Healthcare - No Bernie - We Can Do Better
There is no question that Medicare for All would be better
than the status quo.
Individuals with limited income and resources have Medicaid
( https://www.medicaid.gov/
) and Supplemental Security Income (SSI) ( https://www.ssa.gov/ssi ) to seek assistance
with. Oft times these government
assistance programs have their own complexities. Many physicians and other medical providers
won’t accept individuals with Medicaid coverage due primarily to their
reimbursement rates.
People who are not low income have their own complexities
related to Medicare itself. For most
such people, having a supplement to Medicare is a “must” to avoid potential
bankruptcy as well as to simply get by in their day-to-day life. Medicare Supplements can be costly for those
who aren’t high income. Comparing plans
and choosing options isn’t easy.
All of this is separate from the issues related to what is
not covered by Medicare. Virtually all
dental care isn’t covered by Medicare.
Eye care that is related to needing glasses, for example, is not covered,
unless one has a direct medical issue requiring treatment. Elderly and disabled people may require
custodial care, where short-term medical improvement is not to be
expected. Basic care for such people to
stay in a nursing home or similar facility is not covered by Medicare.
I will give a concrete example related a limitation of
Medicare (alone) which be relevant to me, if I was financial reliant upon
(solely) Medicare. Roughly four or
five years ago my partner took me to Northwestern University Hospitals’
emergency room in Chicago, where we lived.
I was admitted to the hospital and was kept for two nights due to (extremely
painful) kidney stones. Several months
ago, following having a planned US ABDOMEN RETROPERITONEAL, my urologist
recommended that I consider having out-patient kidney stone removal.
As a retired federal employee, my health coverage is through
an Aetna Administered health plan as well as Medicare Part A. This is most financial expedient for my
partner and myself. In researching the
kidney stone issue. I determined that
the costs of my having this surgery in Oakland, California, near where we now
live would include surgical costs of at least $35,000. With my health insurance coverage, this
would cost us at least $3500, which isn’t viable for us now.
If, I have another kidney stone “attack” (10% likely in any
year, per my urologist), I could end up hospitalized again, as I already noted
above.
Let’s translate this example to a Medicare (or presumably
Medicare for All) individual, presuming that this person is hospitalized for
two nights in a hospital for inpatient treatment in 2026. The individual most likely will have free
Part A (hospital) of Medicare. They
will pay $202.90/month for their Part B (physician/surgeon) Coverage under
Medicare. If one has Medicare Part D
(drug) coverage, the average cost of coverage would be $34.50 per month.
My Part A cost for my hospitalization is: $1736.00. Presume, for this example, that:
1.
My total physician/surgeon costs are $35,000,
2.
I’ve had no prior physician/surgeon expenses in
2026,
3.
The surgeon “accepts assignment” which means
that they will accept “the customary and reasonable charge” that Medicare determines
in my case and
4.
The “customary and reasonable charge” is
determined to be $35,000.
One owes: $283 (first $283 in 2026 physician/surgeon bills is
the individual’s responsibility) + 20% of $35,000-$283 ($34,717) = $6,943.40.
The total hospitalization costs are thus at least: $1736 +
$283 + $6943.40 = $8,962.40.
I would note related to normal costs when one has solely
Medicare are:
1.
If one has either a catastrophic medical condition
requiring hospitalization– as in hospitalized for a year or a chronic hospitalization
where one doesn’t stay out of the hospital for 60 consecutive days over several
years or longer – the costs not covered by Medicare would easily go into the
millions of dollars,
2.
Physician/surgeon bills when one is hospitalized
can easily go well over $100,000 which would result in patient responsibility which
could be well over $20,000
3.
Oft times, physicians will not “accept
assignment” which will result in higher bills.
In the $35,000 surgeon bill example, noted above, if “the customary and
reasonable charge” was determined to be $30,000, Medicare would pay 80% based
upon the $30,000, not $35,000 – e.g. the patient would be required to pay the
$5000 difference (in full).
--
It is instructive to look at per capita
health care costs and life expectancy by country. The figures of health care costs are from
2022 and life expectancy from UN figures from 2023. See below:
Country ++ Cost
++ Life Exp
Canada: + $6207 + 82.63
France: + $6517 + 83.33
Germany + $6191 + 81.38
Grt Brit: + $5139 + 81.30
Japan: + $5251 + 84.71
New Zea: + $6061 + 82.09
Norway: $8693 + 83.31
Switzerland: + $8049 + 83.95
U.S. + $12474 + 79.30
https://en.wikipedia.org/wiki/List_of_countries_by_life_expectancy
https://worldpopulationreview.com/country-rankings/health-care-costs-by-country
Obviously income and wealth inequality hurt
the United States. At the same time It
is striking how the health care costs are so much higher in the U.S., while
life expectancy is clearly the lowest.
