Should Medicare be expanded to cover more Americans.

[mandrew]

I am curious if this group feels that lowering the age for Medicare eligibility is a step in the right direction for this country. If you feel that it is a bad idea, please elaborate. Thanks.

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[Adam Smasher]

I've stated this elsewhere, but Medicare only covers 80% and people would still need secondary insurance. So when people say they want Medicare for all, I think they may not realize they are asking for VA Insurance for all.

The biggest problem with insurance is there's no market for it. You get it through your employer most of the time and there's no interstate competition so we create what are effectively monopolies. Hence no reason for insurance companies to do any better. A blogger I used to follow (back when blogging was hip) would ask "why don't we see health insurance companies with slogans like a 15 minute phone call could save you 15% or more on your health insurance?" In 2008 John McCain campaigned on severing the connection between employment and health insurance by eliminating the income tax exemption for employer sponsored health plans and he was practically tarred and feathered for it. So I guess Medicare for all is the only other solution, because I'm just a lowly podiatrist so how could I know any better.

 

[heybrother]

Giving people Medicare isn't going to actually solve problems unless you are willing to actually change the system.

Consider that the government solution to college tuition is loan forgiveness.
The government solution to the uninsured is subsidies to insurance companies where the people essentially pay nothing but no one else can afford a plan.

Moving more people on to Medicare bankrupts Medicare sooner unless you are willing to pay more in taxes. It likely moves more people onto Medicare Advantage plans who will tell them you don't need a subsidy because we'll peel it out of the doctor's skin. The MA companies then rip Medicare off by overcharging, upbilling, fake codes, etc.

If your solution to insurance is just moving the pieces around you are just propping up the lawyers and all the current people in power who know the rules better than you.

 

[bloxxeeey]

This would be moving more towards a socialist system and we know how that works out.

Look at countries in Europe or Canada. Way worse quality of life and overall care, worse outcomes and doctors are poor. It’s a terrible system and what we have is the best in the world by far. Our patients do better, our doctors do better and everyone’s bank accounts do better. If you’re in Europe and you have a serious problem, you’ll quickly lose whatever “saving” you had by flying here to get superior care.

Also consider this, their taxes are higher. I compared the tax for Alberta to my state I practice in. I chose Alberta because there was that podiatrist here recruiting for docs in Alberta.

On a 150k salary in Alberta I’ll walk home with a 106k salary after taxes, meanwhile my state I’ll walk home with 107k. So you’re paying 1k in extra taxes for lackluster care when we have the freedom to choose our own plans and don’t have death panels denying our care.

 

[Feli]

Humana for all and Tricare for all would be more like it. Lol.
Unless you want massive inflation, you can't just print up the money to cover 100+ million more mid age ppl. And, as said, MCR still has sizeable coinsurance for visits, procedures, tests, everything.

Health care costs too much in USA because we expect too much and because the education and tech is too expensive. End of story.

There is no something for nothing. There are no easy answers besides teaching ppl the importance and the "why" of taking care of their body diet/exercise. (but don't get me wrong, that'll never happen... so I still have thousands of shares of NVO and probably a thousand OZEM).

 

[pod squad]

No, certainly not. The government is simply not capable of doing ANYTHING better than the private sector (with a few key exceptions such as policing, military, basic law and order type stuff). There's a reason the best and brightest doctors are not at the VA, FQHC, IHS etc. Gov't is certainly necessary to act as a check on the excesses/abuses of unfettered capitalism, but it is not a replacement for it.

Now the problem with healthcare is, these insurance companies are not actually subject to the forces of the free market. As Adam Smasher said, there's not really a market for health insurance. You get what your employer gives you or what the gov't gives you. But they get all the benefits of free market capitalism (i.e. there is no cap on profitability).

If you want to improve healthcare, eliminate as any middle men as possible. Health insurance should be for catastrophic/major medical expenses only. Everything else should be cash pay. No one expects their car insurance to pay for their oil change. Hell, it doesn't even pay if you need to get an expensive repair done.

HOWEVER, this would royally screw over us lowly DPMs because of the oversaturation. It'd be a race to the bottom of who can charge the least for toenail grinding. Such is life.

