PUMPING IRONY: Meddling With Medicare

When a frightening medical emergency last spring sent My Lovely Wife to the ER via an ambulance, we found ourselves for the first time in a situation thousands of seniors face every day: thanking the EMT squad, the nurses, and the doctor for their help and then waiting nervously for the bills to arrive in the mail.

There was nothing for a few weeks, which had me wondering whether there was some fine print in my employer’s high-deductible health plan that completely covered the cost of ambulance rides and ER treatment if they happened to occur between 8 a.m. and 10 a.m. on a Thursday in April after a full moon. When the bill finally did show up, we marveled at our good fortune. The insurance company had lopped off about a quarter of the cost, leaving just over $900 for us to pay. Could be worse, we agreed.

I should note here that MLW and I come by our naivete honestly. We generally avoid practitioners of conventional medicine and thus rarely interact with the American healthcare system and its highly idiosyncratic financial apparatus. So, we were slightly abashed to receive a second bill several weeks later for the ambulance ride ($1,200) and a third one just the other day from the ER doctor ($1,600).

“I wonder,” MLW noted, half-jokingly, “if there’s going to be one coming from the guy who escorted me up and down the hallway to see if I could stay upright before they sent me home.”

It’s particularly ironic, it seems to me, that all this is occurring just as MLW and I are preparing to transition from my employer’s health-insurance plan to Medicare, and while Congress is poised to debate the merits of expanding the program’s benefits. Whether either of those moves will free us from future healthcare-driven financial distress, however, is anyone’s guess.

Just as social security was never designed to provide a livable income, Medicare’s core benefits are not nearly as generous as we’d like to believe. The basic plans cover only a limited range of services, require some copayments, and do not cap a beneficiary’s annual out-of-pocket costs. And, as Julie Rovner reported last week in Kaiser Health News, legislative attempts to improve the offerings over the past half-century have proven a tough sell — for lawmakers and seniors.

Congress added some preventive care, including pneumonia vaccines and mammograms, to the basic menu of benefits back in the 1980s and 1990s, Rovner notes, and in 1988 legislators passed the Medicare Catastrophic Coverage Act — a bipartisan effort to add prescription drug coverage and limit consumer copays. A year later, however, the law was repealed after seniors found the accompanying income “surtax” necessary to fund the benefits too much to swallow.

Prescription drug coverage finally arrived in 2003 — but only as a separate package, now known as Medicare Part D. Otherwise, the core package of benefits and services has remained essentially unchanged since the program’s birth in 1965, a fact that continues to mystify public-health experts like Jonathan Oberlander, PhD.

“Medicare is the kind of program where you’d expect the benefits would be expanded over and over again. It’s popular, and benefits expansions poll well,” says Oberlander, a health policy professor at the University of North Carolina-Chapel Hill and author of The Political Life of Medicare. “It’s one of the great puzzles of Medicare politics: why benefit expansions have been so rare.”

On the political front, the shift shouldn’t be so surprising when you consider that the Great Society programs of the 1960s — everything from Medicare and Medicaid to Head Start and food stamps — were in many ways the last gasp of the New Deal era. The rise of fiscal conservativism in the 1980s diverted the narrative from expanding benefits to containing the program’s costs. And the introduction in 1982 of supplemental Medicare Advantage plans offering expanded coverage options eased some of the pressure on politicians.

The pressure is once again building. Our rapidly aging population and the exorbitant cost of healthcare (medical bills account for two-thirds of all personal bankruptcy filings) have combined in recent years to create unprecedented popular support for assorted versions of a “Medicare for all” concept that would transform the U.S. healthcare system into something resembling that which currently operates in pretty much every other industrialized country. No one expects such a dramatic shift to pass muster in the current political climate; even lowering the age of eligibility from 65 to 60 terrifies the medical-pharmaceutical complex and its many enablers in Congress. That’s why Rovner suspects they may find themselves more amenable to the modest proposal currently making its way through the legislative sausage grinder on the Potomac.

Congressional Democrats want to add vision, hearing, and dental services to Medicare Part B (the outpatient side of the program) as part of the massive budget bill Senate Majority Leader Chuck Schumer outlined last week. It’s not cheap: A similar measure the House passed in 2019 would cost some $358 billion over 10 years, according to the Congressional Budget Office. But it’s chump change compared with the 10-year price tag — estimated at $34 trillion — attached to the single-payer package Sen. Bernie Sanders has long been promoting, a fact that may garner a few votes from his more conservative colleagues who have been hearing from their elderly constituents.

MLW and I are hedging our bets. Like many Medicare Advantage plans, the one we selected does include vision, hearing, and dental services, but the copayment and other aspects of the vision and dental options are less appealing than the supplemental plans my employer already offers. So, we’ll be paying a reasonable monthly fee to maintain that coverage while shifting to Medicare for our medical insurance. It would be the height of irony, I suppose, if Congress agreed to make those options part of the core Medicare plan just after we signed up.

Thankfully, we’ll get a chance to review all those options around this time next year and make some changes if necessary. Maybe by then the final bill from last spring’s ER visit will have arrived.

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