premiums would not have to, because the government subsidy that keeps the premiums as "low" as they are would be able to go up because they would be subsidizing fewer people.

    It would really extend the life of the Medicare trust fund, and would not hurt those who got medicare.  Of course those who couldn't work until they were 70, or didn't have health insurance in the first place would be screwed, but Medicare would be O.K.

    It would also tend to increase, not reduce, the total amount spent on health care in this country, which is the real problem, but let's sweep that under the rug, because ObamaCare = Socialism, which means death-panels.

    Numbers are like people . . . Torture them enough and they'll tell you anything.

    by Actuary4Change on Fri Oct 12, 2012 at 08:55:44 AM PDT

    [ Parent ]

    •  Yes but assuming the 65-70 try to buy insurance (13+ / 0-)

      Either they pay enormous premiums or costs go up for everyone to even them out.  Maybe if we have some history with ACA we can see how we cover this but otherwise I think you just destroy many people in their 60's with health costs.  

      •  With a pre-existing condition such (7+ / 0-)

        as cancer.  The ACA would allow my husband to be covered by at what cost?

      •  It's outrageous (6+ / 0-)

        Rates for people in the 55-65 category are already absurdly high; I"m paying about $25k/year for a high deductible plan!  That's in Massachusetts, as a small business plan (age rated), and it's lower than the Romneycare rates.

        The 65-70 group is as desirable to private insurance companies as bedbugs are to the Hilton Corp.  They don't want these high-cost patients, especially if not backed up by the government.  So raising the age of Medicare will probably throw a lot of 65+ people off insurance, and/or bankrupt them.  It would "extend" the trust fund, but so would just killing anyone who got sick.  Come to think of it, that would be much of the impact.

        Remember, too, how the basic Ryan (not Romney's modified and-doesn't-add-up version) plan saved the most.  Because it required the senior to pay the difference between the groupon value and the private insurance rate, millions would have gotten absolutely no coverage.  Romney's version claims that there will still be some residual basic Medicare, but it's not clear what it could be if he's also giving money to private insurance.  There's already some of that in Medicare Advantage, so any additional privatization would have to come at the expense of the current Medicare public option.

    •  They really only care about the cost to govt. (21+ / 0-)

      That is what "entitlement reform" is all about: making that cost go down. They don't care if the cost to seniors goes up.

    •  If you are 62 you can receive SS (11+ / 0-)

      at a reduced rate. Why not increase that age to 65 and not raise it to 67.   Believe me I was an ER nurse for years and there is no way I could be doing that at age 65 and the patients wouldn't want me treating them after 3 twelve hour shifts.   I know many people who started or are planning to take SS at 62 because they think it is going broke and  won't be there for them.  To us baby boomers SS and Medicare is scared.  
      Bring all of our troops home and use that money to shore up medicare and expand treatment for those vets who need treatment from Bush's wars.

      •  Because that woudln't save money (12+ / 0-)

        The value that you get by retiring at 65 vs. taking a smaller payment at 62 is approximately the same, so taking that option away would not save the govt any money.

        BTW, the current law already says that the age will slowly raise to 67, so anyone talking about increasing the SS retirement age is talking about something more than 67.

        Numbers are like people . . . Torture them enough and they'll tell you anything.

        by Actuary4Change on Fri Oct 12, 2012 at 10:25:50 AM PDT

        [ Parent ]

      •  It is easier than that, eliminate the income cap o (9+ / 0-)

        SS tax and with both Medicare and SS tax all income including investments. Jan 1 this year investment profits will be taxed at 3.8% for medicare for the first time. A lot of us already pay on everything or virtually everything we earn. This could provide a good basis for Medicare for all which is IMO the smart way to go.

        •  cherie clark - there is no cap on Medicare (8+ / 0-)

          and as you note investment income will now also be taxed for Medicare starting 1/1/13.

