Ever since Senator Bernie Sanders made “Medicare for All” (M4A) the centerpiece of his campaign, it has attracted support, and others have joined the bandwagon. In a Kaiser Family Foundation poll earlier this year, 56 percent of respondents and 81 percent of Democrats backed “a national health plan, sometimes called Medicare for all,” which has been used to assert a mandate for M4A.
Medicare’s Unfunded Liability
Since exactly what M4A details (where the devil lurks) are less than crystal clear, and even the best-articulated versions are more like political talking points than complete plans, backed by questionable, if not provably incorrect assumptions, the goal is clearly to pass a bill that would be very hard to undo before most citizens have any clear idea of what is involved.
Consequently, it is important to remember what most stories hyping the popularity of M4A leave out: When people were informed it would entail a massive increase in costs and taxes, support cratered. Given that Sanders’ proposal could add $3.2 trillion in annual government spending (when America now spends $3.5 trillion annually on health care), that is easy to understand. However, there is also another multi-trillion-dollar reason why many who now support M4A might switch sides: Medicare’s massive unfunded liability.
As with other Social Security expansions, when Medicare was created in 1966, those in or near retirement paid little or no more in taxes but got substantial benefits throughout retirement. That imposed a large unfunded off-budget liability on later generations. And every expansion since (most recently, Medicare Part D’s prescription drug benefit, whose officially estimated unfunded liability at the time was $17 trillion) has created another free lunch for those older, expanding the huge tab facing later generations.
The same sort of conclusions were reached in an Urban Institute study of Medicare, which found that in 2012, average-earning males were “buying” $180,000 in Medicare benefits for $61,000, while similarly situated females, with smaller lifetime contributions and longer life expectancies, did even better.
The result, as reported by Michael Tanner, was a 2015 forecast of almost $48 trillion of unfunded liabilities under implausibly optimistic assumptions. A return to higher medical cost inflation rates could make it $88 trillion. A continuance of lower birthrates than forecast would push it higher. So would including future commitments to recipients who have qualified for but not yet received all their benefits as of the end date of a study.
So why might recognizing that massive unfunded liability and its continued expansion move Americans into the “anti-M4A” camp?
Because of the wealth transfer to early enrollees, as well as from ensuing expansions, Medicare provided many with a great deal. But that deal was the result of dumping an enormous bill on future generations (bigger than the unfunded liabilities for Social Security plus the national debt).
With that bill starting to arrive, Medicare is not even close to sustainable in its present form, much less to be leveraged to cover the entire population (although one can understand the vote-buying potential in promising massive new M4A generational transfers).
Not only is a massive expansion of an already far-in-the-hole Medicare program a fool’s errand, but the massive unfunded liabilities it has built up also mean that the previous costs were far higher than what recipients paid and continue to be so (even underestimates of its unfunded liability growth add more than $1 trillion per year of hidden costs to Medicare).
As a result, Medicare was a far worse deal than M4A salesmen and women admit, and it is now decaying at an increasing rate, making its extension to all a 14-digit boondoggle, not a boon. And doubling (or more) down on the already unpayable burdens Medicare has laid on future generations also highlights the blatant hypocrisy of backers who, at the same time, preen about all the new plans they have to “invest in the future.”
Gary M. Galles is a professor of economics at Pepperdine University. His opinions are his own. This article originally appeared on fee.org, then pennypress.com Reprinted with permission.
Bernie Sanders is strongly promoting “Medicare for All,” and claims to be its father (“I wrote the damn bill,” he proclaimed to the nation during the second round of Democratic Presidential debates).
His plan does not look like Medicare at all. It appears that he hardly knows anything about Medicare. He probably has no experience with it. Despite his advanced age, he does not need to depend on it. Members of Congress are allowed to receive Medicare benefits, but unlike most other Americans, they can receive other benefits in addition.
Sitting members of Congress can get routine examinations and consultations from the attending physician in the U.S. Capitol for an annual fee. And military treatment facilities in the Washington area offer free emergency medical and dental care for outpatient services.