 

[dtrack22]

What we have is the best in the world?

We have better outcomes when treating cancer than anyone else in the world. There’s a reason that foreign dignitaries with money, fly to Rochester, MN and HSS in NYC to receive medical care.

Artificial supply constraints (ie the medical school/training/licensing cartel), administrative burden/costs, and the fact that health insurance is not “insurance” are some of the biggest drivers of bloated healthcare costs. Increasing the number of Medicare eligible Americans doesn’t solve any of these. We need more providers of healthcare, fewer administrators, and we need health insurance to function like almost every other insurance product we buy.

 

[heybrother]

Public utilities are cheaper for customers than private utilities ie. water, electricity, etc.

Medicare is superior to Medicare Advantage plans for physicians, for hospitals, for delivering patient aftercare.

Obamacare through the government market pays insurance companies to provide insurance for patients. The patients can't afford the insurance so they receive often a 100% subsidy. The patient very possibly has had the government pays $10,000-20,000 for their family in premiums, but now that the patient has BCBS Blue Advantage they have a co-pay for every visit, a max out of pocket, and a deductible. You the physician likely now have to secure a referral to get paid and collect your bill from the patient. They likely have a limited access network of hospitals that accept the insurance. And icing on the cake - these plans routinely pay less than Medicare to private practice physicians. Obamacare sucks you say, but the care is being rendered by private companies so it must be great according to someone in this thread who previously advocated that insurance companies care about us and want to ensure we have good outcomes.

Whatever you think about medicine currently - love it or hate it, think its efficient or not, your future is to bent over by Humana twice a day for the rest of your life because that's what the political party that just won thinks is the best form of healthcare ie. Medicare Advantage crony capitalism.

We will miss Medicare as it was when its gone. Its so terrible it pays more than all of the main commercial plans in my area except Cigna for an E&M. Its so terrible that it pays more than Aetna and United commercial plans for everything and all the Medicare Advantage plans.

There is not some amazing free market option coming. Medicare advantage is coming for you.

 

[msion]

Medicare rates will continue to drop. The currents rates already don't make sense for surgeries if you bill properly. Medicare for all isn't going to solve our problems.

Our current system is not flawless but it works. It's a winner take all system just like other sectors. This country has always been this way since the arrival of Mayflower. This is what attracts talents and sparks innovation. People don't come to this country to pursue social equality, instead they come here because they want more stuff. Americans pay for this but also enjoy higher incomes to compensate for the lack of a good safety net.

I know other countries may have universal health care but you will also be earning less and paying more in taxes. Quality of life isn't necessary better. Living space tends to be smaller in other countries. Spending power is also less. 30-year fixed rate mortgages are unheard of in pretty much the rest of the developed world. The UK is notorious for low salaries and high cost of living, but sure they have the NHS.

 

[Feli]

Medicare rates will continue to drop. The currents rates already don't make sense for surgeries if you bill properly. Medicare for all isn't going to solve our problems.

Our current system is not flawless but it works. It's a winner take all system just like other sectors....

I could not agree more.
Medicare will become more people for the same pool of $ (same percent of the tax pie).
Many, many more people will be on MCA ("marketplace" stuff) with AI, self driving, automation, etc eliminating many jobs.

It's a competitive system in USA. It's a dog-eat-dog economy. It's hard to get rich, but fairly easy to stay rich.
PPs will have to spend on marketing and produce good results to attract refers and patients - esp the well insured or cash pays.
Hospital pods (and all types of facility-employed docs) will have to work harder or risk lower pay and/or job security.
The docs/hospitals who depend on govt pays (MCR/MCA/VA/etc) will do mediocre at best.

A very key thing to remember is credit spends same as cash.
Yes, credit is generally used stupid (lifestyle/pleasure) more often than for productivity (tools/biz/edu)... but regardless, whether someone buys a house or a car or a phone or health care with cash or with credit, it is still the same $$ to the seller/provider. A shockwave or orthotics or cash pay procedures are the same as swiping their Visa card. The employed with BCBS can also buy (or charge) OTC and non-covered stuff, but the MCAs can't and MCRs often won't. So, not only do people/companies who are rich and doing well (good job/assets) have more money, they also have much more access to credit. Rich get richer. That's murikuh.