          Your proposal for SocSec would end the program as it was intended and has operated to this point. It was designed as "wage insurance" with its own funding mechanism and not funded by general tax revenue. It is not an income redistribution plan, but rather a program where people earn a benefit by the contributions they make into the system, as well as their employers. There is a reason why there is a cap. The thought is that people at higher incomes likely have other retirement assets and don't need to "insure" all of their income. Investment income isn't included because investment income isn't tied to employment and doesn't end when we retire. Therefore, there is no logic to "insure" it. There are two issues with eliminating the cap, one is that if all the extra income is included the benefit formula, SocSec payments to very high income earners could be six figures per year. If you take the cap off of contributions, and cap the benefits, you have changed SocSec as we know it and violated every principal that FDR set out for it when it was started. The program shares such bipartisan support because people think it is fair and your benefits are tied to your contributions. That link cannot be broken or you have an income redistribution program that FDR warned us would be perceived as welfare, he called it the "dole".

          I favor raising the cap, and allowing benefits to rise to reflect the higher contributions. A staged increase in the cap solves nearly all of SocSec's financial problems.

          "let's talk about that"

          by VClib on Fri Oct 12, 2012 at 03:45:29 PM PDT

          [ Parent ]

          •  You just made me learn something! nt (4+ / 0-)
            Recommended by:
            VClib, NWTerriD, marina, cherie clark

            I was wise enough to never grow up while fooling most people into believing I had. - Margaret Mead

            by fayea on Fri Oct 12, 2012 at 04:27:44 PM PDT

            [ Parent ]

          •  How much would it help? (2+ / 0-)
            Recommended by:
            NWTerriD, cherie clark

            I don't know enough about SS finances to know how much raising the cap and benefits would help.

            Numbers are like people . . . Torture them enough and they'll tell you anything.

            by Actuary4Change on Fri Oct 12, 2012 at 07:38:17 PM PDT

            [ Parent ]

            •  A4C - I don't know the math (0+ / 0-)

              But the system stays in balance if about 90% of wages and salaries are subject to withholding. We are now in the low 80s. We need to stair step the amount up until we hit 90%. That might require us to take the cap close to $200,000. The current maximum cap is $110,000 and the max benefit is under $3,000/mo. If someone had 40 quarters at $200,000 plus my guess is that the benefit would be about $5,000/mo. There are some formulas on the SocSec website to play with and you are just the type of person with the expertise to work on a few examples.

              "let's talk about that"

              by VClib on Sat Oct 13, 2012 at 10:46:42 AM PDT

              [ Parent ]

          •  That is fine too, it would be nice to raise (1+ / 0-)
            Recommended by:

            benefits because the average benefit barely keeps one above the poverty level. What makes me crazy is this idea it can't be fixed. I did know that there was no cap on medicare just forgot., one of the reasons I retired, memory issues. I paid in for 56 years, from the time I was 12 years old and it isn't an entitlement, someone needs to drive a stake thru the heart of that meme. When you work and pay into a benefit it isn't the DOLE, it isn't a hand out, it is a contract we make with the government. Simpson Boles saw the merit in raising the cap and raising the monthly benefit amount to something that would allow seniors to retire with dignity.

            •  cherie - I think there are two issues (0+ / 0-)

              We completely agree that SocSec is an earned benefit.

              The issue of raising the monthly payment at the bottom is expensive and complex. The formula that determines benefits is currently modestly weighted in a progressive fashion, that is a low income person receives higher benefits per dollar contributed than a person contributing at the cap amount. There is certainly strong support from Dems to tweak the formula to make that low income benefit higher, but it is very expensive because of the sheer number of SocSec checks that go to people who were low income workers. I would hope that if we significantly raised the cap, say from $110,000 to $200,000 over the next ten years, that we could continue to shave some return on those higher income participants and bolster the current and future benefits to lower income workers.  

              "let's talk about that"

              by VClib on Sat Oct 13, 2012 at 10:54:12 AM PDT

              [ Parent ]

    •  And it would make it very very hard (11+ / 0-)

      for people in the 65-70 range to buy health insurance.

