Will We Eventually Insist on Medicare for Everyone?
I highly recommend for your reading a slim 72 page volume written by Dr. Tim Johnson, ABC News Senior Medical Contributor, titled The Truth About Getting Sick in America: The Real Problems with Health Care and What We Can Do (Hyperion: 2010).
In addition to his impressive medical credentials, Dr. Johnson is an ordained Protestant Clergyman (I had the privilege of worshipping for 14 years in the Evangelical Covenant Church in West Peabody, MA where he has served as an associate pastor for many years). As a “follower of Jesus,” he draws on the Parables of the Good Samaritan (Luke 10) and the Final Judgment (Matthew 25) to argue that “it is impossible to be both a true follower of Jesus (or many other religious leaders and prophets) without also advocating basic health care for all” (p. 57).
But, in that light, the Affordable Care Act gets mixed reviews; “The good news is that the newly passed health care bill should eventually provide some kind of health insurance … to more than 30 million Americans now uninsured. The bad news is that the bill does not provide any assured way of controlling costs and guaranteeing quality” (p. 71).
Johnson does present some common sense proposals for control of medical costs. His most cogent proposal, in my estimation, is that the health care system needs to get away from an “ultimately disastrous financial incentive,” whereby “the more you do [as a doctor or hospital] the more you make” (p. 15). For example, he believes “we must pay all our doctors by salary … and a key component of that salary should be outcomes [not the number of procedures and tests that are ordered],” citing the fact that “some of our best health care facilities, such as the Mayo and Cleveland clinics, pay their doctors by salary in order to free them up from making decisions based on how much more money they could make” (pp. 18-19).
Dr. Johnson proposes some other cost-cutting measures, such as the creation of national information technology standards (p. 64). But in the end, Dr. Johnson is not optimistic as to the large-scale possibility of the cost-cutting measures that he proposes gaining much traction because “the political and economic pressures (for jobs and profits) from the medical-industrial complex will override truly significant cost control” (p. 71).
So, what to do? Johnson proposes that “there is no way to get costs and quality under control without a strong role for the federal government” (p. 31), by creating “a sensible partnership …[with] private industry” (p. xii). He cites the “congressional plan” that members of Congress participate in as example of such a partnership, since it “strikes a balance between choice and oversight” by means of an “insurance exchange” program (pp. 33-34). Johnson therefore applauds the “insurance exchange” aspect of the Affordable Care Act, scheduled to be established at the state level by 2014, since “health insurance companies will be competing for your business,” which “Conservatives” will like, and the Federal Government will “play a strong role in order to guarantee that all insurance companies play by the same rules and standards,” which “Liberals” will like. Johnson only bemoans the fact that these state exchanges are not scheduled to be operative until 2014; and he strongly urges “government planners to push up that starting date as much as possible” (p. 69).
But, after making what I take to be some excellent proposals, Johnson does not envision adequate implementation in the near future in light of the current political and economic climate. Hence he concludes his book with an extremely provocative “Big Prediction”: “No matter what legislation Congress develops this year or in the years to come, health care costs will continue to rise. Within five to ten years, health care costs will be so out of control that we – the public – will demand that the government bail us out. At that point, the easiest and quickest action will be to expand Medicare to cover everyone” (p. 60); a “public option as the only insurance choice for everyone” (p. 47).
I can’t imagine a more controversial prediction as to the future of health care in the United States. I welcome your comments.
