Please persuade me why Medicare ought not be means tested

Great Debates
121

I’m aware of the cost. I’ve studied the system we have. I do have good insurance, and my own situation is very good. Part of the problem with America’s system is that there aren’t enough people that have it as good as I and my family do. As a society, America tolerates more inequality in general, and healthcare is just another example of that. Now, something like 70 to 80% of America is OK with their healthcare. But that leaves 20 to 30% who aren’t. And that’s too much. It shouldn’t be as unequal as it is.

It’s the political reality that we have to deal with. If I could be dictator for a day, I’d scrap what we have and start over. But that’s not how it works in the US. As a political system, we tend to make changes incrementally with less than perfect measures. I’d argue that Obama and Biden have both made very good advances in our healthcare, and even Bush contributed for that matter. Perfect? No. But the US is gradually approaching UHC. We’ve cut our uninsured population to about 8%, less than half of what it was when Obama came to office. And the growth in healthcare costs has slowed. Bush created the Medicare Drug “Part D” entitlement. Obama/Pelosi were the architects of the ACA. Biden made some great improvements to the ACA. Red States are gradually accepting the Medicaid Expansion. And Biden passed legislation that allows Medicare to bargain for drugs (which is a game changer for cost control in the prescription arena). So, changes and improvements are being made. Will we ever become a country where everyone is covered, and costs are similar to other countries. Maybe on the first and I doubt it on the second. But we inch closer and celebrate the improvements we can make.

America is not a country that does “one size fits all” for anything. We do everything patchwork. It doesn’t matter whether you’re talking about zoning laws or marijuana laws or healthcare or sports betting or energy drilling…almost nothing is the same everywhere you go (maybe the interstate highway system is a big exception). For some things, patchwork is a good idea. We don’t like being told that there’s only one way to do something. But for healthcare, that creates unique problems.

122

I can’t speak for American ERs. Most people in Canada have coverage and many still use the ERs. Given reasonable use of blood work and imaging, I would estimate about 20% of the patients could have been seen by their family doctor if they were available. My experience is that patients are rarely being unreasonable in their use; they may be overanxious or could have waited for less acute care, but it is not the job of the patient to have fulsome medical knowledge. A much bigger contributor to long wait times is when admitted patients have no available hospital bed and are warehoused in or close to the ER, a frustrating situation for all concerned.

123

It would cost me maybe $100.

But I have heard that for many no like threatening procedures, the wait can be very long on NHS?

In a list of nearly 200 nations, the USA ranks 40th.

Above france, Canada, the UK, , etc.

124

And that can become a challenge. GPs are the gatekeepers; they’re the ones who refer you to the specialists. You need a cardiologist, you get a referral from a GP. You need an ENT, you get a referral from a GP. You need an OB/GYN, you get a referral from a GP.

What you don’t do in Canada, is open the Yellow Pages, pick up the phone, and call a cardiologist, an ENT, an OB/GYN. It is likely they won’t even take your call if you haven’t been referred by a GP.

In many ways, it makes sense: you may think that you’re having heart problems, but the GP finds that it’s just indigestion. Or you don’t need a full-blown ENT; the GP determines that what you need is a much-less-expensive audiologist to prescribe a new hearing aid.

But in order for this system to work, there has to be an adequate supply of GPs. Right now, there isn’t. I recall an undergrad friend who got his M.D., and went to a remote place in Newfoundland, because they helped with the cost of his education (kind of like “Northern Exposure”). But too many GPs want to become specialists, and those who don’t, want to become GPs in Toronto, Montreal, Vancouver, and other big cities.

How can we make places like Lethbridge, Peace River, Brandon, Kelowna, Swift Current, Wawa, Edmundston, Corner Brook, etc. attractive to GPs?

125

The same way as most economic matters: pay them more.

126

Those numbers are absolutely bizarre and I’d sure be interested in their methodology, including how they define what a “physician” is. Another part of the problem may be inconsistent or out-of-date information from the different countries. The Commonwealth Fund survey is a lot more credible; it shows the US and Canada per-capita physician count to be very similar, with Canada slightly ahead.

This table in Wikipedia shows that the US was ahead of Canada in prior decades but the per-capita physician count in the two countries is exactly the same now according to the latest data.