 

[bloxxeeey]

Public utilities are cheaper for customers than private utilities ie. water, electricity, etc.

Medicare is superior to Medicare Advantage plans for physicians, for hospitals, for delivering patient aftercare.

Obamacare through the government market pays insurance companies to provide insurance for patients. The patients can't afford the insurance so they receive often a 100% subsidy. The patient very possibly has had the government pays $10,000-20,000 for their family in premiums, but now that the patient has BCBS Blue Advantage they have a co-pay for every visit, a max out of pocket, and a deductible. You the physician likely now have to secure a referral to get paid and collect your bill from the patient. They likely have a limited access network of hospitals that accept the insurance. And icing on the cake - these plans routinely pay less than Medicare to private practice physicians. Obamacare sucks you say, but the care is being rendered by private companies so it must be great according to someone in this thread who previously advocated that insurance companies care about us and want to ensure we have good outcomes.

Whatever you think about medicine currently - love it or hate it, think its efficient or not, your future is to bent over by Humana twice a day for the rest of your life because that's what the political party that just won thinks is the best form of healthcare ie. Medicare Advantage crony capitalism.

We will miss Medicare as it was when its gone. Its so terrible it pays more than all of the main commercial plans in my area except Cigna for an E&M. Its so terrible that it pays more than Aetna and United commercial plans for everything and all the Medicare Advantage plans.

There is not some amazing free market option coming. Medicare advantage is coming for you.

The current political party is the only one who will fix health care in this country. They'll drive up salaries, get rid of regulation and administrative bloat in hospitals. Republicans plan to lower insurance premiums, cost of living and improve access of care, meanwhile removing people who don't pay into the system like immigrants. That's another issue we have that other countries don't, we have plenty of illegals taking advantage of our system

 

[p100]

The US could have 100% coverage for everyone without raising taxes but there is so much waste and fraud it isn't possible. Also the govt is run by evil people that bribe them to allow and promote all sorts of unhealthy foods that are killing people. Food coloring, sugar, seed oils, hormones in food, pesticides, etc. It is all one big cluster. At least going to one system might make the paperwork, EHR, and system a little easier to use.

 

[diabeticfootdr]

We have better outcomes when treating cancer than anyone else in the world. There’s a reason that foreign dignitaries with money, fly to Rochester, MN and HSS in NYC to receive medical care.

I would respectfully disagree with this.

Some groups of people in the US have better health outcomes, but not as a whole. If you're wealthy, live in the right zip code, know how to navigate the complex system, or can afford a private jet to Rochester, MN, you're likely to have good health outcomes.

 

[diabeticfootdr]

Health care costs too much in USA because we expect too much and because the education and tech is too expensive. End of story.

The cost of healthcare has nothing (or very little) to do with the cost of medical education. Professional fees make up less than 10% of all health expenditures in the US. Physician's don't control their incomes. If they did, they'd have the freedom to raise their fees to account for the expensive cost of education.

The fastest growing piece of the health expenditure pie is administrative costs, which includes payer profits.

A good podcast with Jon Stewart and Mark Cuban on how insurance companies and hospitals collude to keep the costs high, so that the administrative costs (insurance company profits) can be <15% of the total expenditures (to be compliant with the ACA). This causes an increase in the prices for Rx drugs and tests/imaging so that the insurance company profits can continue to grow numerically, but stay under 15% of the whole.

 

[dtrack22]

Some groups of people in the US have better health outcomes, but not as a whole. If you're wealthy, live in the right zip code, know how to navigate the complex system, or can afford a private jet to Rochester, MN, you're likely to have good health outcomes.

Every previous large scale surveillance study has shown the US to have the highest 5 year cancer survival rates. Better than Canada, Australia and every Nordic country. We do a better job of early detection and subsequent treatment (despite our disgustingly obese/unhealthy overall population) than anywhere else in the developed world.

Do you do complex limb salvage procedures on Medicaid patients in Texas? Or do they have to scrounge up enough money to fly to MN? The poorest of our population actually has better access to care that they don’t pay a dime for than most of our working class people. Our social safety net programs are plenty robust and expanding them would do nothing to lower costs. As I’ve already said, you need to increase the supply of people who provide healthcare and lower the ever increasing administrative burden. Insurance needs to be an actual insurance product and then you could see some actual improvements in how much we spend on healthcare as a whole.

