Few seniors have actually paid for their Medicare benefits. According to an Urban Institute estimate, the typical retired couple paid $122,000 in lifetime Medicare taxes but can expect to receive benefits worth $387,000. Social Security is another story. There, the average retired couple paid $600,000 in lifetime taxes for $579,000 in benefits. Put together, it’s $722,000 in taxes for $966,000 in benefits. (All figures are adjusted for inflation.)
While Republicans have dug in their heels against further tax increases, many of Obama’s fellow Democrats have refused to consider cuts to popular health and retirement programs that are projected to eat up a growing slice of the nation’s resources.
As a result, the lion’s share of deficit-reduction efforts so far – apart from tax increases – have come from cuts to military and domestic programs, including the $85 billion in reductions that went into effect last week. The nonpartisan Congressional Budget Office projects that those “sequestration” cuts will eliminate 750,000 jobs.
In the end, as Obama himself understands and has told the other side, he is the one who is going to have to sell the notion of unpopular changes — curbing Medicare spending, reducing Social Security benefits or curtailing popular tax breaks — to a nation that says it wants a balanced bargain but may balk when that bargain is translated into painful specifics. After all, Obama is the only dealmaker with no reelection worries.
FBI raids The Scooter Store headquarters and question executives as company is being probed for $100M Medicare fraud
SAN ANTONIO — A seller of motorized wheelchairs and mobility scooters that was raided by federal agents last month has notified workers that their jobs are being eliminated.
Martin Landon, CEO of The Scooter Store, said in an email to employees Tuesday night that the layoffs take effect March 31, according to the San Antonio Express-News (http://bit.ly/WHA38U ). The majority of the employees, about 1,200, work at company headquarters in New Braunfels, about 30 miles northeast of San Antonio.
Healthcare system wastes $750 billion a year through fraud and waste, claims Institute of Medicine
American health care is falling: A new report claims that the roughly 30 cents of every medical dollar is wasted
Is acupuncture essential health care? Weight-loss surgery? Under Obamacare, states choose.
This exhaustive and informative article comprises thousands of words; it requires a subscription.
Bitter Pill: Why Medical Bills Are Killing Us
Fixing medical bills that are just sick
Robyn E. Blumner, Columnist/Editorial Writer
Anyone who has read a hospital bill knows how indecipherable they can be, with charges seemingly inflated beyond belief. I once tried getting an answer from officials at Bayfront Medical Center about why they billed a breast biopsy at more than $12,000, not including fees charged by the radiologist and lab. All I got were vague answers, and no one would break down the cost.
Now comes the timely and attention-grabbing Time magazine special issue on medical billing by Steven Brill that lays bare the truth: Defense contractors selling $600 toilet seats to the Pentagon have nothing on the extortionist billing practices of America’s hospitals.
Brill’s excellent 25,000-word expose, “Bitter Pill: Why Medical Bills Are Killing Us,” sheds light on this opaque world where even nonprofit hospitals, with their tax exemptions and do-gooder images, are profit-generating machines that mercilessly squeeze uninsured patients until they have no assets left.
In nonprofit hospitals where top executives often are paid lavish compensation of $1 million or more, Brill documents how patients are gouged, charged hundreds of dollars for X-rays and other services that Medicare would have reimbursed at little more than $20. In one typical case, a dose of life-saving cancer medicine, already expensive at $4,000, was marked up by the hospital to $13,700 — with no explanation given.
What’s wrong with health care in the United States? This is. Why aren’t medical ethicists, the conscience of the profession, all over it?
For people with health insurance coverage, insurers will negotiate the obscene prices down. But it’s not enough. The bargaining leverage of insurers is often less than that of dominant (and consolidating) hospitals, which allows the system to wildly overcharge. We overspend on health care by $750 billion a year, Brill asserts, more than the gross domestic product of oil-rich Saudi Arabia.
When people level criticism at the Affordable Care Act for not doing enough to rein in health care costs, this is what they’re talking about. But Brill’s discussion of possible solutions falls short. He rejects the most cost-effective and efficient approach, a single-payer or Medicare-for-all type system with reasonable price controls. He says this type of solution would result in lower incomes for many health care providers and allow government to gain more control over the health sector. (And your point?)
Instead, Brill calls for a hodgepodge of policy changes that, to my mind, offer varying degrees of sense and possibility. One of his less workable suggestions is for a tax rate of 75 percent on all hospital profits and salaries of hospital administrators over $750,000. Targeted taxation of that kind is infeasible.
On the other hand, Brill’s call for real transparency in medical billing is an essential consumer protection reform. And, as Brill suggests, we need to put limits on pharmaceutical pricing to bring U.S. drug charges in line with other developed countries. That reform alone would save Medicare $25 billion a year.
For even better ideas, read Princeton economics professor Uwe Reinhardt’s blog at NYTimes.com. An expert in the funding of health care systems, Reinhardt says our problem is that we allow the free market to determine prices for an essential service in a seller’s market. This has led to exploding costs (we pay double or more of what other developed countries do for the same health care goods and services) and rampant price discrimination. The uninsured, who are powerless to negotiate a better deal, can pay 10 times more for the exact same services.
Reinhardt suggests we adopt a system called “price-setting in quasi-markets,” similar to what exists in Germany and Switzerland. States or regions would negotiate fee schedules with associations of hospitals, doctors and other health care providers. Those fees could be structured as fee-for-service or bundled payments and they would be uniform for all payers. Maryland already does this for hospitals. As a side benefit, it would sharply reduce administrative billing costs.
Brill has helped reopen this conversation. It’s a reminder that even with health care reform coming into full effect next year, an overhaul of medical pricing remains one of America’s most pressing issues.
The Insiders: The Democrats’ denial of our debt woes is harmful
Posted by Ed Rogers on March 21, 2013 at 1:22 pm
Neera Tanden, Ruy Teixeira and John Halpin, from the usually honest Center for American Progress, have written a revealing op-ed for The Post that highlights how the left is preventing an honest debate about the budget and our debt and deficit .
