Spending Too Much On The Elderly? Absolutely Not!

Affirmation: Medicare and Social Security are the bedrock programs of American liberalism.

Question:

 "Then why do so many liberals consider it taboo to even suggest adjusting these systems to ensure their sustainability for future generations?"

Response: Liberals emphatically do not regard it as "taboo" to "adjust" these systems so long as that does not mean outright cuts - which serve no one's purpose. In addition, adjustments have already been implemented including ACA future budgetary fixes to "means test" more middle class seniors in Medicare as well as moving greater medical burdens to individuals, including: higher medical co-pays, higher premiums, etc.

This response is needed given 'We The People Live'  host Josh Zepps' claim of  "progressive orthodoxy" (e.g. to fix Medicare especially)  in an original Salon.com video filmed at the Democratic National Convention. (You can google Josh Zepps video at DNC to pick it up)

Zepps claims that America’s resource allocation is "in need of a serious reexamination"  This is also a theme that's been recycled in a number of media outlets including The Wall Street Journal, The Financial Times and New York Times.  The core argument or thread running through all is: Young workers, families are getting the shaft as more and more resources, funds are funneled to the elderly in social programs.

What is Zepps further justification? He argues:

“Medicare costs more than $500 billion per annum, 30 percent of which is spent on the five percent of beneficiaries who die each year. One third of that is spent on the final month of life. The final month. I mean, you want to talk about priorities, let’s just take that one datum. More than $50 million each year spent on the final month of life.”

Let's examine this at some length. First, Medicare costs are exploding, but a large part of that is due to a program called "Medicare Advantage" (MA) which was created by BushCO and the Republicans with their Medicare Modernization Act of 2003. It basically confected a privatized form of Medicare ("Part C"), with the express purpose of bleeding regular (traditional) Medicare into insolvency by blowing up to $20-25 billion or more a year (based on gamed "risk scores")  and funneling much of it from the older program. Unless this (MA) program is killed (the sooner the better),  no other cuts will matter - because MA will metastasize to the point every $ is swallowed up.. For those who wish to read the details on why MA is hurling Medicare into insolvency check out the content in these links:

https://www.publicintegrity.org/2014/06/04/14840/why-medicare-advantage-costs-taxpayers-billions-more-it-should

And:  https://www.medicareresources.org/blog/2015/11/04/is-medicare-on-the-brink-of-insolvency/

Zepps is correct about the magnitude of Medicare spending in the final months of life. But I believe that is the fault of the medical establishment and its specialist practitioners. This is based on not leveling with severely infirm elderly people regarding limits of additional treatments and their real costs v. benefits.. Missing in most treatment discussions, for example, is any reference to quality of life . The focus is exclusively on quantity and that also often comes with huge medical costs. Missing "the talk" is it any wonder older patients tend to believe medical treatments can offer curative solutions rather than only palliative ones?

In my own case I already mentioned my prostate cancer which has now recurred. I also discussed some of the many treatment options, e.g .

http://brane-space.blogspot.com/2016/07/no-you-dont-have-to-accept-further.html

and:

http://brane-space.blogspot.com/2016/07/why-do-so-many-men-opt-for-castration.html

I have been immersed in research on treatment options and what I have found thus far isn't encouraging, including:

1) Cancer experts themselves can't agree on which primary treatment is best.

2) The same experts (oncologists) can't agree on which ("salvage") treatment for recurrent disease is best, or when to start it.

3) Most agree that if a guy has recurrent disease and a biopsy shows it has spread to the bones ("bone mets"), his days are basically numbered - though certain treatments (e.g. hormone) will allow some limited life extension.

The question then becomes: How much life extension? While I don't want to croak prematurely and deprive my many readers of my blog posts and insights, I also recognize that once I hit a certain phase in possible further treatment (called "castration resistance") it is basically time to pack it in. Game over. Finito. Some will yelp: "You can't give up or quit!" but the flip side of that is Zepps' point that we spend excessively to stay alive in the last months when all the pointers show we ought to be going to hospice care and telling the medical industrial complex 'Enough!'