      It would mean people younger than 70 - or people with a spouse younger than 70 - would not retire if they could possibly help it, even if they're to the point where their health interferes with job performance. Perhaps especially if their health is creating problems. So instead of these people retiring gracefully, private and public employers have to spend a lot of time and energy documenting, disciplining, and firing these workers.

      And don't forget that study that shows that people who are 64 and appear in ERs die at a much higher rate than people who are 65 and appear in ERs.

      Fry, don't be a hero! It's not covered by our health plan!

      by elfling on Fri Oct 12, 2012 at 10:03:47 AM PDT

      [ Parent ]

      •  Do you have a link to that study? (2+ / 0-)
        Recommended by:
        ladybug53, NWTerriD

        it would be helpful.

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        by JamieG from Md on Fri Oct 12, 2012 at 10:52:03 AM PDT

        [ Parent ]

        •  I think this is it (5+ / 0-)
          Recommended by:
          JamieG from Md, kurt, NWTerriD, marina, splashy

          Does Medicare Save Lives?
          David Card, Carlos Dobkin and Nicole Maestas*
           June 2008

          The health insurance characteristics of the population changes sharply at age 65 as most people become eligible for Medicare. But do these changes matter for health? We address this question using data on over 400,000 hospital admissions for people who are admitted through the emergency department for “non-deferrable” conditions—diagnoses with the same daily admission rates on weekends and weekdays. Among this subset of patients there is no discernable rise in the number of admissions at age 65, suggesting that the severity of illness is similar for patients on either side of the Medicare threshold. The insurance characteristics of the two groups are very different, however, with a large jump at 65 in the fraction who have Medicare as their primary insurer, and a reduction in the fraction with no coverage. These changes are associated with small but statistically significant increases in hospital list charges and in the number of procedures performed in hospital. We estimate a nearly 1 percentage point drop in 7-day mortality for patients at age 65, implying that Medicare eligibility reduces the death rate of this severely ill patient group by 20 percent. The mortality gap persists for at least nine months following the initial hospital admission.

          I recall there may be another study, because I recall a finding that the lower mortality rate is apparent even when you drop the 64 year olds who had no health insurance.

          Fry, don't be a hero! It's not covered by our health plan!

          by elfling on Fri Oct 12, 2012 at 02:56:38 PM PDT

          [ Parent ]

    •  Alternatively... (12+ / 0-)

      Drop the minimum age to 50, or 45.  Allow companies or older individuals to buy in before 65, for a standard premium, keep the full premium subsidies only for 65 and up.

      Average cost of a medicare patient goes down.  Average cost of private insurance patients goes down as well - we're moving the more expensive segment of the private market, who are still less expensive than the retirees.

      This my require a trivial tax increase to bring the premium in line with private insurance for the healthy crowd, but under this plan the diarist spends at least half a decade subsidizing the rest of the medicare population before his health deteriorates.

      Of course, this presumes that the populace will react sanely to the creeping socialization of medical care, and I admit that this would be a step toward single payer healthcare.

      This also presumes that the purpose of insurance for our retirees is to provide them with medical care, not just take the money for their premiums.

      •  Fascinating! (2+ / 0-)
        Recommended by:
        ladybug53, NWTerriD

        Move Single Payer Forward? Join 18,000 Doctors of PNHP and 185,000 member National Nurses United

        by divineorder on Fri Oct 12, 2012 at 11:13:16 AM PDT

        [ Parent ]

      •  Stop confusing "insurance" with "medical care" (9+ / 0-)

        > Of course, this presumes that the populace will react
        > sanely to the creeping socialization of medical care...

        No one is talking about socialized MEDICAL CARE. Even
        a single-payer "Medicare-for-all" system only socializes
        medical insurance -- NOT the doctors and hospitals.

        ...not that there'd be anything wrong with that,


        I think you're some kind of deviated prevert.

        by ColBatGuano on Fri Oct 12, 2012 at 11:15:58 AM PDT

        [ Parent ]

        •  Good point (3+ / 0-)
          Recommended by:
          Actuary4Change, NWTerriD, splashy

          Socializing the cost structure really isn't the same as starting a NHS.  