I’ve seen this kind of bullshit before. On another message board years ago I had long debates with some guy who passionately argued that the US had the best health care system in the world in all respects. Later on I saw a post from him in a different thread complaining that a hospital was demanding thousands of dollars in upfront payment in order to get his kid admitted, and how could this possibly be legal. What looks great on paper often turns out not so great when medical care is based on entirely mercenary practices that are often even predatory, as they are in the US.

This is standard anti-UHC scaremongering being promulgated by the health insurance racket. Yes, wait times are triaged according to urgency, as they should be, because resources are finite. They are in the US, too. The difference in the US is that if you’re not in the right employment and financial circumstances, the wait time is infinite.

I should also point out that this is not a thread to debate about health care systems although it’s closely tangential to it, and we’re veering off topic here.

127

Because they’re… gaming the system? What’s the thrust of this observation?

128

So back to the OP’s premise, it is significantly cheaper, easier, and deliver better outcomes through UHC by collecting the cost through taxation general revenue and eliminating the administrative overhead.

129

This so much this.

130

Because they are wasteful of medical services since they have no skin in the game.

First record today was a 100% disabled vet. (TBI from slipping and falling in the shower.) No waste of services THERE!

131

Sorry, I was the one who resurrected the thread. I’ve been off the board for a while. The other day, I scanned the topics, and saw this topic, and decided to weigh in.

I think as a society (I’m an American), we should decide what the basic package everyone should have as a minimum, an “at least this level of coverage” must exist. And we should then make that package affordable to everyone, and require everyone to be enrolled. The exact mechanism to do that can be many different ways, as there are a thousand ways to get to UHC. Just look at Europe and different parts of Asia, and you’ll see many approaches. But the approaches all have 3 things in common: 1) Everyone must be enrolled in coverage; 2) Government or private plans must offer coverage to everyone; 3) Government must make sure that everyone can afford it, i.e., via subsidies. It’s the three-legged stool that must exist for UHC, however you technically go about it.

And the US, quite uniquely amongst the developed world, falls down in all 3 of these measures.

As for your comment on the wealthier, I don’t agree really. I think they should get the same co-pays as everyone else. Perhaps, they get less premium subsidies. But it must be affordable for everyone. And I have no issues if the wealthy want to up-purchase something supplemental, as long as they pay for it themselves.

132

I think you’re being sarcastic, but I don’t see why. TBIs are serious, and can absolutely be caused by falls at home. Heck, I had a case a few years ago where a woman died from a head injury caused by a fall in the shower.

133

So you support universal health care, as long as people have to pay for part of it themselves as a condition of getting healthcare?

That doesn’t match my concept of universal health care, where we all pay generally, by means of taxation, rather than individually.

134

I would support no copay for a narrower range of health care, with a progressive scale beyond that. For example, I don’t know that I would include coverage for boner pills or infertility treatments. Sorry. Just my personal opinion/bias. Perhaps there would be a middle range of care provided free to poor people, but at a cost to wealthier. And a higher range that are provided only for pay.

The fact that health care has progressed to a point that various things CAN be done, does not translate for me that ALL such things ought to be done for everyone at no cost to the individual.

And I’d pretty broadly require that people exhaust the initial prescription of stop smoking, stop drinking, stop eating so much crap, and get up off your lazy ass first.

But I oughtn’t say much more here. Sufficient to say the US system is set up about as lousy as possible. So I have no desire or persuading anyone of how it ought to be, nor do I have any expectation that it will be meaningfully improved at any time in the near future.

135

Perhaps you can understand how dangerous it is to allow personal opinion/bias to erode the edges of universal healthcare. You don’t want to allow fertility treatments, John doesn’t want to allow contraceptive services, Bill doesn’t want to allow vaccinations, etc etc.

Universal health care should be universal.

136

I have Kaiser, and that would be the total of my co-pays. I have been to the ER before, not expensive at all.

But not all American insurances are the same.

https://www.health.org.uk/waiting-list#:~:text=NHS%20England%20has%20an%20elective,weeks%20will%20be%20very%20challenging.
What matters to individual patients is the time spent waiting. NHS England has an elective care recovery plan to eliminate long waits. Median waiting times stand at 14.5 weeks and only 58% of people are being treated within 18 weeks, so further action will be needed. Eliminating the backlog and restoring waiting times to 18 weeks will be very challenging. The achievements of the early 2000s, when waiting times were brought down from 18 months to 18 weeks, shows it can be done. However, this will require significant investment alongside sustained focus and effective supporting policies.