The problem is that the medical complex doesn't want to quit since they see it as a renunciation of their practice to fight for life all costs.  Hence, they regard the palliative option as failure, even though added treatments may only marginally increase life - but usually at the expense of life quality. (E.g. hormone treatments for advanced prostate cancer can increase life by 1-3 years but usually with side effects including: memory loss, depression, diabetes, cardiovascular problems, enlarged and tender breasts, shrunken testicles, zero libido and hot flashes such as suffered by menopausal females.).

So in this I do side with Zepps. The tricky question for him (and other would be "adjusters")  is: WHO assumes responsibility for telling an older patient his or her days are numbered and they need to just go gently into that good night? Medicare now has a special program where end of life issues are addressed, but as yet too few patients are getting these consultations, often because their nervous PCPs don't refer them.

I encountered this when I told my own PCP back in June - after the latest PSA test came back at 6.0 - that I planned to do nothing more. I wanted no urologist referrals, no more biopsies, no more anything.  Her reaction? She wouldn't hear of it. Short of strapping me down to the exam table and coercing me, she said I HAD to see the urologist and listen to what he said concerning the latest MRI results  So, while my inclination was to halt all further medical involvement, she wasn't going to play along.  In effect, she intended to add more medical intervention and expenses to my Medicare account. .(Mind you, her adamant stance could well be traced to our litigious culture, especially relative to  medical practitioners, whom we often hold to absurd standards of action and  judgment.)

Same thing with an oncology RN at UCSF who phoned me up after the MRI and stated I "sounded too young" not to accept brachytherapy salvage therapy, i.e. instead of possibly dying at 74 or 75.  When I asked about the side effects she kind of dodged the extreme "level III toxic comorbidities" which included loss of bowel and urinary control and extreme pain with every excretion - thanks to the radiation (36 Gy delivered in two fractional treatments a week apart - under general anesthesia)

How does Zepps propose we deal with  such situations? Clearly, his superficial call for simple "adjustments" shows he doesn't want to get "in the weeds".  But at the same time, you can't just uniformly cut $50b from Medicare and tell sick oldsters to "sink or swim".  And as I noted, Medicare already has the end of life palliative care option in the program (as part of the ACA), ostensibly to limit end of life expenses. But how does it get maximized without resorting to draconian cuts? The devil, as always, is in the details.

Zepps adds:

"The left needs to reckon with the uncomfortable truth that what this country is doing is sapping the vitality of the young and pumping it into the elderly,” he says. “It is a gigantic resources Hoover from young professionals into old retirees.”

But as I pointed out the ball is not in the "Left's" court, it is really in the province and court of the medical establishment.  It is also in the court of the craven politicians who are not prepared to tell Medicare Advantage folks that they need to come out of that too expensive program and go into regular Medicare. Their MA is costing taxpayers way too much each year.

First, if Medicare Advantage had been mothballed, as Obama originally vowed to do back in 2011-12,  we would already have seen more than $75 b saved over the past 4 years. Second, if that Part D Medicare drug plan had been altered to allow bargaining for lowest cost prescription meds like the VA, another $200b would have been saved. (Especially in the wake of the news that costs for catastrophic disease drug prescriptions (like for Hepatitis C) have gone up 85% since 2013.

Third, if the medical establishment more faithfully implemented end of life palliative care conversations with patients - via the Medicare program for that purpose - we'd save a lot of that $50b used in the last months of life. But this portends a massive change in perception by that same medical establishment, to wit, maybe they themselves need retraining especially in the nature of palliative care. This latter as opposed to pushing new and expensive treatments that only marginally improve life extension.

How then do we convince patients as well as the medical experts that end of life quality is as important as quantity?