Members are also eligible for the Federal Employees Health Insurance Program, and they won’t be kicked off as soon as they reach Medicare age. They do have to go through an Obamacare exchange, but it is a small one, the DC Health Link, which reportedly functions well. There are 57 gold-tier plans to choose from, not one or two as in many states. Their portion of the premiums could be as little as 25 percent of the total premiums. Apparently, subsidies for senators don’t run out just because their salary exceeds 400 percent of the federal poverty level.
Funding for Medicare for All will apparently be vacuumed up from all other sources of payment for “healthcare,” and will go into the big collective pot. Then people can get everything without premiums, copays, or deductibles—so they say. This is not at all like Medicare.
Medicare Part A, for hospital care, is funded through the Medicare payroll tax: a 2.9% first-dollar tax—no deductions--on all employment income, half of which is paid by the employer. Seniors believe that they have been funding this through their working years, as they are constantly told. They have indeed paid, but their taxes were immediately used to pay for the care of older retirees. So, their hospital bill today will be paid from the wages of about 2.5 workers (say the persons pumping their gas, collecting their trash, and repairing their plumbing). Already that is not enough, so the IOUs in the “trust fund” are being redeemed from general tax revenues. That fund will soon be gone, according to the Medicare trustees, as Baby Boomers are flooding into the system. It would vanish in a nanosecond if we loaded in everybody, with or without illegal immigrants.
Medicare has long been implementing ways to curb runaway expenditures. From the mid 1980s comes the Prospective Payment System, or Diagnosis Related Groups (DRGs), under which payment has nothing to do with services rendered to a particular patient. According to my 1985 “Ode to DRG Creep”:
“Now the pay’s by the head, if alive or if dead,
Diagnosis determines the money,…
We need costs less than average, and discharges quicker
We will get no advantage -- For care of the sicker.”
Since “quicker and sicker” discharges might cause a need for readmission, the government penalizes hospitals for readmission. One way to prevent readmission is to discharge to hospice or directly to the morgue. If Bernie were an anonymous Medicare patient, he’d get a consultation on POLST. That’s Physicians Orders for Life-Sustaining Treatment, which translates in the Newspeak Dictionary to “Legally Enforceable Orders to Terminate Life-Sustaining Treatment Including Food and Water.”
Bernie might think he had been admitted—say he had an IV in a hospital room. But if he gets discharged before his second midnight, he might be classified as an outpatient, which is covered under Medicare Part B, and get a “surprise” bill for thousands of dollars, because of the “Two-Midnight Rule.”
Or Bernie might expect to have a little rehab after an orthopedic procedure, but if he is in hospital for fewer than three midnights, rehab isn’t covered. He might have the choice of paying out of pocket, or going home where he will be alone, unable to get out of bed.
Yes, Bernie on Medicare will have free choice of doctors—except for the ones who aren’t accepting Medicare patients.
If Bernie himself were stuck on Medicare with no way out, he might think it not so wonderful. Has anyone heard him tell people about these Medicare problems?
Maybe he means the Canadian Medicare system. It does have a way out for non-senators—called the United States.
Intensified by the early fight for money and backers among Democratic presidential hopefuls, Medicare for All and similar single-payer insurance programs have been promoted with increased volume. While there are differences among the “I’ll give you more for less” sales pitches, they share the common central premise that such plans have far lower administrative costs than private insurance, so their version of reform will produce a massive infusion of available resources.
However, the “proof” offered for those administrative cost savings claims mainly consists of constant repetition, with candidates then quickly moving on to the free lunches they would supposedly enable. But given that claim’s central place in their proposals, we must question that premise and with it, the glib answers claimed for it.
How Should We Measure Administrative Efficiency?
For health care plans, the standard measure of efficiency is administrative costs as a percentage of total costs. And in those comparisons, Medicare appears substantially more efficient. But that does not mean there would be savings if people were moved from private insurance to Medicare for All.
The primary reason is that Medicare beneficiaries are far older and less healthy than the population. That makes health care costs far higher per Medicare beneficiary. In fact, before Obamacare, medical expenditures per Medicare beneficiary were routinely more than double those for the privately insured. However, nonmedical administrative costs are only slightly related to total medical expenditures. They are primarily related to the number of persons covered. This causes the standard measure to grossly exaggerate Medicare’s relative administrative efficiency.