As if it were a remarkable insight, the authors have discovered that those who become dependent on government will seek to protect their benefits at the ballot box. Put simply, when the authors state that, “The nation has moved on from the anti-government sentiment of the past,” what they are really saying is that a growing number of Americans are now relying on government benefits and won’t give up those benefits if they don’t have to. For example, the Obama economy has 47 million people on food stamps, and given the tepid growth and lack of economic opportunity, these people are unlikely to vote for any repeal of food stamp benefits.
Republicans aren’t seeking to “starve the government,” as the authors say. Republicans simply recognize that the path we are on is unsustainable. Fair-minded people believe there is a tipping point where too few taxpayers will be trying to support too many beneficiaries.
Secondly, the op-ed is shamefully dishonest about the Republican intentions regarding the budget. For example, the authors refer to the Republican plan as “harsh.” But the Ryan budget is a plan to get America’s fiscal house in order and balance the budget without making any true cuts.
To be clear, we’re not talking about less money, we’re just talking about slowing the rate of growth. Oh by the way, as Sen. Jeff Sessions (R-Ala.) explained on the Senate floor this morning, the Republican plan lets spending grow every year by 3.4 percent, while the current Democratic budget increases spending by 4.9 percent annually. Sessions rightfully pointed out that growing spending at a slower rate is not a cut. While we’ve lost that battle in the media, the truth is still useful from time to time. Democrats are being dishonest about the Republican budget and about government spending.
This brings me to my third point, which is that Democrats are choosing to be silent or are outright denying that we have a serious problem with the growth of our national debt and spending. Not once in this op-ed do the authors mention the words “debt” or “deficit.” This is stunning, given that it is supposed to be a thoughtful piece about our government’s budget and spending. The authors are clearly following the example set by President Obama, House Minority Leader Nancy Pelosi, Democratic Whip Steny Hoyer and other Democrats who have begun to peddle the notion that “we don’t have a spending problem.”
And let’s not forget it was President Obama who, as a senator, once called President George W. Bush“irresponsible” and “unpatriotic” for adding $4 trillion to the national debt during his eight years as president – an amount less than what Obama added to the national debt during his first four years as president. The Democrats are trying to become the party of more and label the Republicans as the party of less. This may be good politics in the short term, but it lets the cancer of our debt grow unabated.
The new liberal approach is to deny the existence of our problems. It’s the ultimate capitulation to their failure in government and it’s harmful to suggest there will be no day of reckoning. The debt is a problem, and it needs to be dealt with in a responsible way. The sooner Democrats recognize this, the better off the country will be.
Repairs to Medicare
By Editorial Board, Published: January 6
ON NEW YEAR’S DAY, President Obama looked ahead to the post-“fiscal cliff” deficit-reduction battles and declared: “I agree with Democrats and Republicans that the aging population and the rising cost of health care. . .[make] Medicare the biggest contributor to our deficit. I believe we’ve got to find ways to reform that program without hurting seniors who count on it to survive.” The question — a tricky one for a president who won reelection in part by defending “Medicare as we know it” — is how to accomplish this feat. Medicare as we know it is not sustainable.
Medicare cost $555 billion in 2012, according to the Congressional Budget Office. The CBO has projected that this number, already 15 percent of non-interest federal spending, will nearly double by 2022. Medicare’s trustees estimate that the hospital insurance fund supported by the payroll tax will run out of cash by 2024, but this is mainly a symbolic threat: The government will draw on general revenue to keep Medicare going. The real threat is that Medicare spending will crowd out other necessary federal endeavors, forcing undesirable cuts, substantially higher taxes, unsustainable borrowing — or some combination of the three.
There are two major reasons for Medicare’s rising costs. The first is the program’s design, often tweaked but left fundamentally intact since its creation in 1965, which basically pays doctors and hospitals fixed fees for whatever they do. At a time of rapid (and often beneficial) medical innovation, the dominant incentive has been to provide more, and more expensive, care. Hence the House Ways and Means Committee’s 1965 estimate that Medicare hospital insurance would cost $9 billion by 1990 fell short by $58 billion. The second reason costs keep going up, of course, is the rising number of elderly eligible for Medicare, which is inevitable; the 50 million beneficiaries today will be 78 million in 2030.
The ultimate solution is structural: to limit growth in expenditures per beneficiary. Easier said than done. Liberals would empower the Independent Payments Advisory Board (IPAB) to stop payment for treatments it deems not cost-effective. The idea hasn’t gotten very far, partly because Republicans denounce it as “rationing.” Conservatives favor “premium support,” which would subsidize seniors to shop among competing insurance plans, but Democrats, the president included, have tarred that idea as a skimpy “voucher.”
It’s unfortunate but not disastrous that no structural solution is, for the moment, politically possible. Not even their advocates can guarantee that a beefed-up IPAB or premium support would work as advertised. The impact of policy changes on health-care costs is notoriously difficult to project. Indeed, the past three years have seen an unexpected and so far unexplained slowing in Medicare spending’s rate of growth. This happy development doesn’t mean that there’s no problem — far from it. But it buys time to mitigate Medicare’s costs incrementally, while working out the partisan impasse over more fundamental reforms.
The problem is that demographic realities make current promises to the middle class, particularly the baby boomer middle class, unsustainable. The number of seniors will roughly double over the next three decades. The average senior takes more than twice as much out of Medicare as he or she pays in. The result is the most predictable, precisely quantifiable economic crisis in U.S. History.
Fortunately, there is no shortage of money-saving ideas, including several that have enjoyed bipartisan support. Gradually raising the premiums that beneficiaries pay for physician and other outpatient services to cover 35 percent of the programs’ costs could generate $241.2 billion over 10 years, according to the CBO, while imposing no additional burden on the poorest 18 percent of seniors.
The current Medicare program includes a hodgepodge of cost-sharing requirements that neither give participants clear incentives to limit consumption of services nor shield them from catastrophic expenses. Therefore many buy “Medigap” coverage — which eliminates out-of-pocket costs, further reducing their skin in the game. The CBO has estimated that establishing uniform cost-sharing and restricting Medigap plans could save $92.5 billion over 10 years.
The Simpson-Bowles deficit-reduction commission found that Medicare could save $46 billion over 10 years by reducing reimbursements to providers for their patients’ unpaid deductibles and co-payments and by reducing the overcompensation of teaching hospitals for treating Medicare patients. Mr. Obama’s fiscal 2013 budget endorsed both ideas. Among the fastest-growing Medicare costs is home health care, projected by the CBO to double to $52 billion in 2021. Imposing a 10 percent co-pay — about $600 on average — for each 60-day episode would save $40 billion over a decade.