Please note, I am in favor of UHC. So you can stop with the anger.

But my question was addressed to glee who has direct experience.

137

I’ll just add a couple more points here. First of all, as @Johnny_Bravo just suggested, such limitations dangerously chip away at the fundamental principle of universal health care. Some well-meaning but very misguided pundit once suggested that smokers shouldn’t be covered by UHC for smoking-related ailments. This absurdity was immediately shot down. This is not about possibly making an attribution about cause that might be wrong; even if it was absolutely, positively determined that the person’s disease was self-inflicted, it is fundamentally contrary to the principle of why we have universal health care in the first place to deny or limit treatment to anyone for any reason.

Your various proposals for means testing or limiting coverage in various ways seem to be based essentially on concern about the cost of an unlimited universal Medicare program. Let me point out that the US health care system is so incredibly inefficient and costly that the US government already spends more taxpayer dollars on health care per capita than Canada spends for a fully universal and unconditional health care system. Overall, the per capita cost of health care in Canada is around half of what it is in the US, despite a very similar socioeconomic system. The chart below tells the story. It’s somewhat dated as I believe the current per-capita cost in the US is now around $13K, but the proportions shown for different countries are basically the same…

Would you revise your opinions if a fully universal health care system without conditions, limitations, or co-pays actually cost less than it does today?

138

Skimming through the thread, I don’t think the following thoughts have been addressed (specifically regarding means testing).

To some extent, Medicare IS means-tested. Or, at least, someone with a higher income is paying / has paid more for basic Medicare than someone with lower income. As noted, there’s no cap on Medicare contributions - so someone earning twice what I do pays twice what I do (ignoring unearned income such as dividends and interest). Yet they get roughly the same medical care that I do, for the same price. Yes, they have more opportunities for non-covered services, and the copays will hurt less - but the government’s outlay is likely to be similar.

Second: If your income in retirement is high enough, you pay a surcharge on your Part B and D premiums (IRMAA). This surcharge can be fairly steep. If you have a year with unusually high income (e.g. you’ve sold assets to fund a large purchase, as happened to my brother), you get nailed 2 years later. That surcharge goes away if your income drops again, but if it remains high, you continue to pay more.

As far as Social Security: Everyone pays in, everyone benefits (let’s ignore eligibility etc and just discuss people who are subject to SS withholding etc.). If you earn more, you pay in more; there is indeed a cap on the income which is subject to it, but relatively few people hit that cap.

THEN, if you look at the formula for calculating SS, it is weighted toward lower income people. Someone whose average lifetime earnings are 100K a year is not going to get twice the benefit of someone who earned 50K year. I plugged some made-up numbers into Excel for someone whose earnings are10,000 a month, 5,000 a month, and 1,000 a month - and their benefits would be 3405, 2246, and 900 a month respectively.

That person getting 3400 a month is also very likely to pay income taxes on their Social Security benefits.

As far as whether a higher-earner is more likely to live longer, or use more medical care - I have not seen any statistics, but it’s plausible. They are likelier to be able to afford large copays etc. and thus not delay treatment due to lack of funds. They may have had better healthcare during their working years, so they start retirement off better than others.They may be able to afford household help, reducing the risk of death due to neglect or injuries. And so on. All that could conceivably let them live longer, thus using more Medicare and Social Security funds.

All in all, while there are certainly many flaws in how Medicare and Social Security are implemented, I don’t think means-testing has been overlooked.

139

I imagine I would.

just got back from a bike ride w/ my sister (S). She mentioned a phone call she had with another sister (C), who is just turning 65. C was really happy to be qualifying for Medicare, as she was complaining about a mammogram that cost $1200, and her monthly premiums of $1000. S told C her next mammogram would be free and her premiums would be around $150.

C and her husband are some of the wealthiest people I know - as well as some of the most conservative (IMO selfish.) The folk who moved from our town after their kids graduated high school because “the taxes were too high.” Moved to Florida, and immediately started complaining about the level of public services.

I just know too many such people, which has skewed my perception of who pays what.

140

The rich should be paying more. In taxes. Their entire lives. Let them pay capital gains taxes and estate taxes, and get rid of the loopholes they no doubt use to limit their tax liabilities in other areas of their life.

But this? Let the rich get cheap healthcare, sure. We should all get cheap healthcare.