Questions for those on Medicare (or who have experience with it)

[democrattotheend]

15. Interesting. I am actually proposing the opposite in my paper

I started out writing about why they should not raise the Medicare age, but decided to expand the paper to propose alternative cost-savings. I am proposing that Medigap be reformed to have some cost exposure rather than covering everything, in order to bring down the premiums and enable more people to be able to afford it, as well as saving Medicare money by forcing patients to ask questions about cost and consider cost in deciding whether to do an expensive procedure, particularly one with little chance of success.

The way I structured my proposal, it is targeted primarily at ensuring that cost is not completely absent from the equation when patients and their families make decisions about life support or aggressive treatments with low probabilities of prolonging life. Medicare spends 27% of its budget on care in the last year of life, and studies showed that 1/3 of Medicare beneficiaries who died in 2008 had surgery in their last year of life, 1/5 in their last month. The way Medicare is currently structured, there is no incentive for doctors or patients who have supplemental insurance to consider cost in making these decisions, and family members who have no cost considerations often want the doctor to do everything they can despite the low odds of success, which is both enormously expensive for Medicare and often causes the patient more suffering than if she had been moved to hospice or pallative care or allowed to go home and die on her own terms.

I know this is going to be controversial on both the left and the right, but Medicare spends a huge chunk of its budget on a relatively small number of beneficiaries. I think it's only fair that people who want to use public funds to keep someone on life support or perform expensive "hail Mary" surgeries ought to pay at least a small fraction of the cost.

On a broader level, I think ensuring that patients have some relationship to the cost of their care is important to prevent waste and overbilling. Without cost-sharing and with loose enforcement from Medicare there is little accountability for doctors who upcode or perform expensive and unnecessary tests, which often result in treatment procedures that were arguably unnecessary and cause the patient more discomfort and complications. For example, most men who have prostate cancer will die of something else before they become symptomatic. Having the surgery often causes impotence or incontinence or both. I wish I had known that before my dad had his prostate surgery...I would have at least encouraged him to seek a second opinion. But in his case, it was arguably the right thing to do because they caught it when he was 58. PSA tests are almost completely useless for men over 75 and the medical community does not recommend them, but they continue to be conducted (in part because of lobbying from oncologists and the diaper industry) and often lead to unnecessary surgeries that cause impotence or incontinence.

I know a lot of seniors are struggling and I don't want anyone to go bankrupt paying for healthcare, but I think completely disconnecting people from the cost of their care and not allowing the government to set any limits (heaven forbid, death panels!) creates so much waste and drives up costs and makes the system unsustainable in the long run.

Since I know the American people would never accept having Medicare set limits on how much it will spend per patient or refuse treatments that have a low probability of keeping someone alive, I am proposing restructuring Medigap and Medicare Advantage to require some cost-sharing so that people cannot insist on aggressive hail Mary treatment for terminally ill patients or unlimited life support without baring any of the cost.