Consider an example. Say both Medicare and private insurance beneficiaries had identical administrative costs of $500 each, but the Medicare patient received $5,000 in benefits, while the private patient received $2,500 in benefits. Medicare would show a 10 percent share of administrative costs, and private insurance would show a 20 percent share. In other words, despite the same administrative cost per beneficiary—that is, the same actual efficiency—the standard measure makes private insurance administrative costs look twice as expensive as Medicare.
Simply ask what would happen to administrative expenses if one private insurance beneficiary was moved into Medicare in the example above. Despite Medicare supposedly being half as costly in that regard, administrative costs would not change. No resources would be freed up. And given that the administrative cost per Medicare beneficiary is actually higher than for private insurance, the shift of someone into Medicare would increase administrative costs—leaving fewer resources, rather than more—available for medical care.
What Should Be Included in Medicare’s Administrative Costs?
The public-private comparison also typically compares the administrative costs of private insurance to those that show up in Medicare’s budget. But many of the administrative costs do not show up there. They appear in other agencies’ budgets. The costs of collecting taxes appear in the IRS budget. The costs of collecting premiums appear in Social Security’s budget. Many of the accounting, building, and marketing expenses appear in the Health and Human Services budget. Including those costs would roughly double Medicare’s reported administrative costs.
How Should We Count Taxes on Private Insurance?
Private insurance administrative costs are generally defined as premiums paid in minus claims paid out. However, that means everything except claims payments are counted as administrative costs whether or not they have anything to do with administration. For example, many states impose a premium tax (averaging about 2 percent) on health insurers, and those tax payments are incorrectly categorized as administrative costs. This also makes Medicare, which is exempt from such taxes, look relatively more efficient than it really is.
How Should We Count Disease Management and On-Call Consultation Services?
As with taxes, counting private insurance administrative costs as total premiums minus claims paid introduces other measurement distortions, as well. Insurance companies offer disease-management and on-call nurse consultation services. However, those services do not generate insurance claims. Consequently, those costs are also counted as administrative rather than medical.
How Should We Count Fraud and Fraud Prevention Efforts?
Waste, fraud, and efforts at their prevention also complicate administrative efficiency comparisons. Consider what happens if Medicare (estimates of whose excess spending exceed $50 billion yearly) spent less on prevention efforts. It would look more efficient because its administrative costs would be lower and because undetected excess spending would be counted as medical expenses, not waste. In contrast, insurance companies, whose bottom lines are at stake, are much more diligent about eliminating such excess spending. But those efforts, even though they can generate very large overall savings ($1 of fraud prevention has been estimated to reduce those costs by as much as $15), raise their measured administrative cost percentage, making them look less efficient.
How Should We Treat the “Excess Burden” Caused by Switching to Single Payer Systems?
In addition to all these biases exaggerating private insurance administrative costs and understating Medicare’s administrative costs, another large difference should be noted. When people pay more to get better private insurance coverage, they don’t treat it as a tax, but as part of their employee compensation. Under Medicare for All, however, higher payments into the system will not provide greater benefits. That means that Americans will rationally start treating those payments as taxes in exchange for nothing.
It will, therefore, act as a large income tax increase with correspondingly large economic distortions. Those distortions, created by the wedges taxes impose between what buyers pay and what sellers keep, reflect the wealth destroyed by the reduction in mutually beneficial market arrangements that result, which economists call excess burdens. While not incorporated in official comparisons, they are very large added costs of single-payer systems compared to private medical insurance.
One study found that even the “lowest plausible assumption about the excess burden engendered by the tax system raises the true costs of delivering Medicare benefits to about 20-25 percent of Medicare outlays,” imposing costs far higher than any supposed private insurance administrative cost deficiency.
It is striking how much single-payer promoters rush past their repetitions of administrative cost savings claims before quickly turning to their vote-buying promises in large part funded by them. It almost seems that they don’t want voters to think carefully about those claims. And that might reflect an accurate judgment. If people questioned the basis of those promised solutions, it would reveal supposed administrative cost savings to be the opposite once the compounded mismeasurements are deciphered, and it would not be anyone’s ticket into the White House.
