Please persuade me why Medicare ought not be means tested

Great Debates
101

Just curious……you perceive well-off retirees getting expensive medical services that they don’t really need for free? Where does this perception come from? And where are you that you see poor people seeking treatment for the sniffles on what I assume you perceive is your dime?

Are you employed in a hospital, or do you get these perceptions from media sources? Sometimes media sources are more interested in pushing an agenda than they are in transmitting truthful information.

I’m not going to deny that there is non-zero number of hypochondriacs in this world, but I also think they are probably outnumbered by people like me who hate going to the doctor for anything but the most serious reasons. If you start throwing up additional barriers to keep people like me from seeking medical care, the end result might be more expensive courses of treatment for conditions that weren’t caught early and worse outcomes all around.

There is a pattern I’ve seen several times when a patient goes to the doctor or ER, is repeatedly brushed off as a hypochondriac for days or weeks or months until it turns out that …….guess what, they were right.

My fiancé went to doctors for six months before his pancreatic cancer diagnosis, and was brushed off with suggestions that he might need anti-anxiety or anti-depressant medication. Then there’s the time that my mom went to the ER for “the sniffles”, they tried to send her home, she tried to refuse, they flat out accused her of attention seeking, she left and came back the next day, she was hospitalized for six weeks with a strain of pneumonia she’d picked up while traveling overseas…let’s just say that she almost died and the CDC was deeply involved with her case.

The bottom line is that medical care isn’t pleasant or fun, most of it is actively unpleasant, and I believe most people that seek it genuinely need it, they aren’t going to the doctor because they are bored or want attention.

I think the fact that countless other people are getting expensive government subsidized chemotherapy and other treatments while I’m not is a cause for gratitude, not bitterness.

I will concede that there is are a minority of people that will abuse any system, knowingly or unknowingly, but I don’t believe in denying a large population a service that they really need, like food assistance, just because Fox News was able to dig up a story about a guy that buys steak and lobster with food stamps.

And I’m not sure why you think Medicare is free. I pay $175 a month in addition to the large amount of money I contributed during my working years. Since I went on Medicare almost two years ago the benefits I used cost my insurer a total of about $300, and that’s only because I use my allowance for OTC meds. So they are coming out ahead with me.

The bottom line for me is that the system needs to be completely and properly socialized. I say this not because I’m a fan of socialism - I believe capitalism is the best solution for most economic sectors. But with healthcare, the best the free market has been able to come up with is what they’ve labeled “insurance” but is really just a privatized kludge that attempts to mimic a socialized system, a system that can’t survive without significant government subsidies.

That’s the best the free market can do, and it isn’t working. We need to do something else, but I don’t think less medical care is the answer and I don’t understand being jealous of people that have expensive medical conditions.

102

Health care doesn’t work in a capitalistic scenario because health care isn’t consumed in a capitalistic fashion. People don’t want to consume health care other than maybe something like plastic surgery. Elective plastic surgery doesn’t need to be part of a public health care plan.

Having lived my own life and dealt with family members in various health conditions, I cannot understand why someone would see someone consuming health care as lucky. They aren’t. Versus not going to the doctor. That’s the stuff that should be public. Things that are needed but not benefits. Which is what health care is.

BUT clearly Dinsdale sees people visiting the doctor as being lucky. Dinsdale sees it as capitalistic. That they are lucky or undeserving people getting a “goodie” they didn’t earn. I have zero sympathy towards this way of thinking as a living human being. How someone cannot see how bad having ill health is. But Dinsdale clearly thinks that way. This is basically “fighting ignorance” at this point.

103

I agree with your entire post but quote this part just for extra emphasis. Speaking as a Canadian with relatives in the US, I really don’t think most Americans realize how incredibly screwed-up their health care system is. Most are complacent about it because most of the time they’re among the lucky ones who more or less get health care when they need it, and are ignorant of the enormous costs they have to pay for it, both directly and indirectly, and the enormous bureaucracy they have to endure to get it – which bureaucracy is a big part of what they’re paying for, and is mainly intended to discourage or prevent them from getting health care.

This is why I get sick and tired of all the ill-fated half-measures that say that “we have to improve health care in America” while being adamant that the system has to keep all the capitalistic for-profit elements and the money-obsessed consumer culture that broke it in the first place. Health care has to be treated as an unconditional public service for it to work, and its funding (not necessarily the provision of it, but the funding) has to be provided by public funds with no cost at the point of service.