--
I would suggest that while Medicare is a good model in some
ways, it is Not Enough by itself! It in
no ways limits, as my health insurance does, one’s out-of-pocket costs. I have a yearly maximum of $6,000, after
which I owe no further co-payments at all for the year for all my basic medical
costs.
The Medicare Supplement system does not make it easy for individuals
to clearly compare plans such as between private companies such as: Blue Cross
and AETNA.
The Swiss healthcare system is a combination of public and private options, characterized by a mandatory health insurance requirement for all residents. Here are some key points:
- Universal Coverage: All residents must purchase basic health insurance, known as LAMal (Assurance Maladie) or KVG (Krankenversicherungsgesetz), which covers essential medical services like illness, accidents, and maternity.
- Private Insurance: While the basic insurance is mandatory, individuals can choose from approximately 60 private insurance companies, which offer varying levels of coverage and premiums.
- Regulation: The system is regulated by the Federal Office of Public Health, ensuring that all insurers must offer the same basic package, regardless of the provider.
- Access: Patients have direct access to specialists and hospitals without gatekeeping, and waiting times are typically minimal.
- Costs: Monthly premiums depend on factors like age, health, and the canton of residence, with an annual deductible ranging from CHF 300 to CHF 2,500.
Germany has a universal, multi-payer healthcare
system mandatory for all residents, primarily funded through payroll-based
contributions to statutory health insurance (GKV) for most,
with higher earners able to opt for private
insurance (PKV), featuring a solidarity principle where everyone
contributes based on income but receives the same care, funded jointly by
employees and employers, with direct payments to providers via health cards and
minimal patient co-pays.
Key Features:
- Mandatory
Coverage: Health insurance is compulsory, ensuring everyone has
access to medical services.
- Dual
System: Most people are in the public GKV system, while
high-income earners, civil servants, and the self-employed can choose
private PKV.
- Funding: Contributions
(premiums) are a percentage of income, shared by employer and employee for
GKV, fostering solidarity.
- Provider
Choice: Patients can choose their doctors and hospitals, using
their electronic health card.
- Solidarity
Principle: GKV premiums are income-based, not risk-based, and
cover family members without income.
- Cost-Sharing: Small
co-pays for prescriptions (€5-€10) and a daily fee for hospital stays (max
28 days/year) apply, but most costs are paid directly by insurers.
I think that we are short-sighted
in seeking to push for a Medicare for All system as a solution to our
healthcare issues in the United States.
It would make much, much more sense to:
1.
Appoint a committee (with diverse
representation) to look seriously at the healthcare plans in countries such as:
Switzerland, Germany, Canada, Great Britain, France, Italy, Australia, New Zealand,
2.
Work with a clear focus/parameters such as
perhaps requiring Federal Government regulation and private industry involvement,
universal coverage etc.
3.
Determine if Medicare should be modified
seriously and become universal or a new system should be created with Medicare
and Medicaid moved into the new system,
4.
Have journalists, medical professionals,
hospital representatives, drug company representatives, and others consulted
with, research ideas etc. both before the committee starts and as it moves
forward
5.
Work towards win/win inclusive outcomes – clear responses
to divisive/ propaganda/ lobbying efforts etc
6.
Discuss short term and long-term planning and
outcomes
One possible system might be similar to Switzerland in some
ways. Assume for example, that Blue Cross,
AETNA, CIGNA, Humana, Kaiser Permanente, AARP, Bright Health and others all
could offer health care plans. The
plans (as with the Swiss system) would have two parts:
1.)
Basic Coverage – uniform – not-for-profit +
2.)
Supplemental Coverage – varied – for profit
Through such a system, for example:
1.
Those with “high needs” – could choose more
expensive plans – which were more comprehensive,
2.
Insurance companies – could offer multiple plans
3.
Physicians and other healthcare providers – who opted
to participate in the – “health care system as a whole” – would both have
guarantees and a system for processing disputes – in terms of fair payments for
their services and a requirement that they would accept patients in
non-discriminatory ways
4.
Payments – for services – could be handled completely
through the health insurance companies, so medical providers would not need to
have complex billing support staffs, as well as hire collectors for unpaid
bills
5.
Medicaid – could be in a sense be wrapped into
the National System – so private insurance companies – would contract with
state and/or federal government agencies – to handle the insurance needs with
lower income people – this could be tied in with filing federal tax returns,
being on SSI (Supplemental Security Income)
In describing a possible system, I’m not trying to outline
exactly how things might be. I’m rather,
seeking to help show the breadth of how the system could be realistically
comprehensive.
Lobbyists and entrenched interests have shaped our health
system into one that is highly inefficient, ineffective, strongly inequitable,
and dysfunctional. A new system should
be built to help all of us in a variety of ways that help encourage us to
holistically move forward.
It seems hopeless with the divisiveness today! We need to move beyond images/ names that
trigger many, fear and hatred. Those
who really want meaningful change need to reach to those who mistrust us. Pressure needs to build from the bottom
up. The politicians – even individuals
like Bernie Sanders – won’t “save us” or necessarily really help us!
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