Obviously, "healthcare" and health "insurance" are extremely complicated issues. Ironically, when I was a poli sci major back in 1982, in one of my classes I had to debate "national health insurance" and took the side advocating for it. Now, working in the healthcare industry for the past five years (but by no means speaking on behalf of my employer), it would benefit our clinics and hospital if everyone was indeed covered by at least some minimum level of insurance, for the way it is now, uninsured or underinsured individuals sometimes wrongly use the ER (expensive) and/or simply do not pay their bills, leaving the health system with over a million dollars in "bad debt" each year. Also, what many people don't know is, a critical access hospital (CAH) gets reimbursed by Medicare, just one percent more than the costs to provide patients services. One percent. From another perspective, I know of people who consider their health care "free." Since they don't have to pay anything for it, they too "abuse" it, through use of the ER or even other medical services that, if they did indeed have to pay for it, they may be better stewards of their own health and well-being, and make better choices. One of the unanswered questions, I believe, is, what level of insurance will people be required to have? Everything including clinic co-pays, or only "catastrophic" coverage? Recently the leader of one of our local major employers told me that, despite the fact that their business offers incredibly affordable and really good health insurance, there are lots of employees, many who are immigrants who likely don't understand the need for "insurance," who elect not to take out the company insurance and pay the premiums, and then are un-insured; again, often resulting in use of the ER or not paying their medical bills, or if they do, find it difficult to pay them at times. If carrying health insurance is a requirement for all Americans, through a "tax" system, will this include these people as well? Finally, one thing to note regarding "fee for service" issues. Doctors don't just order tests and procedures to make money. Often they order them to ensure that they don't miss something and then get sued for extreme amounts of money. And sometimes, too, patients demand that their doctor "find an answer" to some ailment, and somehow feel duped if they don't do a bunch of tests in an attempt to cure their problems. Finally, having worked in the medical device design and manufacturing industry for 10+ years, and getting to know how "reimbursement" through CMS works, I understand how a medical provider has to choose what kinds of services and even products they use in patient care based on whether or not they will get reimbursed for it. Let's face it: they can't offer something if Medicare or insurance won't pay them for it, because they need money to pay their employees, their heating and cooling bills, and their own malpractice insurance. One time I flew to Baltimore to do a presentation at CMS to try to get a reimbursement code for a new device/procedure designed to greatly improve the accuracy of radiation delivery for cancer patients. It was nearly impossible to get the code, and so our customers (radiation oncolocy centers) had to wait to use this new technology until they could get paid//reimbursed. Like I said, these issues are more complicated than most Americans realize.
In a personal email response to my report on the provocative prediction from Dr. Tim Johnson that health care costs will eventually “be so out of control” that the public will “demand that the government bail us out” by expanding Medicare “to cover everyone,” a friend of mine posed two simple questions: “Who will pay for the Medicare? How”?
Of course, these simple questions do not have simple answers. Although I certainly am not speaking for Dr. Johnson, let me give the outline of my own personal response.
These questions raise once again the thorny issues related to the federal budget that were addressed in some detail in our very first APC conversation on the topic of “The Federal Budget Deficit” (which illustrates the fact that although our Alternative Political Conversation deals with one topic at a time (e.g, Health Care, The Federal Budget Deficit), many of these topics are inter-related, which further complicates political life).
In our conversation about the Federal Budget Deficit, there appeared to be general consensus among our “regular commentators,” who situate themselves at various points along the political spectrum, that the solution to our federal budget deficit problem will require BOTH a cutting of federal expenditures and increased revenues (by means of some kind of tax reform), although they disagreed on which of these two approaches should be tackled first. In the pointed words of Amy Black: “Can we adequately reduce the current federal budget deficit by only enacting cuts in federal expenditures? No. Can we do so solely by enacting tax reform? No. The only way to address our current budget deficit problem is to rein in spending, revisit the tax code with the understanding that we likely need to increase some taxes, end many tax breaks and fundamentally reform existing entitlement programs. Everything has to be on the negotiating table.”
Now that everything is out on the table, so to speak, let me give the broad outline of how I would proceed. On the cost-cutting side, I embrace Dr. Johnson’s prescriptions for cutting health care costs, including possible changes in the Medicare (and Medicaid) programs (as well as some cost-cutting changes in social security, such as increasing the retirement age).
But just cutting costs will not be sufficient to provide “Medicare for all.” Steps must also be taken to increase revenues (especially if Dr. Johnson is correct in his prediction that health costs are not going to come down any time soon). Toward the end, I would propose significant tax reform, including the closing of present loopholes and exemptions. But I also believe we need more progressive tax rates where the wealthy pay their “fair share” to cover the costs of entitlement programs.
For those who “wince” at my suggestion that the wealthy have to pay a larger share of the costs of entitlement programs, I argue that the American public needs to create a better balance then now exists between the social obligations that come from a focus on “community” and the freedom that comes from a focus on “individuality” (for the details of my argument, based on my understanding of my Christian faith commitment, see my recent Blog musing on this web site titled “Individuality or Community: A False Choice”).
In a personal email response to my report on the provocative prediction from Dr. Tim Johnson that health care costs will eventually “be so out of control” that the public will “demand that the government bail us out” by expanding Medicare “to cover everyone,” a friend of mine posed two simple questions: “Who will pay for the Medicare? How”?
Of course, these simple questions do not have simple answers. Although I certainly am not speaking for Dr. Johnson, let me give the outline of my own personal response.
These questions raise once again the thorny issues related to the federal budget that were addressed in some detail in our very first APC conversation on the topic of “The Federal Budget Deficit” (which illustrates the fact that although our Alternative Political Conversation deals with one topic at a time (e.g, Health Care, The Federal Budget Deficit), many of these topics are inter-related, which further complicates political life).