In the American context, they actually are lucky, in the sense of “lucky to be alive”, compared to those who don’t have access to decent health care because they can’t afford it. And yes, Dinsdale’s whole approach here is distinctly capitalistic.

104

About poor people going to the ER for the sniffles and other routine matters - I worked with populations of poor people for 30 years and I’ve never seen people go to the ER for sniffles . Why would they sit there for hours for the sniffles ? But if you mean something else by routine matters , if you mean they went to the ER for something that could be treated less expensively in an outpatient clinic , well, that happens all the time here. Because the public hospital ER will treat you even if you can’t pay while an independent medical office is likely to want payment up front if you don’t have insurance.And probably doesn’t take Medicaid

105

I’d like to focus on this one piece of this post talking about market rates.

Elder health care pretty much has to be non-market rate, because if it existed at the market rate there would be no market - by which I mean, companies would have to charge massive amounts for insurance, which would force most seniors who start getting sick to drop out of their insurance plans and essentially bid for healthcare on the free market, paying whatever the market would bear. Without the advantages of scale, costs would shoot up and fewer people would be able to afford care.

A huge chunk of your well-off retirees would probably end up drained of their savings, and plenty of those slightly less well off would end up dying earlier of treatable conditions they simply wouldn’t be able to afford.

It should be noted as well that one effect of Medicare reimbursement rates is to hold down health care costs - effectively a drag on medical cost inflation. Without it, you would see a higher prices across the board, though the side effects (doctors hustling through visits, etc.) aren’t exactly welcome either.

106

Talking about a healthcare market in general is foolish. Healthcare costs are hidden from the public. Remember the study that showed hospitals in one city had wildly different prices for the same procedure? Not to mention what the hospital gets from the insurer, the actual price, depends on the insurer. And the exact procedure done depends on the situation. It’s not like someone is going to get next of kin to sign off on a new estimate of costs when a person is on the operating table and something unexpected is found.
Plus, a market depends on the possibility of choice. Someone having a heart attack has no choice. Car repair prices have a cap, since someone is not going to spend more on a car than it is worth (in general.) Not so true for people, though I wonder some time if conservatives would rather inconvenient sick poor people go away instead of increasing their taxes.
As mentioned above, someone having plastic surgery does have a choice, so that particular one is a market, which is fine.

107

I know many many upper middle class people with many millions in net worth who are maximize what they CAN get under Medicare, paying well under what they did when they were working.

And I handle Social Security disability applications, so I read medical records every working day.

Let me see - tomorrow when I start working, I wonder how long before I read the record of someone going to the ER for a cold/flu - mild URI.

And - yeah - I probably disagree with a lot of you in that I think a whole lot of older folk should just die sooner rather than receiving a helluva lotta medical care! :wink:

108

I’m not eligible for medicare yet (mid-fifties) and we’re pretty wealthy, but just this year we exceeded $200,000 in medical expenses–crazy expensive MS drugs (which work, at least), MRIs for said MS, ruptured quadricep surgery plus PT, plus normal medical expenditures. Given our financial situation, we could cover expenses like this for a while, but most people even with what they consider a decent retirement fund sure couldn’t…

109

Since flu can be very serious for some people and it kills about 30,000 people a year in the US, I’m not going to get outraged if someone goes to the ER for it. I had a bad case last year and there were a few times when the respiratory distress got so bad I considered going to the ER. If I can’t breathe on Saturday night, I’m not waiting until Monday to call my doctor.

And a mild UTI becomes a severe UTI if left untreated.

I will agree that the ER is overused, but that’s a side effect of our confusing patchwork of a healthcare system, and it’s gotten worse post-COVID since now a lot of doctors won’t let you in their office if you have a fever, they’ll send you to urgent care or the ER.

I think it’s fine if YOU want to make the decision to die rather than undergo expensive medical treatments, but I’m firmly opposed to death panels.

110

Not a loaded term at all, huh?

111

That depends. If someone is injured in the workplace and needs facial reconstruction, that’s not a choice.

112

But why are they going to the ER? is it because they don’t have health insurance to go to a clinic, and the ER is the only place they can go?

113

Even up here in the land of the Canada Health Act this is a problem, certainly in Ontario. GPs are in short supply and have few appointments, but due to how the province pays doctors through capitation if you can’t get an appointment and go to a walk-in the GP gets penalized financially and they threaten to withdraw services. An ER visit does not penalize the GP.

114

I’ve not heard of that here. Each province has its own billing processes, so I’m not sure that we can extrapolate to all of Canada.

