Looking Ahead

It’s easy to lapse into despair at the daily destruction of the America we once inhabited. There’s no use whitewashing the fact that an anti-science “health” administration threatens the lives of thousands of people unnecessarily, that insane trade “policies” will inflict enormous damage on the economy, and that– thanks to the Mad King– our global stature may never recover.

Those things and many others even worse are all true. But it’s also true that our government was far from perfect, and that the wholesale destructruction we are experiencing will–when the fever breaks–leave us with a task that is arduous, but that also will represent an opportunity to–in Biden’s phrase–build back better.

I have occasionally quoted my cousin, an eminent cardiologist, for insights into America’s fragmented healthcare system. Today, I’m sharing an op-ed he recently published with a co-author whose expertise is financial. They are looking beyond the devastation, and explaining how we might eventually build a better health system.

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HOW THE DEMISE OF MEDICAID MAY BENEFIT US ALL

By Morton Tavel, MD, and Paul Nolan, CPA

The recently passed “Big Beautiful Bill,’’ among its many deficiencies, contains changes that will negatively impact the already suboptimal nationwide Medicaid programs. Among these changes is a reduction of the federal funding for these various state programs, which, according to estimates of the Congressional Budget Office (CBO), these provisions could result in 11.8 million fewer people enrolled in Medicaid over the next decade, meaning a loss of all financial support of healthcare for many of our neediest citizens. But, as is suggested by this title, how could such an apparently egregious act pave the way for better national healthcare? Let us now delve into the obvious answer:

PRESENT HEALTHCARE IN THE UNITED STATES

Currently, national healthcare is provided through a fragmented healthcare system, with private health insurance companies competing with each other and the government. Private insurers offer health insurance primarily through employers. The government also supports healthcare coverage through programs such as the Affordable Care Act (ACA), Federal Employees Health Benefit Plans, and Veterans Benefits, Medicare, and Medicaid. In many plans, premiums are collected through payroll taxes and general tax revenue, often leaving significant out-of-pocket costs (copays, deductibles, and coinsurance), at an unsustainable cost. The overall healthcare cost in the United States is approximately 18 percent of Gross Domestic Product (GDP), the highest in the world. This compares with costs in other western nations that generally range from 10-12% or lower, yielding national health and mortality rates equal or better than those of the U.S.

WHY ARE HEALTHCARE PRICES SO HIGH IN THE U.S.?

Although comparison shopping makes sense when we buy consumer goods, such normal market forces do not apply to healthcare. Negotiation of prices of various treatments is seldom available, and as costs of tests and treatments constantly rise, the multiple private insurance plans provide no effective means to control prices, simply passing on the expenses to consumers. Although the Affordable Care Act (ACA) has introduced insurance reforms that reduce the average costs to individuals, this nation’s presently excessive overall price tag continues to rise, and given our current healthcare structure, there is no evidence that these costs can be controlled. Thus, more measures are needed to solve this problem.

Insurance companies, in addition to their inability to limit prices, have balked at ACA’s requirement to spend at least 80-85 percent of their revenue on health care. By contrast, more than 98 percent of Medicare’s expenditures are devoted to this end. Estimates vary, but one-quarter to one-third of our current healthcare costs are driven by insurance companies’ profits together with their administrative costs.  Thus, roughly half of these costs could be recovered under a single-payor system.

MEDICAID

Medicaid began in the 1960s, as was Medicare; however, Medicaid was not created as medical insurance but rather as a broad public welfare program to provide states with the opportunity to receive federal funding for services given to eligible, needy people, providing many important supportive, non-medical, functions. By contrast, Medicare was formed to provide broad healthcare insurance coverage for all citizens, but it has been limited to the elderly, for reasons explained below. As a result, Medicaid functions by default as a broad welfare safety net for more than 70 million impoverished Americans with spending of over $860 billion in combined state and federal funds. On average, the federal government covers about 70 percent of the program’s costs. In addition to hospital care, Medicaid recipients are covered with a broad range of custodial services that include helping those with chronic illnesses, disabilities, or age-related self-care limitations with activities of daily living that include eating, bathing, dressing, toileting, walking, and continence, etc. Although Medicaid is a joint federal and state program, each state has the flexibility to administer the program differently within broad federal guidelines. Therefore, eligibility criteria for Medicaid inclusion varies unevenly from state to state, relating to factors such as personal income, assets, dependents, disability status, and age. Although all states are required by federal law to provide Medicaid’s mandatory healthcare benefits, each state decides its own criteria for covering many specific medical procedures and payments. The average yearly national Medicaid expenditures for all needy individuals are placed at approximately $8,800. But these amounts vary widely from state to state, ranging from $10,000-$13,000 in most New England and middle west, south central, and mountain states. This is contrasted with approximately $4,000-$6000 in east, south central, west south central, and mountain states.  Florida falls in this latter, lowest spending group, at approximately $5,500.

Thus, Medicaid is an inherently inequitable low-level healthcare system. In addition to relegating a substantial number of people into an inferior status, it also compensates physicians less, and in comparison to Medicare, Medicaid caregivers receive an average two-thirds of these fee amounts, often barely sufficient to support office expenses. This leads to substandard care and frustration for the caregivers. This factor alone causes many physicians to limit or refuse care for such recipients. By contrast, Medicare’s Physician Fee Schedule pays more fairly and consistently across the nation.

Although Medicare is a primary payor of hospital charges, one vital role played by Medicaid is in the support of long-term care in the U.S., covering a major portion of spending on nursing home services. In 2022, Medicaid spent approximately $154.4 billion on these long-term care services, paying for nursing home care for periods that meet the program’s eligibility limits that vary by state. Abetted by support of patients’ hospital charges, Medicaid also acts as a financial lifeline to rural hospitals, which is a major factor contributing to their viability.