In our conversation about the Federal Budget Deficit, there appeared to be general consensus among our “regular commentators,” who situate themselves at various points along the political spectrum, that the solution to our federal budget deficit problem will require BOTH a cutting of federal expenditures and increased revenues (by means of some kind of tax reform), although they disagreed on which of these two approaches should be tackled first. In the pointed words of Amy Black: “Can we adequately reduce the current federal budget deficit by only enacting cuts in federal expenditures? No. Can we do so solely by enacting tax reform? No. The only way to address our current budget deficit problem is to rein in spending, revisit the tax code with the understanding that we likely need to increase some taxes, end many tax breaks and fundamentally reform existing entitlement programs. Everything has to be on the negotiating table.”
Now that everything is out on the table, so to speak, let me give the broad outline of how I would proceed. On the cost-cutting side, I embrace Dr. Johnson’s prescriptions for cutting health care costs, including possible changes in the Medicare (and Medicaid) programs (as well as some cost-cutting changes in social security, such as increasing the retirement age).
But just cutting costs will not be sufficient to provide “Medicare for all.” Steps must also be taken to increase revenues (especially if Dr. Johnson is correct in his prediction that health costs are not going to come down any time soon). Toward the end, I would propose significant tax reform, including the closing of present loopholes and exemptions. But I also believe we need more progressive tax rates where the wealthy pay their “fair share” to cover the costs of entitlement programs.
For those who “wince” at my suggestion that the wealthy have to pay a larger share of the costs of entitlement programs, I argue that the American public needs to create a better balance then now exists between the social obligations that come from a focus on “community” and the freedom that comes from a focus on “individuality” (for the details of my argument, based on my understanding of my Christian faith commitment, see my recent Blog musing on this web site titled “Individuality or Community: A False Choice”).
In a personal email response to my report on the provocative prediction from Dr. Tim Johnson that health care costs will eventually “be so out of control” that the public will “demand that the government bail us out” by expanding Medicare “to cover everyone,” a friend of mine posed two simple questions: “Who will pay for the Medicare? How”?
Of course, these simple questions do not have simple answers. Although I certainly am not speaking for Dr. Johnson, let me give the outline of my own personal response.
These questions raise once again the thorny issues related to the federal budget that were addressed in some detail in our very first APC conversation on the topic of “The Federal Budget Deficit” (which illustrates the fact that although our Alternative Political Conversation deals with one topic at a time (e.g, Health Care, The Federal Budget Deficit), many of these topics are inter-related, which further complicates political life).
In our conversation about the Federal Budget Deficit, there appeared to be general consensus among our “regular commentators,” who situate themselves at various points along the political spectrum, that the solution to our federal budget deficit problem will require BOTH a cutting of federal expenditures and increased revenues (by means of some kind of tax reform), although they disagreed on which of these two approaches should be tackled first. In the pointed words of Amy Black: “Can we adequately reduce the current federal budget deficit by only enacting cuts in federal expenditures? No. Can we do so solely by enacting tax reform? No. The only way to address our current budget deficit problem is to rein in spending, revisit the tax code with the understanding that we likely need to increase some taxes, end many tax breaks and fundamentally reform existing entitlement programs. Everything has to be on the negotiating table.”
Now that everything is out on the table, so to speak, let me give the broad outline of how I would proceed. On the cost-cutting side, I embrace Dr. Johnson’s prescriptions for cutting health care costs, including possible changes in the Medicare (and Medicaid) programs (as well as some cost-cutting changes in social security, such as increasing the retirement age).
But just cutting costs will not be sufficient to provide “Medicare for all.” Steps must also be taken to increase revenues (especially if Dr. Johnson is correct in his prediction that health costs are not going to come down any time soon). Toward the end, I would propose significant tax reform, including the closing of present loopholes and exemptions. But I also believe we need more progressive tax rates where the wealthy pay their “fair share” to cover the costs of entitlement programs.
For those who “wince” at my suggestion that the wealthy have to pay a larger share of the costs of entitlement programs, I argue that the American public needs to create a better balance then now exists between the social obligations that come from a focus on “community” and the freedom that comes from a focus on “individuality” (for the details of my argument, based on my understanding of my Christian faith commitment, see my recent Blog musing on this web site titled “Individuality or Community: A False Choice”).
Dr. Tim Johnson just emailed me his reponses to the two questions posed by my friend: "Who will pay for the Medicare? How?" What follows are direct quotes from Dr. Johnson's email:
1) The answer to the "who will pay" question is easy: As is the case now, it will be the taxpayers (both individual and corporate). The tough question is "how" given ultimately limited tax resources in relation to what seems potentially almost unlimited demand – i.e., when it looks like the supply side from the "medical industrial complex" (a phrase first used by the editor of the New England Journal of Medicine in 1989) is theoretically unlimited.