When Zepps can answer these difficult questions, as opposed to merely interjecting "adjustments" (read cuts) for the sake of cuts, we would be more likely to take his arguments seriously.  It is evident to this observer that Zepps, like so many of his younger cohort, is too ready to blame oldsters for what are really faults of the health system we have. That includes the presence of insurance companies with their built in extortion and selective rules As I noted before, the only way out is a single payer system such as my wife and her activist group are fighting for here in Colorado with ColoradoCare and Amendment 69, see e.g.

http://brane-space.blogspot.com/2016/07/janice-gives-robust-defense-of-colorado.html

Sadly, Zepps objects to those who would "change the topic" by pointing to other items in the federal budget that could use cutting. But this is being myopic and foolish. Because unless we closely examine those other items, especially military spending for which the GDP allocation has doubled since 9/11, we will never get anywhere in terms of real world priorities.  See e.g.  http://brane-space.blogspot.com/2012/07/muricans-need-to-wake-up-about-military.html

Does the U.S. REALLY need 900 foreign military bases worldwide to fund to the tune of over $1 trillion a year? Especially as the Pentagon already "misplaced" $1.2 trillion in budget allocations prior to 9/11, according to former Defense Dept. analyst Chuck Spinney in a 2002 PBS NOW appearance . Does U.S. "defense" spending REALLY need to exceed that of the next 25 nations?  Clearly Zepps needs more education, though one must give him a prop or two for his audacious salon.com video. But to shed needed light (for his benefit) we can thank Nancy J. Altman and Eric Kingson, authors of 'Social Security Works' .

As the authors observe (p. 40):

"It is false that most older Americans are on "easy street". A very small percentage are, many more are poor or near poor, while some maintain a modest, middle class life style, often struggling to make ends meet."

So much for Zepps' indiscriminate claim of a "resource Hoover" hoovering up everything not bolted down for the benefit of fat, complacent seniors.  (Many of whom still have kids living in their homes, basements because they can't get decent jobs).

Last but not least, Zepps doesn't cover Medicare fraud at all, which could easily be neutralized by implementation of a computer system to track care received over time by different providers.  

I have shown in this post (including links) that Zepps' arguments are immature and don't take full account of: a) how seniors have been exploited by the existing system, and b) how younger workers and families are being exploited by a Neoliberal system with misplaced priorities.  One whose design and financial reward basis finds it more profitable for companies to fund massive stock buybacks than create jobs with decent salaries.

But one thing we cannot do is permit superficial memes and facile arguments against senior health and other benefits to be spread, thereby propelling a push for an elderly  "hunger games" . 

Btw, if the Reepos in the Nov. election seize  all branches of the government, Zepps may get his wish of massive cuts, thanks to Paul Ryan's Medicare voucher plan..  That will save hundreds of billions for sure, but leave most elderly in the same position they were in before Medicare arrived in 1966. That is, begging and scraping for financial help from family, offspring just to stay alive to deal with normal health issues - never mind treating stage IV prostate or breast cancers.

Janice Gives Robust Defense Of Colorado Care Single Payer Plan

As I wrote in a previous post, Colorado Care represents the next iteration in a state providing single payer health care after Vermont's efforts failed. Never mind, the backers of Colorado Care learned from Vermont's mistakes as I indicated in my   post, e.g.

http://brane-space.blogspot.com/2016/07/why-colorados-single-payer-health-plan.html

I also noted that my wife Janice is one of the activists contributing to the overall effort. She has helped in crafting letters to be published in several Colorado newspapers as well as websites, and Facebook forums. Most of this is beating back the extreme misrepresentations of the plan, mainly from libertarians and right wingers - most of whom don't even know the details.