Gary M. Galles is a professor of economics at Pepperdine University and a guest columnist to the Penny Press. His recent books include Faulty Premises, Faulty Policies (2014) and Apostle of Peace (2013). This piece was originally published on fee.orgm then pennypresslv, reprinted here in full, with permission.
Senator Bernie Sanders during the 2016 Presidential Election called for a single payer system to cure our healthcare woes. Now Democratic contenders for the 2020 election are calling for the same. Some voters are salivating at the thought, tired of high insurance premiums and deductibles. Others are cringing at the idea of the government running our healthcare system. Yet most are confused and want more details. So let’s break it down.
Medicare is the health insurance offered by the federal government for those over 65 and with disabilities. According to medicare.gov they breakdown medicare as the following:
Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services.
Part D adds prescription drug coverage to:
These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans
Originally suggested by Senator Bernie Sanders, Medicare for All would essentially allow all Americans to qualify for Medicare. According to Unitedmedicareadvisors.com:
The concept sounds nice but Medicare doesn’t currently cover many of the above such as hearing aids, dental exams, and long-term care.
Unitedmedicareadvisors.com reports the following:
Unfortunately, tax hikes on employers could lead to price hikes and less employment.
So the concerns I have are Medicare doesn’t currently cover what Medicare for All is touting and the expense may be underprojected.
Moreover many healthcare providers do NOT take Medicare so access can be an issue.
However, until premiums and deductibles go down, and more Americans become insured, plans such as this will gain attention and popularity.
The most recent World Health Organization rankings of the world’s health systems has the United States at 37th -- seven spots behind its neighbor to the north, Canada, and 19 spots behind its American predecessor, the United Kingdom. That might not seem so bad on a list 190 nations long, but the United States ranks last in health care system performance among the 11 richest countries included in a study conducted by The Commonwealth Fund. In that study, “the U.S. ranks last in Access, Equity, and Health Care Outcomes, and next to last in Administrative Efficiency, as reported by patients and providers.”
Much of our inflated health insurance premiums in America comes from paying to create your bill. That’s right -- 25 percent of total U.S. hospital costs are administrative costs. The United States had the highest administrative costs of the eight countries studied by The Commonwealth Fund. Scotland and Canada had the lowest, and reducing U.S. per capita spending for hospital administration to Scottish or Canadian levels would have saved more than $150 billion in 2011.
Treating healthcare like any other marketplace requires careful, complicated codification of products sold and services rendered. People must be paid to determine how much your healthcare costs, and that can’t be changed, but it can be improved upon. Allowing insurance companies to profit from people’s health makes for a marketplace in which every cent of cost is counted and every penny of profit is protected. Profit motive always results in more scrutiny by the haves at the expense of the have-nots.
You might think that an industry that preys on the unhealthy and the healthy alike would prefer their consumers healthy as to enjoy the profits from your premium payments without paying for healthcare. But the cost of your health insurance premium already includes your health insurer’s profit margin. The health insurer is going to do all it can assure a certain amount a profit except for a catastrophic health emergency that consumes the country. But if the consuming population is unhealthy relative to other markets, the health insurer has good reason to inflate prices to cover its projected costs. That is indeed the case in the United States.
The United States is the 34th healthiest nation in the world, according to 24/7 Wall St. That’s not terrible, but not what you probably expect from a nation advertised by Americans as the greatest in the world. And you’re paying for it.
Not unlike a mortgage or auto insurance premium, the cost of your health insurance premium is an average based on the health insurer’s risk. That risk is the potential costs the health insurer could incur based on the perceived health of its insured consumers. I’ve written in the past how Republicans can’t repeal and replace Obamacare because their constituents, most of whom reside in the South, need Obamacare. Southerners are the least healthy Americans, with 20 percent reporting fair or poor health in 2014. The South also has the highest rates for diabetes, obesity and infant mortality in the nation. The South also accounts for nearly as many uninsured people as the rest of America combined, and 17 percent of the uninsured fall into the coverage gap for Medicaid expansion. Your health insurance premiums pay for their healthcare as well as your own, which is why, given the current for-profit health insurance marketplace, I would welcome a fat tax.