2) The truth is that every developed country is struggling with health care costs because of this unlimited flow of new drugs,devices,tests, etc. However, almost all other developed countries have been willing to honestly face this question of "hard choices" through various federal government programs/departments aimed at developing "outcomes/results" data to help make more rational, cost effective rationing decisions. We now ration health care in this country based on income, insurance,knowledge, etc. Other countries are trying to do it more rationally and are therefore (generally) making better decisions than those being made in the wide open medical marketplace of this country.
3) Most health care economists estimate that about a third of what we spend on health care in this country is – the word they usually use – "unnecessary" meaning that the money spent doesn't result in measurably better outcomes like life expectancy, survival rates, etc. Now one third of 2.7 trillion is 900 billion – more than enough to (at least currently) provide proven and basic health care to all of our citizens. The huge problem is how to make that happen politically. For sure, the Medicare for All process would have to taken out of the hands of the current "board of trustees" – the Congress – where such tough decision making would be utterly impossible. But when the country is facing national bankruptcy because of health care costs, strange things might happen – just as it did (remember that emergency weekend meeting in Washington?) when it looked like the banking system might collapse.
Dr. Tim Johnson just emailed me his reponses to the two questions posed by my friend: "Who will pay for the Medicare? How?" What follows are direct quotes from Dr. Johnson's email:
1) The answer to the "who will pay" question is easy: As is the case now, it will be the taxpayers (both individual and corporate). The tough question is "how" given ultimately limited tax resources in relation to what seems potentially almost unlimited demand – i.e., when it looks like the supply side from the "medical industrial complex" (a phrase first used by the editor of the New England Journal of Medicine in 1989) is theoretically unlimited.
2) The truth is that every developed country is struggling with health care costs because of this unlimited flow of new drugs,devices,tests, etc. However, almost all other developed countries have been willing to honestly face this question of "hard choices" through various federal government programs/departments aimed at developing "outcomes/results" data to help make more rational, cost effective rationing decisions. We now ration health care in this country based on income, insurance,knowledge, etc. Other countries are trying to do it more rationally and are therefore (generally) making better decisions than those being made in the wide open medical marketplace of this country.
3) Most health care economists estimate that about a third of what we spend on health care in this country is – the word they usually use – "unnecessary" meaning that the money spent doesn't result in measurably better outcomes like life expectancy, survival rates, etc. Now one third of 2.7 trillion is 900 billion – more than enough to (at least currently) provide proven and basic health care to all of our citizens. The huge problem is how to make that happen politically. For sure, the Medicare for All process would have to taken out of the hands of the current "board of trustees" – the Congress – where such tough decision making would be utterly impossible. But when the country is facing national bankruptcy because of health care costs, strange things might happen – just as it did (remember that emergency weekend meeting in Washington?) when it looked like the banking system might collapse.
Dr. Tim Johnson just emailed me his reponses to the two questions posed by my friend: "Who will pay for the Medicare? How?" What follows are direct quotes from Dr. Johnson's email:
1) The answer to the "who will pay" question is easy: As is the case now, it will be the taxpayers (both individual and corporate). The tough question is "how" given ultimately limited tax resources in relation to what seems potentially almost unlimited demand – i.e., when it looks like the supply side from the "medical industrial complex" (a phrase first used by the editor of the New England Journal of Medicine in 1989) is theoretically unlimited.
2) The truth is that every developed country is struggling with health care costs because of this unlimited flow of new drugs,devices,tests, etc. However, almost all other developed countries have been willing to honestly face this question of "hard choices" through various federal government programs/departments aimed at developing "outcomes/results" data to help make more rational, cost effective rationing decisions. We now ration health care in this country based on income, insurance,knowledge, etc. Other countries are trying to do it more rationally and are therefore (generally) making better decisions than those being made in the wide open medical marketplace of this country.
3) Most health care economists estimate that about a third of what we spend on health care in this country is – the word they usually use – "unnecessary" meaning that the money spent doesn't result in measurably better outcomes like life expectancy, survival rates, etc. Now one third of 2.7 trillion is 900 billion – more than enough to (at least currently) provide proven and basic health care to all of our citizens. The huge problem is how to make that happen politically. For sure, the Medicare for All process would have to taken out of the hands of the current "board of trustees" – the Congress – where such tough decision making would be utterly impossible. But when the country is facing national bankruptcy because of health care costs, strange things might happen – just as it did (remember that emergency weekend meeting in Washington?) when it looked like the banking system might collapse.