Now we’ve saved almost $420 billion — more than the $400 billion in unspecified savings for all federal health programs that Mr. Obama floated in his abortive talks with House Speaker John A. Boehner (R-Ohio) over a “grand bargain” to avoid the fiscal cliff. And we haven’t even mentioned replacing administered prices for such items as durable medical equipment and orthotics with competitive bidding. Mr. Obama’s health-reform law already does this to some extent, but accelerating the phasing in of reform and extending it to more items, such as lab tests, could save the government $38 billion over 10 years, according to the Center for American Progress.
We’re loath to let Washington off the hook for a more permanent, fundamental Medicare fix. But given the uncertainties, political and economic, of that endeavor, pursuing specific incremental reforms is a plausible second-best solution. It won’t be painless, but neither is inaction.
There are only two responses. The conservative approach (which I share) is to change the entitlement system so the federal government does not need to vastly increase taxes. This would involve focusing public benefits on the poor while requiring the wealthy and middle class to accept a greater share of their health costs. The liberal approach is to increase the percentage of the economy taken in taxes well above historical norms to support the commitments of an essentially unreformed entitlement system. But this can’t be done without taxing the middle class.
Social Security Reform and Medicare Modernization Proposals
January 16, 2013
CEOs want to raise the retirement age to 70
Shining a light on Medicare payments
By Charles Lane, Published: January 14
Now costing more than $500 billion per year, Medicare is central to the United States’ fiscal predicament. For this complicated problem, there are many complicated proposed solutions.
But what if we try something simple, like journalism?
In essence, that is the argument that Dow Jones, publisher of the Wall Street Journal, is pressing in a federal court in Jacksonville, Fla. Dow Jones is asking District to lift a 1979 court order that exempted from the Freedom of Information Act all provider-specific data on Medicare payments. Arguments ended in August, and a ruling could come at any time Judge Marcia Morales Howard to lift a 1979 court order that exempted from the Freedom of Information Act all provider-specific data on Medicare payments. Arguments ended in August, and a ruling could come at any time.
Thanks to the 33-year-old injunction, the press and the public cannot examine the treatments individual physicians billed to Medicare or — most important — how much Medicare paid for them. Yet this is a matter of obvious public concern, given that Medicare made $28.8 billion in improper payments in 2011, according to a Government Accountability Office report last February.
Media coverage could be a powerful weapon against waste, fraud and abuse, Dow Jones argues — plausibly, given the Journal’s recent work.
In 2009, Dow Jones and the nonprofit Center for Public Integrity sued the Department of Health and Human Services for access to its database of physician fee-for-service claims. HHS resisted but ultimately agreed to supply a small portion of its information in return for a fee and a promise not to reveal individual physicians’ names.
Even with those limitations, the Journal produced articles in 2010 and 2011 documenting many millions of dollars’ worth of excessive spinal-fusion surgery, questionable prostate-cancer treatments and dubious billing for home health-care services.
More irregularities might turn up if all journalists could comb through Medicare’s records using data-mining techniques. And imagine how many irregularities would be deterred if providers knew that they might be named and shamed.
Doctors, of course, see a threat to privacy — theirs, not patients’, since patients would not be identified no matter how a lawsuit turns out. “Privately employed individuals have a substantial interest in the privacy of their personal financial information, including their income,” the American Medical Association argued in its brief to the court.
The doctors warn of “deleterious effects on the physician-patient relationship.” One physician affidavit avers that “it would undermine my ability to care for my patients if they think that I might be prescribing” a particular therapy “for the money rather than for their well-being.” Public disclosure of Medicare billing would increase such purported misconceptions, because non-experts can’t interpret the data accurately, the doctors claim.
How paternalistic can you get? Information about doctors’ incentives might in fact empower health-care consumers, as it generally does in other markets. Surely patients who got some of the 276 spinal fusions performed by a single Midwestern surgeon in 2008 would have wanted to know, as the Journal reported, that the doctor received more than $400,000 in payments from spine-device makers.
Privacy was the doctors’ argument in 1979, when they first sought, and won, a permanent injunction to stop a Carter administration plan to disclose Medicare reimbursement data.
Though issued by a single Florida district court, the injunction applied nationwide and can be lifted only if the court that imposed it finds, in essence, that times have changed.
They have: Medicare cost a mere $37.4 billion in 1980. For that reason alone, the nation’s interest in cost control today far outweighs doctors’ interest in billing secrecy. Sens. Charles Grassley (R-Iowa) and Ron Wyden (D-Ore.) agree and have introduced legislation to overturn the injunction, though their bill is moving slower than the Dow Jones lawsuit.
In a way, it’s too bad that Dow Jones framed its case as a matter of fighting fraud. It is indeed that. But the vast majority of providers are honest.
Still, doctors’ resistance to disclosure illuminates the mentality bred by a system of open-ended public financing on the one hand and private provision of fee-for-service care on the other.
The latter creates powerful incentives to exploit the former, yet it is often legal to do so. Congress can only partially counteract this design flaw by limiting reimbursement rates and other expedients. And while Medicare makes sense, sort of, to those who must deal with it on a daily basis, who knows how the public would react if people could see, in detail, how the system really works?
Fuller disclosure about Medicare could help curb abuses. Even more important, it might inform a debate about why Medicare spending keeps rising even when everyone does follow the rules.
Why ‘Mediscare’ may not work this time for Democrats
E. Thomas McClanahan
The other day I was watching former Vermont Gov. Howard Dean on CNBC do his best to bash the Medicare reform plan authored by Paul Ryan and endorsed, with a key change, by presumptive Republican nominee Mitt Romney.
Dean botched it and the other panelists called him on it. He simply didn’t know the details.
You can almost smell the panic. Dean and many Democrats try to dismiss the Romney-Ryan plan as a “voucher,” suggesting it would send checks to seniors with a note saying, “This is for your health insurance. Good luck.”
Well, no. Today’s seniors wouldn’t be affected at all; the plan wouldn’t be implemented for 10 years. And the money wouldn’t go to individuals, it would go to providers (see below).