 

[heybrother]

The cost of healthcare has nothing (or very little) to do with the cost of medical education. Professional fees make up less than 10% of all health expenditures in the US. Physician's don't control their incomes. If they did, they'd have the freedom to raise their fees to account for the expensive cost of education.

The fastest growing piece of the health expenditure pie is administrative costs, which includes payer profits.

A good podcast with Jon Stewart and Mark Cuban on how insurance companies and hospitals collude to keep the costs high, so that the administrative costs (insurance company profits) can be <15% of the total expenditures (to be compliant with the ACA). This causes an increase in the prices for Rx drugs and tests/imaging so that the insurance company profits can continue to grow numerically, but stay under 15% of the whole.

The discussion you linked to is also found here - about 1/2 way in


My kids keep interrupting me, but I was very interested to hear the comment very early in the discussion about how the current system turns doctors into debt collectors. Awhile back I was reading about hospitals dropping Medicare Advantage plans and a healthcare consultant named Nate Kaufman was apparently telling hospitals not to accept MA unless they were paid at least 115% of MA. I don't claim to have read all of his materials, but he was the first person I ever read discussing "first dollar risk" for physicians and hospitals

ie.

"Insurance companies made the unilateral decision not to provide first-dollar coverage. The theory was that by putting first dollar risk on the patient they would 'shop' for care. The data shows that rather than shopping, out-of-pocket costs served as a barrier to care, and many patients got sicker rather than sought care at the first sign. Increasing out-of-pocket costs have contributed to the record profits of the insurance companies since at least half of the commercial patients don't meet their deductible limits. That is the insurance company collects the premium but pays nothing out. Don't blame the providers for medical debt. Up to 65% of the hospitals are currently losing money, providers did not ask for this financial risk, but they have no choice but to collect it given their financial situation and the payers have the balance sheet to absorb it yet the payers keep increasing co-payments and deductibles thus enhancing their profitability."

There's new papers coming out on the fact that UHC pays their internal doctors better than external doctors and that essentially through their PBM, ownership of physicians, etc it in combination allows them to avoid many of the 15% profit rules. Airbud actually introduced me to a couple of UHC employed physicians and them described in their daily lives the kind of things that get written about UHC - for example - a UHC owned surgery center won't accept UHC plans.

 

[MortonExtension]

The fact that so many of us are paid on collections just incentivizes us to bill nefariously sometimes doing unjust or unwarranted procedures. Doctors will look at the insurance of the patient and dump the patient to someone else if they can’t get paid..

Not sure if this adds to the discussion but just wanted to say it

 

[Feli]

The fact that so many of us are paid on collections just incentivizes us to bill nefariously sometimes doing unjust or unwarranted procedures. Doctors will look at the insurance of the patient and dump the patient to someone else if they can’t get paid..

Not sure if this adds to the discussion but just wanted to say it

Yes, and it's worse than that: we can't set our prices (rare exception plastics, derm, maybe 0.X% of podiatrists).
That is the main reason we're effed: we can't set our own rates.
Further, we're generally not paid up front, and have we have no collateral.
We also can't really strike as that's quasi-terrorism to bargain with human lives/health.

We largely work for rates determined by "the system" ...aka the area payers. We all do it.
It's even worse for DPMs than other med specialties as we're saturated and easy target to lowball from payers or from employers (always other DPMs nearby who will take the job offer or the crap HewManna, MCR adv, TryCare, MCA carrier, etc contracted rates).

...Attorneys, pilots' unions, mechanics, nurse unions, HVAC, comp scientists, CEOs, etc etc etc professionals or skill trades can set their rates.
The mechanic has someone's car, the computer ppl have your website or machine or etc, building contractors have your building materials, and the unions can strike. And sure, the crap lawyers or architects or whatever will work for less... while the good and in-demand ones can charge more per hour or per job or whatever. Docs have almost none of that ability (short of cannibalizing each other by shaving productivity on other docs they employ).