115

Right. I should have said elective surgery, the way the original reference did.

116

This needs clarification. The capitation system mainly exists only in Ontario, and even there, only about a quarter of Ontario doctors participate, and those are primarily (or exclusively) larger offices with six or more doctors. Furthermore, dropping a patient from the roster for going elsewhere for care can be very short-sighted because the amount being negated from the capitation payment is usually minimal, and in any case the whole point of having a PCP is continuity of care.

I’ve been in Ontario my whole adult life and have never had any interest or concern with how my doctor gets paid, which I assume has always been fee-for-service, and in any case when I have a relationship with a trusted PCP that’s where I always go. And of course I can always switch my PCP without any restrictions.

117

There could be a myriad of reasons. Maybe they don’t have established health care practitioners and they live in a location without storefront urgent care businesses , or maybe they aren’t aware of the urgent care businesses. Maybe they called a few doctors and couldn’t get a fast appointment, which is to be expected if they aren’t an established patient. Maybe the condition comes on at a time when nothing else is open. Maybe it’s what their parents always did, or they just aren’t thinking clearly because they’re sick or some other reason related to the inability to perfectly navigate our confusing health care system.

People aren’t thinking to themselves “Wow, I have a mild UTI, so I think the best thing to do is to go hang out in the ER for 4 hours some can score some free antibiotics.”

They are reacting to the sudden onset of painful and alarming symptoms (and the symptoms of a UTI are painful and alarming) and they get scared. They don’t know it’s an UTI, they don’t know all you need is a course of antibiotics and and OTC anesthetic, they don’t know if the symptoms are going to get progressively worse. And frequently it’s a parent bringing in a child, and parents are notoriously paranoid about their children’s health, especially if the child is too young to communicate.
It’s easy to look at the situation after the fact once the diagnosis is in and say “that’s not so bad, there were better ways to handle that than an ER visit”, but you have to remember that at the time of the visit the patient might not have known the condition wasn’t that serious and didn’t have the potential to turn serious fast.

Again, going to the ER is a universally unpleasant experience, and people aren’t doing it because they are bored or because they are deliberately trying to be inefficient in order to drive up your healthcare costs.

There is a lot wrong with our healthcare system besides the payer model, and I actually agree that there is a lot of overdiagnosing, overprescribing and overtreating that’s driving up costs. I believe this is in large part due to the financial model of our current system, which turns doctors into salespeople and patients into customers. If you want to reform costs, that’s the place to start.

But don’t blame the patients, because that dynamic is misguided in the same way that blaming homeowners for the 2008 financial crisis was.

118

The issue is that while you have the right to switch at any time, we have a huge shortage of GPs so very few are accepting patients. I also have an amazing GP who I’ve had for 25+ years that can get me in on short notice, doesn’t make me sit around waiting for hours for him, and actually listens. As someone in their mid-50s with a number of chronic conditions, that’s tough to replace. I dread him announcing his retirement.

119

I grant you that few countries exactly have an excess of physicians, and Canada isn’t doing great in that regard, but guess who’s worse? Yeah, the US – in addition to all their other health care problems like the whole “insurance” fiasco and physician and hospital choices being limited to “networks”:

The analysis by the Commonwealth Fund, a health-care advocacy group, finds Canadians have 2.7 practising physicians per 1,000 people, compared with 2.6 for the U.S. Norway has the most at 4.8.
Canada lags behind peers in doctors per capita, but average in physician visits

The above stats pertain to doctors overall, but approximately the same ratio seems to hold with PCPs.

120

Oh, in no way am I presenting this as a defence of US healthcare or, in keeping in line with the op, suggesting this as a reason for moving away from socialized medicine. I’m just pointing out that our system isn’t perfect.

Two weeks ago I went from perfectly fine to writhing on the floor in pain at 6pm. My wife signed me up for a virtual ER appointment with less than 1 hour wait. A nurse practitioner called me on Teams, took a history, came up with a differential diagnosis of kidney stones or appendicitis, and told me to go to the ER. She checked the wait times to send me to the best location and transferred my file to Triage. I had an IV, pain meds, a CT scan, and a diagnosis of a kidney stone by 10pm and was sent home after the IV finished at midnight. The virtual ER submitted a follow up lab request for 2 days later and called me literally minutes after the labs came back to tell me all was well. I was told to see my GP in about a month for follow up.

Of course my direct cost for all of this was $0. This is the way it should work in the US too.