          Not that I'd be against that either.

          •  But it would be a good idea (1+ / 0-)
            Recommended by:

            to just get it over with and start an NHS!  The cost would fall tremendously for better coverage.

            Bain capital has of course invested heavily in proprietary hospitals, so they want costs to stay high.

            •  KSLV - we need to build a surplus of primary care (4+ / 0-)
              Recommended by:
              fayea, mudfud27, Actuary4Change, NWTerriD

              clinicians first. We have a severe shortage of primary care physicians and it will get worse and more people acquire health insurance. I just read an article in a medical journal with just with the advent of the ACA half the primary care physicians won't take new Medicare patients (25% have no Medicare patients) and a shocking number are reducing hours or planning to transition to a concierge practice by 2014 just as new patients come to into the system. If we tried to impost a NHS on physicians today 75% of those over 60 would retire and we have no one to take their place. It takes ten to twelve years post college to train physicians and five years post college to train nurse practitioners and at present they pay those costs themselves. If we want to drive down healthcare costs we need to dramatically increase the number of medical school students and graduate level nurses and change the economics for them.

              Even in the UK there is now a parallel private pay market and the US medical societies are a strong opponent of any NHS type program.  Moving to a Canadian style single payer is the next likely step and like Canada it may start in the states. It would actually be good to have a few states try it and see what works so that a national program could learn from their mistakes.

              "let's talk about that"

              by VClib on Fri Oct 12, 2012 at 04:35:25 PM PDT

              [ Parent ]

              •  Excellent point (5+ / 0-)
                Recommended by:
                VClib, kurt, Actuary4Change, NWTerriD, marina

                I'm a specialist (and we take Medicare) but can easily see how primary care docs have to limit their care of Medicare patients. Reimbursement is so poor that many physicians actually lose money on them.

                Look, if I wanted to get rich I'd have become a banker but that's crazy...

                Squeezing providers for reimbursement has its limits, and there are plenty of people who are, as you correctly point out, getting out of the primary care business altogether in part because they can't afford it.

                A better plan would be to increase reimbursement rates and look for savings elsewhere, such as on pharmaceuticals , imaging, and devices. We need to encourage primary care but instead we're doing the opposite.

                •  mudfud - my primary care physician (1+ / 0-)
                  Recommended by:

                  stopped taking new Medicare patients five years ago. He does, thankfully, keep his long term patients as they turn 65. Because I am also in the life science business, but not as a clinician or payer, we have very candid conversations about practice economics and technologies. I believe him when he tells me that, even on a marginal cost basis, he loses money on Medicare. Fortunately for me he is not only one of the premier internal medicine diagnosticians in my area, and primary care physician to many other doctors, but feels a real sense of obligation to his aging patient population and continues to see me. I am very lucky.

                  "let's talk about that"

                  by VClib on Fri Oct 12, 2012 at 06:40:38 PM PDT

                  [ Parent ]

              •  An NHS would encourage primary care (2+ / 0-)
                Recommended by:
                Actuary4Change, NWTerriD

                The idea of NHS would be to put the doctors on salary, not on fee-for-service.  Then the disparity between underpaid primaries and overpaid specialists could be reduced.  It's service-based insurance reimbursements that encourage the current mess.

                The US used to have a lot more public care than now.  Before WW II made insurance common, many cities and states had public hospitals offering free care.  That's pretty much gone now, replaced by emergency room unreimbursed care, and by some community health centers (expanded by the ACA) that take insurance but also serve the uninsured.

                •  KSLV - most physicians don't want to be on salary (1+ / 0-)
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                  or have a boss who tells them what hours they have to work. Those that do work for Kaiser, or other similar groups, and there is nothing wrong with that at all. However, most US physicians like being economically independent and have no interest in being a US government employee earning US government employee compensation.  

