By Ann Troy, M.D.
Marin (County, Calif.) Independent Journal, August 11, 2022
One of the best things about turning 65 is finally being able to get Medicare. Free, at last, from the yoke of health insurance.
For me, this meant no longer having to pay more than $20,000 a year for insurance, then a $4,000 deductible plus co-pays and co-insurance before getting any help with medical expenses. Usually I got none: Being healthy and fit, I was pure profit.
Individuals and families (and their employers) pay huge amounts in premiums, then have to deal with deductibles, co-pays, co-insurance, narrow networks and denials of care.
People without insurance or with high deductibles wait longer to seek help for illnesses and injuries, thus, problems become more deep-rooted and more difficult to treat. Sometimes they die because they wait too long. People stay in jobs they hate rather than going back to school or striking out on their own because they need health insurance. Half of bankruptcies in the U.S. are due to medical debt.
American companies are at a disadvantage compared to companies in other developed nations that are not saddled with the high cost of providing health care. Smaller companies can’t compete with larger ones because they can’t afford to offer health insurance. Unhappiness over health benefits is the leading cause of labor unrest.
The United States is the only developed nation without a national health program. Despite spending double the average per capita spent by other developed nations and almost double the average percent of gross domestic product, we have the worst healthcare statistics in the developed world. On overall measures of health, the World Health Organization ranks us No. 37.
For all of these reasons, I advocate a single payer system or Medicare for all.
Medicare, as originally set up (aka “traditional” Medicare), allows seniors to go to almost any doctor, clinic, lab and hospital in the country. Medicare pays 80% of their contracted rate for outpatient services and the patient is responsible for the remaining 20%.
When first signing up for traditional Medicare, seniors can also opt to purchase “medi-gap” or supplemental insurance that pays the additional 20%. There is a small monthly premium to pay for the peace of mind of knowing that is all you will pay.
The existence of traditional Medicare is being threatened by the health insurance industry with the establishment of Medicare Advantage plans and, more recently, Direct Contracting Entities (DCEs), Accountable Care Organizations (ACOs) and Realizing Equity, Access, and Community Health (REACH) plans.
Medicare Advantage plans attract seniors by offering perks such as gym memberships, and some vision, hearing, and dental care (not offered by traditional Medicare) but they come with all the things we hate about insurance: narrow networks, co-pays, deductibles, and denials of care.
What’s worse is that patients with traditional Medicare are being enrolled without their knowledge or consent into DCEs, ACOs and REACH. The only way out is to find another doctor, one who is not contracted with the entity to which they have been assigned. Again, there is everything we hate about insurance, including denials of care.
These entities are paid a capitated amount per patient in their group. In addition, they are paid more for patients with more complicated diagnoses. This results in “up-coding” on billing to get even more money from the government.
If patients cost the plans too much, they are encouraged to drop out and apply for traditional Medicare. At this point, they may have trouble getting supplemental insurance as they now have to disclose pre-existing conditions.
Traditional Medicare is efficient and well run with an overhead of only 2%. Medicare Advantage plans are allowed to keep 15% of what the government pays them and DCEs, ACOs and REACH are allowed to keep up to 40%. This, in addition to providing less care, creates endless hassles for patients and providers, as well as costing the government more per patient.
We need to get the insurance industry out of Medicare and make traditional (and improved) Medicare available to all Americans regardless of age, employment status, or health.
Dr. Ann Troy is a pediatrician who has been in practice for more than 30 years.