COULD A SINGLE PAYOR (MEDICARE-STYLE) PROGRAM PROVIDE A SOLUTION?

At its inception in 1965, the architects of Medicare believed that establishing a successful program for the elderly would serve as a steppingstone toward future general coverage. To gain support, their approach was to introduce a program that could be incrementally expanded later, rather than presenting a universal health insurance plan upfront. However, the political landscape during the cold war era was marked by much anti-communist sentiment, and the idea of universal healthcare was derided as “socialized medicine;” however, because of Medicare’s current wide public acceptance and satisfaction, this label is no longer applicable.  Nevertheless, political fears of excessive costs have limited the idea of Medicare expansion. Contrary to popular belief, this method, as we explain, could be far more economical than our current system. Moreover, if we wish to adhere to our egalitarian principles, i.e., basic healthcare available to all, an effective remedy is to replace the entire system with a single payor entity, resembling “Medicare for all.”

Ideally, Medicare and Medicaid would be best combined into a single administratively efficient financing system. Eliminating Medicaid’s role in healthcare is justified because, as noted, such a low-level system provides substandard, poorly compensated medical care. Billing under a single entity would save medical care providers vast amounts of overhead, while also reducing the headaches that trigger much provider burnout that is increasingly being recognized. If properly structured, this consolidation would allow Medicare to assume support for all hospital expenses, both rural and metropolitan, thus providing for evenly distributed, cost efficient, and national support of long-term care.

CONTROL OF DRUG PRICES

The cost of prescription drugs varies widely among health plans from state to state. In efforts to decrease drug prices, pharmacy benefit managers (PBMs) work as middlemen between drug manufacturers, insurance companies and pharmacies, leveraging their large buying power to negotiate lower drug prices to benefit users such as Medicare Part D plans. PMBs, through negotiation, do obtain price concessions and rebates from drug companies, retaining a portion and remitting the rebate balance to insurance companies which in turn are expected to reduce prescription costs for consumers. However, depending upon the portion of the rebates retained by the PBMs, this can even drive up the price of available drugs. Since the Inflation Reduction Act was enacted, Medicare now negotiates directly with drug companies, which could, if expanded, eliminate the PBMs and provide a means for a single payor to control the entire pricing structure. The U.S. Department of Veterans Affairs provides a model for this process by direct negotiation of drug prices, resulting in payments of roughly half the retail price of drugs.

COMPENSATION OF CAREGIVERS AND HOSPITALS

Medicare has a detailed method of setting compensation for both physician and hospital services, all of which are lower than those of private insurers. According to the findings of 19 recent studies comparing Medicare and private health insurance payment rates for all services, private insurers paid nearly double Medicare rates for all hospital services, ranging from 141% to 259% of Medicare rates. For physician services, private insurance paid an average of 143%, ranging from 118% to 179% of Medicare rates. As noted, a single payor would eliminate Medicaid’s meager present caregiver’s  compensations.

VARIED COVERAGE PLANS

Instead of adopting a strict single-payor system, the U.S. may need additional tiers of care as provided presently by private insurers. These strata could offer extra services beyond basic care, such as private room options, shorter waiting times for non-urgent issues, elimination of co-pays, long-term care, and dental care. Such extras could be provided for patients who are willing and able to pay them in addition to a basic single-payor system. Such a structure would also allow the privately run insurance companies to continue involvement, much as they are presently providing in the form of Medicare “supplement” or “gap” plans.

OTHER ADVANTAGES OF UNIVERSAL COVERAGE

Since the entire population would ultimately participate in a basic single payor system, automatic coverage would be provided for everyone, including those with pre-existing conditions, another stumbling block eliminated! This would also eliminate the controversial need for an individual mandate.

Although employer-financed coverage could simultaneously be continued, individuals so covered could opt out at any time to enter a single-payor governmental sponsored system. This choice would provide a means for employers to reduce their financial burdens, while allowing patients the flexibility to move freely within a national system without losing coverage.

WHY HEALTHCARE MORE COST-EFFICIENT IN OTHER ADVANCED COUNTRIES AND COULD PROVIDE A MODEL FOR US.

Advanced western nations have adopted universal healthcare as a basic right that is mandatory for all citizens. In all systems, (Canada and Germany are two examples) the government acts as a central authority that supervises universal fee schedules, either by direct mandates or through other means such as by negotiation among a combination of insurance providers, public funds, and caregivers. This usually results in lower, fixed costs for all services.

In this nation, the federal government, specifically through the Centers for Medicare & Medicaid Services (CMS), sets the prices for hospital and physician services. These prices are not negotiated like in the commercial insurance sector. CMS uses different payment systems for various types of services, such as inpatient and outpatient prospective payment systems for hospitals and for the fee schedule for physicians. CMS updates the payment rates for both hospital and physician services annually, incorporating changes in costs and other relevant factors. If the U.S. were to establish a uniform overall pricing structure in a single payer system, this would closely parallel those of the other advanced nations noted above and result in reduced healthcare costs for the entire nation.

CONCLUSION

Although no system is perfect, the federal Medicare system works reasonably well; by contrast, the federal-state Medicaid system doesn’t. Folding Medicaid into Medicare-for-all would adopt the long-delayed visionary 1965 universal healthcare plan. We are now presented with a timely opportunity to make important corrections, permitting the replacement of Medicaid in its present form, while at the same time, embarking on a truly effective healthcare system for all that has been long overdue.