Last week President Barack Obama joined other Democrats in recycling the “end Medicare as we know it” line, which the left-leaning PolitiFact site labeled the “2011 lie of the year.” The original version of Ryan’s idea would have offered only private-sector policies, but the latest iteration includes traditional Medicare as one of the choices. How would that “end Medicare”?
As Yuval Levin wrote at National Review, it is only now dawning on Democrats that it is Obama — not Romney — who would cut Medicare for current seniors. The Congressional Budget Office recently estimated that Obamacare will yank $716 billion from Medicare’s planned spending over the next 10 years.
Under Romney, Medicare wouldn’t change at all during that time. Ryan’s version, adopted by the House, called for the same amount of Medicare savings as Obama, but without endorsing specific cuts — such as Obama’s planned $260 billion reduction in payments to hospitals built into the 2013-2022 budget baseline.
Medicare actuary Richard Foster has estimated that those reductions will cause one in sixU.S. hospitals to become unprofitable. Democrats say they’re committed to saving Medicare, but what good is this “entitlement” if more doctors and hospitals close their doors to new Medicare patients?
Here’s how the Romney-Ryan plan would work.
Seniors would receive “premium support” they could use to purchase insurance, or choose Medicare. The money would flow to government-approved providers. Each policy choice would have to cover the full range of Medicare services.
How much would each person get in premium support? It would be based on annual competitive bidding by participating insurance companies, with the amount based on the cost of the second-least-expensive plan. Seniors who choose the cheapest plan would get a cash rebate. Those who choose the pricier plans would pay more out of pocket. Sick and low-income people would receive more support. Wealthier recipients would get less.
Suddenly, you would have something new in health care — system-wide pressure to offer more cost-effective deals. Insurance companies, eager to offer the most competitive plan under premium support, would push providers to reorganize, become more efficient and combine services. This competitive element would offer a way around Medicare’s innovation-killing, fee-for-service model that pays lousy hospitals the same as good ones.
Historically, politicians proposing entitlement reform lose in the face of hysterical attacks from the programs’ defenders. Two things are different this year. The Obama administration, not Romney, approved cuts in Medicare’s growth for today’s seniors; that means the usual “Mediscare” campaign will have diminished credibility.
And a long-running movie has been playing in Europe, showing what happens when countries refuse to get their fiscal house in order. There’s a good chance Americans don’t want to be in that movie.
Taking health-care reform a step further
By Ruth Marcus, Published: August 16, 2012
If turning Medicare into a voucher program isn’t the answer to controlling the program’s growth, what is? This is the essential question about the federal budget.
Already, health care consumes 25 percent of federal spending, of which Medicare accounts for two-thirds. On the current trajectory, health care’s share of the federal budget will rise to 40 percent by 2037. Recent slowdowns in spending are encouraging, but they can’t be counted on to continue.
So what’s a responsible Democrat to do? As it turns out, 23 responsible Democrats — some of the left’s leading thinkers in the health-care field — have just come up with a set of answers.
The group includes ex-government types such as former White House chief of staff John Podesta; former budget director Peter Orszag; former Obama health-care adviser Neera Tanden; Donald Berwick, who oversaw the Medicare and Medicaid programs; and former Senate majority leader Tom Daschle.
The chief author of the proposal, developed under the auspices of the Center for American Progress and published recently in the New England Journal of Medicine, is Ezekiel Emanuel, another key Obama health-care adviser. Former, of course.
These are not necessarily proposals that incumbent presidents or sitting members of Congress leap to embrace.
Another crucial point is that these are some of the people who helped give birth to Obamacare. They acknowledge that the health-care law, while making an important down payment on reducing costs, is just that: a start.
During the health-care debate, proponents argued that helping control the growth of Medicare costs could have positive ripple effects because its reimbursement policies influence the behavior of private insurers. If Medicare chooses to cover a certain medication or procedure, private insurers tend to follow suit.
Emanuel et al. now make a mirror image, although not inconsistent, argument: that no matter how hard federal officials work to slow the rising trajectory of federal spending, their efforts will fail if overall health-care costs continue to rise.
“Health costs throughout the system drive federal health spending,” they write. “Reforms that shift federal spending to individuals, employers, and states fail to address the problem. The only sustainable solution is to control overall growth in health costs.”
How? The most far-reaching proposal is to have states, with the encouragement of federal grants, put in place a mechanism to set overall health-cost caps, covering both public and private spending.
Massachusetts, having discovered that its Romney-instituted, Obamacare-like version of reform has been great at extending coverage, less good at controlling costs, has recently adopted such limits. Maryland has capped hospital spending.
The argument for these caps is that otherwise costs are not lowered but merely shifted around in a health-care version of hot potato. If Medicare squeezes providers, they charge more to private insurers. If large insurers squeeze providers, they hike costs to smaller insurers.
But to read the proposal is to understand its political perils. “We recommend that an independent council composed of providers, payers, businesses, consumers, and economists set and enforce the spending target,” the authors write. You can already hear the ads warning of “death panels.”
The other proposals involve changes designed both to lower prices and reduce cost growth, building on and accelerating changes in Obamacare.
Medicare and private insurance, the authors argue, should be prodded to change quickly from a fee-for-service system that pays doctors, hospitals and other providers per procedure, thereby encouraging consumption and fracturing care. Instead, it should reward quality and care, paying doctors and hospitals a fixed amount for services. “Within 10 years,” they suggest, “Medicare and Medicaid should base at least 75 percent of payments in every region on alternatives to fee-for-service payment.”
Competitive bidding for medical equipment such as wheelchairs has lowered costs by more than 40 percent, the authors note; this bidding system, rather than having the government fix reimbursement levels, should be expanded, instituted immediately and used by private insurance exchanges as well.
The federal government should give bonus payments to states that ease laws restricting non-physician providers, such as highly skilled nurses, from providing services. Doctors should be shielded from malpractice suits if they adhere to best-practice guidelines.
In other words, the authors do not shrink from ox-goring, and of a rather substantial herd: hospitals, doctors, medical manufacturers and trial lawyers.
