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Health Care Reform by Medicare Expansion
Posted on Jun 20, 2009
By Eric W. Fonkalsrud, M.D., and Michael D. Intriligator, Ph.D.
With an expanded Medicare system, all Americans would be covered regardless of pre-existing conditions, and they would have complete portability of care and medical records throughout the nation. Those people who prefer more extensive coverage for desirable but not essential procedures such as cosmetic surgery, and many other conditions for which very expensive care provides questionable benefit, or self-inflicted disorders, would be placed lower on the list of covered disorders, similar to what Oregon has provided for more than a decade. All citizens would have the option of purchasing supplemental private insurance for these conditions, as now exists in the Medicare program.
Further expansion of the national quality and assessment programs together with outcomes research studies would play an important role in eliminating unnecessary and ineffective services and treatments and standardizing health care delivery throughout the nation. The very erratic and incomplete employer-provided health coverage would be gradually phased out to reduce costs and to make businesses more competitive with those in other nations. Retiree health benefits were first offered in World War II during a period of wage and price controls when many companies had a young work force with few retirees. Today, however, it’s the reverse, particularly in old-line industries. For example, Detroit’s Big Three automakers currently have more than four times as many retirees as active hourly workers.
The Medicare Expansion program has some similarities with the Canadian health care system, although it differs in some major aspects. There would be no governmental limitation of total physicians produced or of entry into specialty training programs. The individual provinces administer the Canadian single-payer system, and it is a more efficient system than the U.S. Medicaid program. It entails minimal paperwork and middle management, while providing rapid and predictable reimbursement. Prompt care is provided for disorders requiring urgent treatment; some delays may occur for patients seeking elective procedures. Physicians are generally busier with direct patient care than their counterparts in the U.S., while their incomes in many specialties are currently very similar. Canadian physicians and patients have repeatedly voted to continue their current health care system.
In designing a package of basic health care benefits, the Obama administration must not only strike a balance between high-powered competing interest groups but also guard against offering too much or too little, and must seek to reduce fraud and abuse. Too extensive a package of benefits could bankrupt a system that is already heavily committed. Conversely, a package without adequate coverage of medical disorders may lead to people delaying in seeking care until illnesses require much more extensive and expensive therapy.
Considerable attention needs to be directed to what physicians and the government consider to be “basic care,” with reduction of excessive expensive testing and services, based on professional rather than primarily economic or legal considerations, the latter including defensive medicine5. Self-inflicted medical disorders such as obesity could be discouraged somewhat by a low tax on known harmful foods, such as the recently recommended tax for sugar-sweetened soft drinks6, and possibly levies on ammunition for firearms.
The current complex patchwork multiple-payer health insurance programs are much more expensive, regardless of how administered, and do not eliminate the majority of problems. By contrast, Medicare Expansion builds around an efficient and well-established single-payer system, and the incentive-driven but controlled fee-for-service mechanism supplemented by a private partnership for nonbasic and more extensive desired care. Medicare Expansion would thus establish a system of national health care in the United States that would both control costs and provide quality basic health care to all Americans.
1. Iglehart, J., “The struggle for reform – challenges and hopes for comprehensive healthcare legislation.” N Engl J Med 2009; 360:1693-95.
2. Oberlander, J., “The US healthcare system: on a road to nowhere?” J Can Med Assoc, July 23, 2002.
3. Intriligator, M.D., and Fonkalsrud, E.W., “Healthcare reform by Medicare expansion” (blog), 2009-04-21.
4. Ashish, K.J., DesRoches, C.M., and Campbell, E.G., et al, “Use of electronic health records in US hospitals.” N Engl J Med 2009; 360:1628-38.
5. Medicare payment policy. Report to the Congress. Washington, D.C.: Medicare Payment Advisory Commission, March 2009.
6. Brownell, K.D., and Frieden, T.R., “Ounces of prevention – the public policy case for taxes on sugared beverages.” N Engl J Med 2009;360:1805-08.
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