In her most recent letter, Janice delivers a robust comment in support of Colorado Care to a Northern Colorado online paper. The full content is given below, reproduced with Janice's permission:

One Response to “Noam Chomsky endorses ColoradoCare Amendment 69”

Janice Stahl says:

July 21, 2016 at 6:00 pm

That is indeed good news! The current system is truly broken, not only here in Colorado, but in the U.S as a whole. As Professor Chomsky mentioned, we pay twice as much for a health system in which the health outcomes for people have not been great. Every effort to introduce universal healthcare has come up against the power of the huge and immensely deep-pocketed health insurance industry, which is determined to maintain its dominance and protect its considerable bottom line. Previous efforts have failed in part because too many political concessions were made to the insurance industry, resulting in a diluted hybrid system which doesn’t do anything very well.
Colorado citizens have the opportunity here to change that.

We can say no to deductibles (which often force people to pay for their treatment while still paying premiums), no to narrow networks, annual enrollment, unpredictable premiums and denial of service. In contrast to the insurance industry, whose primary interest is to earn maximum profits for its shareholders, ColoradoCare will be run like a cooperative business owned by Colorado residents – patients and providers- whose primary purpose is to provide quality healthcare for Coloradans.

We can say yes to continuous lifetime coverage for all residents when we vote YES on Amendment 69 in November.
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To see the actual link go to:

http://www.northdenvertribune.com/2016/07/noam-chomsky-endorses-coloradocare-amendment-69/comment-page-1/#comment-1363

Why Colorado's Single Payer Health Plan Would Work Better Than Vermont's

All through most of the 2015-16 Dem presidential campaign Sen. Bernie Sanders of Vermont was asked why his single plan proposal would work when the state of Vermont's attempt at it failed. That has now come up for scrutiny again as Colorado seeks to pass an amendment in November with a single payer type system.

Colorado Care, however, contains built in protections that Vermont's law didn't and also leaves out the toxic political concessions that resulted in the downfall of the latter.    The bottom line is that universal health care systems work and cost less in all other industrialized countries. All previous analysis of universal health care showed it was more affordable.

So what happened in Vermont?  The MSM in the wake has repeatedly claimed that the Governor’s Vermont proposal did not find much savings. But, was the Governor correct in saying universal health care was too expensive or did something go wrong? 

Here's what went wrong  in Vermont as determined by those actively supporting 'Colorado Care', including My wife, Janice.

1) Vermont approved a single payer health care system without specifying the policies that would make it work. Not surprisingly, policy issues matter. Dr. William Hsiao, who designed and guided the implementation of the successful Taiwan universal health care system in the 1990s, offers relevant commentary on a similar situation in Taiwan. He reports that before he went to Taiwan, problems arose when four technical experts tried and failed to come up with a successful universal health care proposal. He said, “It was like a wagon drawn by four horses, with each going in a different direction and nobody driving.1”

2)Vermont’s proposal, in which political forces and political concessions shaped a plan that did not have a driver keeping track of realistic economics, is similar to the first, unsuccessful attempt at a plan in Taiwan. Interestingly, Dr. Hsiao, who has experience designing and at times implementing health care systems around the globe, also conducted the preliminary analysis of the Vermont proposal before the political concessions, and he found that it was economically feasible. 

3)The VT governor’s economic proposal featured  a plan with too many political concessions and too little focus on what would work. Vermont adopted universal health care based primarily on a “health care is a human right” campaign without an emphasis on economics. The proposal’s governing body, the Green Mountain Care (GMC) Board, which was not responsible for financing, designed a system without a focus on the economic and policy decisions needed to make it economically feasible. Its design included political concessions to insurers, hospitals, and providers.

4) On top of that, the VT Governor offered financing concessions to low-income constituents, high-income constituents, and the self-employed, and as a result, the cost for the remaining payers—middle-income workers and employers—became too high.  

5) In addition, Vermont faced a number of situational challenges. Vermont has a high per capita health care cost, limited median family income, a small population, and a workforce and medical services that intermingled with neighboring states. All of these factors decreased Vermont’s ability to reduce costs.