This is a valuable addition to an otherwise noisy and unenlightening debate — or it could be, if the candidates would stop practicing bumper-sticker politics and engage on the policy front.
Actually, the share of people who receive federal benefits exceeds Romney’s 47 percent. Based on its Survey of Income and Program Participation (SIPP), the Census Bureau estimates that in mid-2011 — the latest available figures — the number of people with benefits came to 149.8 million, or 49 percent of the population. But this figure is too low, because SIPP doesn’t include several major programs (farm subsidies and college loans and grants). With these, the total probably exceeds 50 percent.
The big programs are well-known. In 2011, Social Security had 49.6 million recipients and Medicare 45.6 million, most of them overlapping. There were 5.2 million Americans with unemployment compensation and 3.2 million with veterans’ benefits. An estimated 107.2 million people received “means-tested” benefits available to those with low incomes. Medicaid had 80.5 million beneficiaries, food stamps 48.3 million and WIC (Women, Infants, and Children) 23.1 million. Among households with means-tested benefits, almost a third received three or more.
Competition and choice in Medicare make a lot of sense
By William McKenzie
The Dallas Morning News Friday October 12, 2012 5:34 AM
In 2008, Barack Obama and Democrats championed better health insurance. This year, it’s Mitt Romney and Republicans who are pressing health reform.
Most headlines are about the GOP’s aim to repeal the Affordable Care Act. Repeal would be a wrong move for political reasons. If Republicans kill Obamacare, Democrats would try to slay GOP sacred cows. The nation would get stuck with a seemingly eternal tit for tat.
Republicans are better off focusing on their ideas to modernize Medicare. Vice Presidential nominee Paul Ryan has made Medicare reform his calling card.
Ryan proposes overhauling Medicare with what Washington’s think-tank land calls a “premium support” model. It would work this way:
Once those Americans who today are 55 or younger become eligible for Medicare, they could choose between traditional Medicare and a private plan. The government would give them a subsidy to pay for fee-for-service Medicare or a government-approved private plan. The amount would be based upon the cost of fee-for-service Medicare or the second-least-expensive private plan, whichever costs less.
The president dislikes this approach. He worries it would weaken seniors’ safety net.
But here’s why this model makes sense: The choice-and-competition emphasis fits the world many people under age 55 are living in.
Just reach into your pocket or purse and pull out your cellphone. Think of all the choices that go with it, from competing apps to different provider plans to various phones.
Choice seems particularly crucial to Americans under 40. Look how often they hop from job to job. And, before entering the workforce, they and their parents likely selected from numerous kinds of elementary and secondary schools. If they went to college, they chose among competitive degree plans.
Navigating among health plans may create anxiety among some of them. But it’s hard to see it being a foreign concept.
The choice-competition-subsidy model, by the way, is the same approach the Affordable Care Act offers the uninsured under age 65. Eligible Americans will receive a federal subsidy to purchase private insurance.
The president notwithstanding, some Democrats support choice-and-competition as a way to stabilize Medicare. Democratic Sen. Ron Wyden of Oregon has co-sponsored legislation with Ryan to promote this idea. Alice Rivlin, Bill Clinton’s former budget director, backs the model. And former Democratic Sen. John Breaux of Louisiana once introduced this approach with then-GOP Sen. Bill Frist of Tennessee.
To be sure, Ryan’s plan limits how much Medicare beneficiaries would receive annually. He’d cap the rise in Medicare payments to the level of growth in the gross domestic product plus half a percentage point. If the economy grows at, say, 3 percent (let’s hope!), Medicare benefits would increase by 3.5 percent.
No fair, some scream. And, lately, Romney has hinted he may not support limits.
Backing off limits would be a mistake. Choice and competition can save money. Medicare’s prescription-drug offering shows that; it has come in under budget, thanks to seniors choosing among private plans.
But choice and competition alone may not always control expenses. And if Washington doesn’t do something to corral Medicare’s costs, the system won’t sustain itself. Its primary trust fund already is headed toward extinction in 2024.
So, we need some sort of cap on Medicare, which is one of the Affordable Care Act’s better policies. If Medicare spending exceeds annual targets, eventually getting to the rate of GDP growth plus 1 percentage point, the law would let independent experts recommend reductions.
Some conservatives see this as Big Government on steroids. That’s a stretch. What’s really worrisome about the panel is that Congress would never uphold its reductions or match them with an equivalent amount elsewhere in the budget. Where would we be then?
In bad shape, which is why we should focus on providing seniors choices and limiting Medicare expenses.
Sunday October 7, 2012 3:22 AM
My wife, 67, and I, 69, got an unpleasant surprise when we received notice that our Medicare Advantage premiums will increase $864 in 2013. This increase is painful to us and other senior citizens on our plan.
President Barack Obama told us in his 2009 speech to Congress that he would “protect Medicare.” His administration is falsely telling many seniors that their Medicare Advantage premiums will rise only a little bit.
According to the Department of Health and Human Services, seniors should expect only very small increases in their Medicare Advantage premiums, $1.47 or if they are in low-cost plans, 57 cents. For my wife and me and other seniors with Medicare Advantage, that is not true.
Health care for an additional 20 million to 30 million people under Obamacare will cost hundreds of billions of dollars. To pay for part of that cost, the government takes money meant for the Medicare Advantage plans and redirects it to pay for Obamacare.
By Robert J. Samuelson, Published: July 22, 2012
It’s no secret that the states are in as much budget trouble as the federal government. Doubters should read a new report from a group headed by former Federal Reserve chairman Paul Volcker and former New York Lt. Gov. Richard Ravitch. By this account, states face four insistent forces: pension underfunding of at least $1 trillion; rapidly rising Medicaid spending; possible cuts in federal aid that provides $1 in $3 of state spending; and weak growth of tax revenue that, in 2011, remained 7 percent below its pre-recession peak.
What looms are higher state taxes and reduced services, affecting schools, police, parks, prisons, public universities, roads and social services. Up to a point, cuts may not do much damage; every government has waste. But we are rapidly passing this point.
Can we do anything? Well, yes. We could nationalize Medicaid — the federal-state health insurance program for the poor. We could transfer all its costs to the federal government; in exchange, the federal government would end state aid for K-12 education and transportation. Though initially a dollar-for-dollar swap, the change would give states more control over their budgets.
