By Anne Scheetz, M.D.
State Journal-Register (Springfield, Ill.), Aug. 2, 2014
Forty-nine years ago, on July 30, 1965, President Lyndon Johnson signed Medicare and Medicaid into law.
Together, the two programs have made health care accessible to millions of people who otherwise couldn’t afford it. The legislation ended racial segregation in hospitals and decreased poverty among the elderly, thereby improving the financial security of generations of their families. And it strengthened local economies by creating health-care jobs that can’t be outsourced abroad.
Transformative though it was, this legislation left a great deal undone. Millions of Americans still do not have access to the care they need, millions more suffer financial devastation in paying for care, and our system is the most inefficient and bureaucratic in the industrialized world.
The contrast between the ways in which people become eligible for Medicare and Medicaid is instructive for the next transformation that American health care needs so urgently: expanded and improved Medicare for all.
For the majority of Medicare enrollees, eligibility is simple. You become eligible on your 65th birthday, and once enrolled you are in for life.
This simplicity allowed the Medicare rollout in the pre-computer era to be more than 90 percent complete within one year. It is also part of the reason for Medicare’s low overhead – less than 3 percent compared to more than 15 percent for private insurance.
Medicaid is another matter. It’s a program for the poor – or rather for certain classes of the poor – but it’s not even as simple as that.
“Poor” is not a single number such as 65. A person’s eligibility for Medicaid rests on a complex, document-based assessment of their income and other changeable factors; hence, the requirement that a Medicaid “redetermination” takes place yearly.
The 2012 Illinois Medicaid reform called the SMART Act resulted in a costly and time-consuming controversy over whether redeterminations should be done by state workers or be outsourced to a private company. The state workers’ union AFSCME ultimately prevailed over those who wanted to privatize this function. Meanwhile, an unknown number of enrollees erroneously lost their Medicaid cards – and therefore lost access to health care – until the mistakes were corrected.
Rarely did reports on the controversy note that every person needs health care throughout their lives, regardless of changes in their income. From that standpoint, every dollar spent on determining eligibility for any coverage (eligibility for subsidies on the Affordable Care Act’s insurance exchanges is also subject to yearly redetermination) is a dollar wasted on a useless function.
What we need then to get maximum value out of every health-care dollar is simplicity. That brings us back to Medicare.
Why shouldn’t everyone in the country, regardless of age, have an improved version of Medicare? It would pay for 100 percent of all necessary care and would be financed entirely by taxes based on ability to pay. (Almost all of us will pay less in taxes than we now pay in premiums plus out-of-pocket costs.) You’d choose your own doctor, dentist, hospital, pharmacy – every provider – and no longer be locked into a restrictive network.
By eliminating useless bureaucracy, we would take better care of everybody and still save money. That’s a description of Medicare for all, and it really is that simple – if we have the will to do it.
Dr. Anne Scheetz is a founding member of the Illinois Single-Payer Coalition and a leader of the Illinois chapter of Physicians for a National Health Program. She lives in Chicago.