6) The Vermont plan did not attempt to retain obvious savings. It claimed there would not be any savings, which ignores potential savings from obvious factors, such as the reduction in administrative tasks when there is one primary payer, the elimination of the marketing and advertising costs in the multi-payer system, and the elimination of the need for insurer profits, among other things. When administrative costs go down, someone has more money, and it appears that Vermont allowed providers to use the administrative savings to increase income

Colorado, fortunately, does not have these challenges. 

Now, how is the Colorado Amendment 69 proposal different? The Colorado proposal for ColoradoCare aka Colorado Health Care Cooperative is a system designed to establish universal, high-quality, and accessible health care; decrease the overall costs of health care through efficiencies; and collect premiums in an efficient and fair manner.

 It differs from Vermont’s approach and plan in multiple ways:

• Colorado’s plan does not make an alliance with the insurance industry. The GMC Board Chair was closely associated with the insurance industry and had been a strong advocate of the RomneyCare program in Massachusetts2, which expanded coverage but also greatly increased costs. The Board agreed to subcontract with a large insurance company and promoted this as a public-private partnership. This partnership did not report the administrative savings that are expected to come from removing the multiple, for-profit, middle managers. 

• Colorado would obtain the benefit of savings, not pass the benefits onto hospitals for higher profits. Vermont made a political decision to eliminate the Hospital Provider Tax, presumably because in a universal health care system such a tax only increases the cost to GMC. However, the economic analysis showed that GMC would not reap any benefit of lower cost, and the hospitals would retain the savings.

 • Colorado would pursue decreases in the cost of pharmaceutical and durable medical equipment. Multiple analyses, as well as model programs such as the VA Hospital system, have found that a unified system can use its market power to lower the costs of pharmaceuticals and medical equipment. However, Vermont decided not to pursue lowering pharmaceutical costs.

 • The Colorado proposal decreases administrative complexity instead of increasing it. The GMC Board decided to implement a complex transition to payment reform through Accountable Care Organizations (ACOs)3,4 in order to pursue a theoretical cost savings later on. While ACOs are supported by health care economists and offer promise, they are still in the process of development and have not yet been shown to maintain quality care and offer savings when applied over a whole state. This expensive transition consumed natural cost savings from administrative simplification. The Colorado proposal minimizes the Cooperative’s administrative expense in order to achieve a savings. Colorado’s proposal phases in ACOs and other payment reforms only to the extent that they decrease cost and improve value.

 • . The Colorado proposal incentivizes the system to benefit from savings. As a provider’s administrative costs decrease, the payments would correspondingly decrease. Colorado’s obligation would be to maintain overall provider compensation at a level that is competitive enough with other states so that Colorado would have a sufficient health care work force.

 • The Colorado proposal is less disruptive to employers.  While in the long run both the employer’s and employee’s premium payments come from the funds available for the wage/benefit package, in the short run, the Vermont proposal requires that employers who did not previously pay for health care pay a 10.5% payroll premium. Such a large increase is burdensome. The Colorado proposal: o Shares the 10% payroll premium between employer and employee so that the employer pays 6.67% and the employee pays 3.33%.  o Allows employers that have previously paid for most of health care to pay employee’s share if the employer agrees to do so by union contract or any other contract. o Covers the medical portion of workers’ compensation, which decreases workers’ compensation costs by 60%. This reduces the administrative and financial burden on employers.

• The Colorado proposal has premiums that are fairer—one combined employer/employee rate for everyone without the large difference between the effective rates for low-income and high-income residents. The Colorado proposal is modeled after the successful Social Security and Medicare insurance premium collections. Everyone pays the same percentage rate for combined employee and employer contributions (10% split between employer and employee). In addition, to be fair to working people, the same percentage rate is applied to non-payroll income. Vermont would have collected its premiums using two methods, a payroll premium tax of 11.5% paid by the employer, and a progressive income premium tax that rose to 9.5% of adjusted income. The combined employer/employee premium contribution varied greatly as the Table below shows.  



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Many thanks to Janice for assembling this information from the Colorado Care site!