Created by Congress in 1965, Medicaid is hijacking state politics. Although the federal government covers a majority of costs (typically, 57 percent), the rapid rise in the states’ share compels cuts in other programs or steeper taxes. In the past decade, Medicaid spending has increased at nearly twice the rate of states’ tax revenue, notes the Volcker-Ravitch report.
The pressures will only intensify as America ages. Although Medicaid serves primarily a younger population (half are children), two-thirds of its costs stem from the 25 percent of much sicker beneficiaries who are elderly and disabled, reports the Kaiser Family Foundation. An older America will raise these costs and squeeze states’ other services.
This makes no sense. It expands the bias — already entrenched at the federal level — to favor the old over the young, the past over the future. And it underlines the need to control health spending, which increasingly is the crux of the national and state budget problems. In 2011, health spending represented 27 percent of the federal budget, up from 14 percent in 1990. For states, Medicaid spending was 24 percent of spending if all state funds, including federal grants, are counted, and 17 percent if only funds from state taxes are measured.
The Obama administration’s effort to expand Medicaid has further focused attention on states’ fears. Under the Affordable Care Act, Medicaid coverage would be extended to an estimated 17 million Americans. But the Supreme Court ruled that states can’t be forced to join. Some states — headed so far by Republican governors — have indicated they won’t, fearing the added costs. Although the federal government will initially cover those costs, it’s reasonable to worry that some future deficit-reduction package might shift more spending to states.
That’s one reason it makes sense to nationalize Medicaid. The idea dates back to at least the early 1980s, when then-Tennessee governor (now senator) Lamar Alexander proposed a “grand swap”: The federal government would assume responsibility for Medicaid and states would surrender federal aid to K-12 schools. Slightly modified, the switch still works. In 2012, states will spend about $200 billion on Medicaid. Against that, federal aid to states for schools and training totals $105 billion and construction grants (mostly for highways and transit systems) amount to $96 billion, says the Volcker-Ravitch report.
Spending and political accountability ought to be aligned. Only the federal government can devise a solution to control health costs; concentrating government health spending at the federal level would intensify pressures to do so. (States have tried mightily to control spending with at best partial success. For example, Medicaid reimbursement rates average only 72 percent of Medicare levels. The low rates have caused some doctors not to accept Medicaid patients.)
By contrast, federal school aid is only about 10 percent of the total; it mainly gives federal officials leverage to meddle in local affairs with little gain in student achievement. The same logic applies to transportation. We already have the Interstate Highway System. The benefits of better roads, transit systems or more bike paths are enjoyed mostly at the state and local levels, which is where the costs — how much to spend and on what — should be decided.
By itself, resurrecting Alexander’s grand swap wouldn’t solve states’ budget squeeze. Remember those underfunded pensions and slow-growing taxes. But it would help. This is one of those pragmatic proposals that ought to unite liberals and conservatives. Unfortunately, history suggests pessimism. President Ronald Reagan actually proposed a swap in 1982. It went nowhere, no doubt because it threatened the power of congressional committees and interest groups. Then as now, the status quo had a stranglehold on the future.
Clueless about Medicare
By Bryan R. Lawrence, Published: May 30, 2012
Bryan R. Lawrence is founder of Oakcliff Capital, a New York-based investment partnership.
Medicare may be the most sacred government program in the United States — even 76 percent of tea-party supporters oppose cuts to it, a McClatchy-Marist poll found in November. Given its central role in our fiscal challenges, it makes sense to examine why this program is so popular.
There are two key factors. First, retired Americans receive high-quality care but have virtually no idea what their Medicare benefits cost. The George W. Bush administration required Medicare to begin providing such information, but it is presented in a way that makes it hard to understand and is read only by people who request it. (The Medicare Web site even cautions that the “files are large so printing them is not recommended.”) While not every retiree takes the time to study the cost, almost all rely on the benefits.
Second, every working American has Medicare taxes deducted from each paycheck and has been told that the money is paid into a trust fund for his or her future benefits. It’s not surprising that Americans feel proprietary about Medicare — they believe that they have spent their working lives paying for their future benefits.
But those Medicare taxes, and interest on the program’s small trust fund, cover just 38 percent of the annual cost of the program’s benefits. Premiums paid by beneficiaries cover an additional 12 percent, but fully half of the program’s $549 billion cost last year was funded by federal income taxes on working Americans.
Put another way, Medicare is a transfer of wealth from younger to older Americans.
As long as the baby boomers were working and paying taxes, their large numbers made this transfer to their parents and grandparents affordable. But the boomers began to retire last year. In its 2011 annual report on the nation’s financial position — compiled in conjunction with the Office of Management and Budget — the U.S. Treasury described the federal government’s finances as unsustainable. Treasury Secretary Timothy Geithner, in testimony to Congress this year, cited the ballooning cost of the transfer inherent in Medicare as a key driver.
The net present value of the transfer — the amount that would have to be set aside today to fund Medicare’s future intergenerational promises — has grown to at least $25 trillion, as calculated by the Government Accountability Office. This number is buried in footnotes of the annual Treasury-OMB report and is so large (almost twice the $14 trillion value of all public U.S. companies) that it defies comprehension. It’s not surprising that Americans can’t relate the alarming cost of this transfer to their own lives.
But recent work by the Urban Institute calculates the amount of the transfer to an average retiree. An American man retiring in 2011 could expect to receive Medicare benefits worth $170,000 (in 2011 dollars). If he had worked from age 22 at the average U.S. wage each year, he would have paid Medicare taxes (plus interest) worth $60,000 (also in 2011 dollars). So the average male worker retiring in 2011 will receive benefits worth almost three times what he paid in. And the transfer to that retiree will be $110,000 from younger Americans, perhaps including his grandchildren.
If that average worker had a wife who didn’t work, she would receive $188,000 worth of benefits, despite having paid nothing in. So the couple’s benefits are six times what was paid in, or a $298,000 transfer from younger generations.
A bill introduced in the House last year by Reps. Jim Cooper (D-Tenn.) and Paul Ryan (R-Wis.) would require the federal government to provide all adult Americans with an annual, personalized calculation of these numbers. As with the annual letter showing what we have each paid into and can expect to get out of Social Security (to save postage, these are no longer sent out but are made available online), this would alert each of us to the amount of benefits we are expecting from younger Americans.