                  "let's talk about that"

                  by VClib on Fri Oct 12, 2012 at 07:02:28 PM PDT

                  [ Parent ]

                  •  May be changing (0+ / 0-)

                    Kaiser Permanente has about ten applicants for every opening, at least in NorCal. So that means there are 9 physicians who would like to be in a large group practice for every one who gets a spot in KP.

                    •  MP - the 9:1 number is misleading (0+ / 0-)

                      I know the Kaiser people well. Every time a physician applies for an available job they are counted as a new applicant, even if the same person has applied 25 times. That being said Kaiser is attracting top flight physicians, particularly young doctors who don't want to take the risks of private practice. Kaiser is the future healthcare model, they actually make more money if they keep you well or they can take care of you on the Internet or by phone. Every time you don't come to see them saves them money, which is the opposite of the fee for service model. The Kaiser physicians have their own corporation who provide services to Kaiser facilities. This structure gives them more autonomy than one might think.

                      There is no doubt that healthcare delivery is consolidating. My primary care physician, a top internal medicine practitioner, recently joined one of the mega groups in the SF area. He is in his early 50s, has a full practice and does not take new patients. He has no Medicaid patients, and stopped taking new Medicare patients five years ago, so his payer mix is well above average. With increasing downward pressure on reimbursement he decided to accept a salary for the first time in his professional career. He based his selection of which group to join based on several factors, his autonomy, work schedule, and total compensation. As part of the change he is earning somewhat less, but has reduced his hours trading off free time for less cash. If someone told him he would be working for the US government, he would retire. And that is why the Canadian model is the only transition for us.  

                      "let's talk about that"

                      by VClib on Sat Oct 13, 2012 at 10:33:57 AM PDT

                      [ Parent ]

      •  Recall that it was Lieberman that killed medicare (1+ / 0-)
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        for younger people.

    •  and by the logic noone wants to talk about (8+ / 0-)

      if we have a medicare BUY IN for people 55- 65
      it would LOWER cost per person

      This buy in could be bore mostly by employers of these middle age  people so it wouldn't add any cost to medicare and probably extend the life of medicare.

      "Although it is not true that all conservatives are stupid people, it is true that most stupid people are conservative." - John Stuart Mill

      by smartone on Fri Oct 12, 2012 at 10:49:43 AM PDT

      [ Parent ]

      •  Lots of people would grab this (8+ / 0-)

        There are lots of people 55-65 with employer provided health care who actually could afford to retire or switch to contracting/ independent consulting but they can't bc they have PECs and need to keep their employer plan.

        ACA SHOULD take care of this but an early Medicare buy in would be great.  These folks want to pay for insurance, the problem is the insurance companies don't want them at any price.  It is more lucrative to charge less but insure 30 year olds.

        Newt Gingrich: Believes marriage is between one man and a series of ever younger women. Wife #1 born ~ 1936, divorced when in her mid-40s...Wife #2 born ~1947, divorced when in her mid-40s...Wife #3 born ~1966.

        by trillian on Fri Oct 12, 2012 at 11:37:09 AM PDT

        [ Parent ]

    •  And more people would die before reaching 70 (12+ / 0-)

      so Medicare wouldn't need to cover them.

      I think republican leadership might view this as a plus.

      Shop Liberally this holiday season at Kos Katalog

      by JamieG from Md on Fri Oct 12, 2012 at 10:50:10 AM PDT

      [ Parent ]

    •  Not necessarily. Those who enter (2+ / 0-)
      Recommended by:
      kurt, NWTerriD

      Medicare having been continuously covered by health insurance cost Medicare significantly less than those who enter without prior insurance.  Unless you raise the age to whatever number it might be that enough people die off and never get to Medicare age, you simply have more expensive people entering Medicare by raising the age.  

      I was wise enough to never grow up while fooling most people into believing I had. - Margaret Mead

      by fayea on Fri Oct 12, 2012 at 04:14:13 PM PDT

      [ Parent ]

    •  Screwed=dead nt (1+ / 0-)
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