A fat tax is a tax on fat people. People who live unhealthy lifestyles should pay more for health insurance. As a healthy consumer of health insurance, I’d prefer to pay a lower premium given my dedication to maintaining good health at the expense of those who refuse to maintain good health. I might be fat shaming some people, but I don’t care. I shouldn’t have to pay for your diabetes because you can’t resist stuffing your face with Twinkies. Maintaining your health is your responsibility and no one else’s, and you should be punished for failing to maintain good health at the expense of your neighbors. But since something that could ever be referred to as a fat tax by the opposition would never pass Congress, a rewarding people with discounts for their healthy habits would be much more likely.
I foresee this program as mirroring the Progressive auto insurance Snapshot program -- “a program that personalizes your rate based on your ACTUAL driving.” Instead of plugging a device into your car, you’d use a Fitbit or similar health monitoring device with a heart rate monitor. Couple your daily monitoring of your exercise and diet with the results of regular checkups with your physician to confirm your healthy habits and you’ll be given a discount on your monthly health insurance premium as determined by your overall health.
Simply scheduling and completing regular checkups will help lower premium prices by catching things early and allowing for preventative medicine to work rather than resorting to more expensive reactionary measures. That could be the first discount bracket: schedule and complete a physical twice annually for two percent off your monthly premium. That way everyone at least has a chance to save some money. Those who fail to do so will pick up the tab.
The real discounts will be reserved for those consumers who regularly show signs of living a healthy lifestyle. People who don’t use tobacco products would receive a one-percent discount on their monthly premiums that the insurer will recoup from charging tobacco users with a one-percent premium penalty.
Non-drinkers would also receive a one-percent discount, as alcohol is a cancer-causing carcinogen and dangerous when consumed irresponsibly. Accessing a penalty for drinking, however, would be problematic, as social and occasional drinkers shouldn’t be penalized for enjoying alcohol responsibly. But say you get a ticket for driving while intoxicated -- that’s two percent tacked onto your health insurance premium for putting your own health and the health of your neighbors at risk. The same goes for possession of illegal drugs, except cannabis. No discount or penalty would be accessed for cannabis use since it is proven to kill cancer cells and be of medical value.
Even if you are a tobacco user and a heavy drinker or drug user, you too deserve opportunities to lower your health insurance premiums. So anyone who meets the Department of Health and Human Services recommendations for weekly exercise for a month gets a one-percent discount on their premium the following month. That’s just 150 minutes of moderate aerobic activity or 75 minutes of vigorous aerobic activity weekly. Add that to the two-percent discount for completing bi-annual physicals, and you could offset the penalties of driving under the influence and smoking.
Big money will be saved based on your body fat. If an adult male or female maintains an athletic body fat percentage (between five and 10 percent for males and between eight and 15 percent for females), they get an additional two-percent premium discount on top of the two percent for completing bi-annual physicals. That same two percent would have to be paid by someone, though, so it would fall on the obese.
Adult males with a body fat percentage over 24 and adult females with a body fat percentage over 37 would receive a two-percent premium penalty. If they make their two appointments for physicals annually, there wouldn’t be any change to their bill. The overweight, being males with body fat percentages between 21 and 24 and females with body fat percentages between 31 and 36, would receive a one-percent premium penalty.
Adult men with body fat percentages between 11 and 14 and women between 16 and 23 would get a one-percent discount for maintaining a “good” body fat percentage. Those men with body fat percentages between 15 and 20 and women with body fat percentages between 24 and 30 would pay no penalty nor receive a discount for maintaining “acceptable” body fat percentages.
These discounts and penalties would motivate consumers to improve their health in order to save money, in turn, lowering premiums for everyone by improving the overall health of all consumers in the marketplace. The higher the U.S. climbs out of that 34th spot in overall health, the less everyone pays in health insurance premiums.
I pay roughly $135 monthly in health insurance premiums for a high-deductible, Bronze package I found on MNSure -- Minnesota’s equivalent to the Obamacare marketplace. I maintain an athletic body fat percentage under 10 (two-percent discount). I exercise and regularly exceed the Department of Health and Human Services’ weekly recommendations (one-percent discount). I don’t smoke (one-percent discount), and I don’t drink (one-percent discount). I saw my doctor twice last year (two-percent discount). Add it all up and I’d save seven percent on my monthly health insurance premiums, or a measly $9.45 monthly. That’s over $113 annually, though, much of which would be recouped from the penalties assessed to the unhealthy. I could think of a lot of things on which I could spend that $113. It would be nice to be able to afford a steak once in a while.