Would Americans be as satisfied with Medicare if we were reminded each year about the hundreds of thousands of dollars that our retirement will cost our grandchildren?
The good news is that this problem is fixable.
Other countries spend far less on health care and have better health outcomes. Reform of our health-care system would dramatically reduce the cost of future Medicare benefits and reduce the tax burden on future generations. But Americans are angry with their elected leaders, and they lack the information critical to understanding the need for change.
Our toxic politics are not helped by our government’s dubious accounting standards and poor disclosure. We deserve better information and an honest discussion of our choices.
It’s the welfare state, stupid
Taking health-care reform a step further
Scare tactics? Which party can claim the moral high ground? Here’s something scary. Politicians, like bureaucrats, are reluctant to act, preferring the status quo. Wake up, wise up, except for the ideologues in the Congress, politicians prefer re-election rather than action to confront America’s problems: illegal immigration, energy, free trade… Forget about raising the debt limit until it’s too late and the economy is damaged. Medicaid and Medicare? Changes must be made, means testing at the least, or nothing will be left for anyone. China will loan US money indefinitely to pay for hip replacement? Unlikely.
Paul Ryan gets a taste of his own shameless demagoguery
By Dana Milbank, Published: May 25
If history, as Mark Twain said, does not repeat itself, this must be one of those weeks when it rhymes in unusually precise pentameter.
On Wednesday morning, Rep. Paul Ryan (R-Wis.), author of the House Republicans’ plan to end the Medicare guarantee, awoke to find that his plan was being blamed for the loss of a solidly Republican congressional seat in a New York special election on Tuesday. So he headed over to the cameras in the Cannon House Office Building Rotunda to vent about Democrats’ “Mediscare” tactics.
“The president and his party have decided to shamelessly distort and demagogue Medicare,” he protested to his former House GOP colleague Joe Scarborough, now host of MSNBC’s morning show.
Moments later, he took his complaint to Fox News morning man Steve Doocy. “It’s a preview of the scare tactics, distortions, demagoguery, to try and scare seniors,” Ryan charged.
He’s right about that. Democrats and, particularly, liberal activists, are engaged in some shameless demagoguery (one group’s ad shows a Ryan look-alike pushing an old woman and her wheelchair off a cliff). And Ryan is well qualified to call out shameless demagoguery and scare tactics: Over the past two years, he has practiced both.
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.
Demagoguery is just one way in which the fight over Ryan’s Medicare reform has followed the rhythm of President Obama’s health-care reform. In both cases, the proponents decided to act without bipartisan support. Opponents whipped up opposition at televised town-hall meetings. Proponents discovered that their nuanced explanations of the policy couldn’t compete with the other side’s shrill sound bites. Endangered lawmakers began to waver, and voters registered their disapproval in special elections (Scott Brown in Massachusetts, and now Kathy Hochulin New York). But the advocates, figuring the public would side with them once all the facts came out, refused to budge.
One difference is Republicans have no chance of enacting Ryan’s plan this year or next — a point Senate Democrats made anew on Wednesday by scheduling a symbolic roll call to vote down the plan. But Democrats are determined to take the issue to voters in 2012, the way Republicans did in 2010 with health care. After Tuesday night’s victory — involving the New York seat once held by Ryan’s mentor, Jack Kemp — Rep. Steve Israel, who runs the House Democrats’ campaign, called it “a very serious warning sign to Republicans who would continue this reckless scheme to terminate Medicare.”
Ryan responded just as the Democrats had responded during the health-care fight: with bookish analysis. Ryan, on Scarborough’s show, went into a numbing discussion of Burkean conservatism, the Brookings Institution and long-forgotten government commissions.
“Paul, so that took you about two, two and a half minutes to explain,” Scarborough pointed out.
“That’s the problem,” Ryan acknowledged.
Yet even 2 ½ minutes was more succinct than Ryan’s earlier effort Wednesday: a 4-minute, 54-second video that employs stick figures, dotted lines and drawings of dollars, doctor bills and medical symbols with snakes.
Ryan might be worthy of more sympathy if he hadn’t been one of the people clubbing Democrats with slogans about trampled liberty as they labored to explain exchanges and cost curves. Now Ryan is the one trying to define the narrow difference between “premium support” and “vouchers” while Democrats accuse him of forcing seniors into destitution.
To his credit, Ryan acknowledged on Wednesday that his own side had been guilty of the same. “Both parties do this to each other,” he told CNBC’s Maria Bartiromo at a forum Wednesday hosted by the Peter G. Peterson Foundation. “Every time you put out a reform plan to fix this, the other party uses it as a weapon against you.. . .What that ends up doing is inflicting political paralysis.”
Ryan had a chance to break this historical cycle when he released his budget. But instead, he cast aside bipartisan solutions and said he wanted to take the issue to voters. Democrats gave him exactly what he asked for.
Wake up Mr Milbank, these programs are ponsi schemes at their worst. And now the pyramid is getting ever smaller at its base, which is why they must be reformed. We have less people putting in and more people taking out, just how do you make that work? The answer is, it doesn’t. Stop with the lies and start being honest with the readers, there really isn’t a free lunch, we all pay sooner or later.
Today 5/26/2011 4:55:26 AM EDT
How are the Democrats engaging in demagoguery? They are simply describing what Ryan’s plan does. It will make medical care unaffordable or even unatttainable for millions of America’s poor and elderly citizens. And this is being proposed so as to avoid ending tax cuts on the wealthiest Americans. The President has already said that he would support spending cuts including modest changes to Medicare and Medicaid if Congress also agreed to eliminate the tax cuts. That is what should be done.
Today 5/26/2011 4:41:33 AM EDT
Paul Ryan is channeling former General William Westmorland: “We have to destroy Medicare in order to save it.”