While Medicare-for-All is picking up steam in Liberal circles, it’s still at least three years away from being seriously considered by Congress as a solution to ever-increasing healthcare costs. Meanwhile, here’s a solution that addresses two problems: ever-increasing healthcare costs and the declining health of Americans overall.
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Now that Republicans’ efforts to repeal and replace Obamacare are finally dead -- this time for good -- Congress can actually do what the American people want, which according to a poll, is improving Obamacare -- not repealing it.
The Congressional Budget Office released a preliminary report revealing that the Republicans’ last-ditch effort to repeal and replace Obamacare would result in millions of Americans losing health insurance. The result was Maine’s Republican Senator Susan Collins opposing the bill, which was a third vote Senate Republicans couldn’t afford to lose.
The now bipartisan effort to improve Obamacare, for which Republican Senator of Arizona John McCain has called, began with a health care debate broadcasted on CNN, Monday. It revealed opportunities for Congress to improve upon Obamacare -- if Republicans are willing to work with Democrats to pass legislation.
The four Senators participating in the debate were Democrat Amy Klobuchar of Minnesota, Independent Bernie Sanders of Vermont, and the Republican writers of the latest effort to repeal and replace Obamacare, Lindsey Graham of South Carolina and Bill Cassidy of Louisiana. The debate remained cordial for the most part, with moments of consensus indicating a bipartisan bill is indeed possible.
Graham pointed out that since the passage of Obamacare, the money has continued to flow away from Americans to health insurance and pharmaceutical companies. He cited the profit increases of the major health insurance providers, with all six of the biggest seeing their stock hit all-time highs this summer. This was music to Sanders’s ears, who acknowledged his Medicare-for-All bill introduced in the Senate won’t pass and that a bipartisan effort to improve Obamacare should be the short-term focus of Congress.
Cassidy even seemed to agree that something needs to be done to reign in the prices Americans pay for prescription drugs. Since Congressional Republicans held the longest roll-call vote for the Medicare Modernization Act, or Medicare Part D law, back in 2003, the federal government has been barred from negotiating prices with pharmaceutical companies.
According to a 2016 Reuters report, prices for four of the nation's top 10 drugs increased more than 100 percent since 2011. The report also shows that sales for those 10 drugs went up 44 percent between 2011 and 2014, even though they were prescribed 22 percent less. Prescription drug expenditures account for 20 percent of healthcare costs. But when Sanders asked Cassidy if he would vote for a bill to reverse the Part D law, much like Klobuchar’s Medicare Prescription Drug Price Negotiation Act, Cassidy instead called Sanders a Socialist who wants to commandeer the formulas for medicines to be produced by the State and disincentivize medical innovation.
A 2016 Kaiser Family Foundation poll found that Cassidy is part of a very small minority on the subject, with 93 percent of Democrats and 74 percent of Republicans in favor of the government negotiating Part D prescription drug prices. The problem, though, is that Congressional incumbents rely on pharmaceutical companies to win elections, which will make both Republican and Democratic votes hard for Klobuchar to attain. Senators Richard Burr of North Carolina, Orrin Hatch of Utah, Mitch McConnell of Kentucky and Roy Blunt of Missouri will likely join Cassidy as “no” votes on Klobuchar’s bill, given the donations their campaigns received from the prescription drug industry totalling $4.35 million between 2003 and the middle of last year.
Another obstacle for Klobuchar’s bill is the fact that this time last year, there were 894 pharmaceutical lobbyists to the 535 members of Congress, with more than 60 percent of them having previously served in Congress or worked other government jobs. It seems the prescription drug industry provides nice retirement work for former government officials, which incumbents won’t want to see go away.
So while CNN’s healthcare debate provided opportunities to improve Obamacare, Congressional corruption presents obstacles to overcome in order for Americans to see their healthcare costs decline.
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