Today 5/26/2011 4:29:07 AM EDT
The interesting part is that two years ago the Republicans claimed that the health care reform law would endanger Medicare as we know it. They used the claimed threat to Medicare to whip up fear and fury against the legislation, especially among seniors. Republicans shouldn’t be surprised that the Ryan proposal to fundamentally alter Medicare would be met with the same fear and fury. If they are surprised by the reaction it might be because they don’t realize that you can’t play subtle spin games with Medicare. People have fully embraced the program. You can tweek it, but you cannot take it away. Medicare is not a messaging plaything. It is the health care light at the end of the tunnel for most Americans. It is hope that they will have full access to the medical care that will make ageing bearable. It was cynical of Republicans to use Medicare to manipulate voters. It is stupid of them to think they can mess with it without raising voter ire.
Today 5/26/2011 4:28:20 AM EDT
Milbank writes a piece blaming someone else of “shameless demagoguery.” Amazing. He can’t possibly have a mirror left in the house.
Today 5/26/2011 4:27:00 AM EDT
Obamacare cut $500 billion from Medicare.
Medicare sucks. I am scared as hell that I will be relying on this stupid bankrupt program when I get old. The best benefits seem to be doctors don’t want it and Obamacare has a panel to ration it.
Too bad WaPo can’t investigate Obamacare waivers and pretend FOIA does not exist. The White House does whatevs and there are no journalists to ask them why don’t they comply with laws they passed.
Today 5/26/2011 4:23:31 AM EDT
Crazy, expensive patchwork system. Time for Single-Payer!!!
Today 5/26/2011 4:05:37 AM EDT
Insurance Executive Compensation 2007
Aetna Ronald A. Williams: $23,045,834
Cigna H. Edward Hanway: $25,839,777
Coventry Dale B. Wolf : $14,869,823
Health Net Jay M. Gellert: $3,686,230
Humana Michael McCallister: $10,312,557
U.Health Grp Stephen J. Hemsley: $13,164,529
WellPoint Angela Braly (2007): $9,094,271
L. Glasscock (2006): $23,886,169
Insurance Executive Compensation 2008
Aetna, Ronald A. Williams: $24,300,112
Cigna, H. Edward Hanway: $12,236,740
Coventry, Dale Wolf: $9,047,469
Health Net, Jay Gellert: $4,425,355
Humana, Michael McCallister: $4,764,309
U. Health Group, Stephen J. Hemsley: $3,241,042
Wellpoint, Angela Braly: $9,844,212
Today 5/26/2011 2:25:55 AM EDT
Mr. Milbank sounds like the biggest demagogue ever… Democrats using fear to get old people to vote for them? No, that’s not demagoguery. Republicans saying, “Stop spending” – oh no, man the brigades.
Mr. Ryan is no more a “demagogue” than Mr. Milbank is a “journalist” or the WaPo or NYTimes actually objectively report “news.”
Today 5/26/2011 2:04:22 AM EDT
The funniest part of Ryan’s reaction so far has been his absolute disbelief that his plan could have upset seniors. “But this doesn’t affect any of them,” he mewled on Fox. “There are no changes for anyone over 55 now.”
Apparently, he’s incredulous that current seniors aren’t behaving in the selfish and greedy way his philosophy predicts everyone should act, and are voting against him. Imagine that! — a social reaction to a change in a social plan!
Either that, or seniors can see that after the Republicans cut off the plan for one age group, they’ll be emboldened to come after the rest.
Meanwhile, all this hand-wringing over costs to the national budget of providing healthcare to a fraction of the population is hilarious. For less public money than we spend (adjusted for total population, including the privately insured and the uninsured), the UK manages to cover everyone in their entire country in a public plan. Instead of trying to break up a patchwork system and make it even more patchwork, we could much more substantially slim the national budget, while raising real net income for individuals and companies (except for the health insurance sector, natch), and even improve health outcomes, by accepting “socialized medicine”. There’s no reason England can make this work while we can’t.
As for quality of care, my brother-in-law in England has been going through hell with colon cancer these last few years. Despite being given two years at the outset to live, National Health has been aggressively treating him these last four years with compassionate care and excellent results, long after I think health insurers in the US would have balked at paying for experimental treatments and repeated courses of drugs, and surgeries to repair some of the collateral damage. For all the hell he’s been through, none of it has involved filling out forms, paying bills, or arguing for treatment, and he manages to have some decent quality of life in between hospital visits. The phrase “socialized medicine” has a pejorative quality it just doesn’t deserve. National Health is actually pretty decent. And, did I mention it’s way more cost effective, with easier to control growth curves than either single-payer or private health?
Today 5/26/2011 1:36:26 AM EDT
Can we now derisivley call this Ryancare?
Today 5/26/2011 12:23:35 AM EDT
This is what happens when 17th century economic philosophy runs into 21st Century reality.
It’s hard to argue that something is impossible when every other industrialized country manages to do it. In the end, he’s become a billboard for a single payer health system now that everybody agrees that a for profit health care system is untenable.
Today 5/26/2011 12:08:53 AM EDT
Wow Dana ,, You hit the nail ( I mean the Nitwit Ryan) on the head! keep up the good articles!
Today 5/26/2011 12:06:52 AM EDT
It is amazing that the GOP is willing to disown the elderly while kissing the a$$-cheeks of millionaires and billionaires.
The average American is finally catching on to these despicable tactics.
Today 5/26/2011 12:04:39 AM EDT
Medicare in its present format is unsustainable and needs to be reformed. What is the democrats plan to fix this problem. Enlighten me please! Gardiner Harris reported in the St. Louis Post Dispatch on 5/12/11 that Medicare spent $116 million on antipsychotic drugs for elderly nursing home residents with a diagnosis of dementia. It is a well known fact that this is not a good practice as antipsychotics are more likely to lead to sudden death than a cognitive improvement but alas, drug companies do pay kickbacks to psychiatrists and nursing home chains. Should we ask the democrats to work on problems of that nature?
5/25/2011 9:47:46 PM EDT
Good luck with that suggestion, asking Democrats to work. Budget submission from the Majority party of the Senate? Almost 2 years and counting.
Hey, their idols are Wisconsin colleagues who fled the state when real work and representation were needed, and this behavior is still applauded in Democrat circles. Yeah, there is the irony of that word, circles. That is the only direction that party works in.
Incumbency is incompetency. Voting for President is not the important slot in 2012. It is your individual state’s primaries and general election for state and federal representatives that will impact as much if not more for 2013.
5/25/2011 9:55:13 PM EDT