Close to Home: Improving Medicine, 50 years later

You were conceived by Senator and then-President John F. Kennedy and born on July 30, 1965, when President Lyndon Johnson signed the law after a contentious debate in Congress.

Has it worked, or does it need to be improved? In every poll taken, people “love” their Medicare and don’t want it taken away.

But let’s look at the data. Only 50 percent of individuals over 65 years old had health insurance in 1965. Now 98 percent do.

Medicare insures 60,000 individuals in Sonoma County, 4.5 million in California and 53.5 million in the United States. In one attempt to improve it, in 1972 Medicare added adults who had been disabled for two years and patients with end-stage renal disease on dialysis. Eighty-five percent of Medicare recipients in Sonoma County are over 65 years old, 14 percent are disabled adults, and 1 percent have ESRD.

But Medicare is actually still very expensive for individuals. In 2013 Medicare spent $11,320/enrollee in California ($600 above the national average). Of this total individuals paid an average of $1,336 out-of-pocket, some as high as $2,500. In Sonoma County 67 percent of those on Medicare live on less than $35,000 and 54 percent less than $25,000. Medicare has drastically reduced but not eliminated the number of individual bankruptcies due to medical debt.

Nationally, Medicare covers only 50 percent of medical costs.

In another attempt to improve Medicare, in 2003 optional drug coverage (Part D) was added as a benefit, and more than 70 percent of Medicare enrollees participate in Part D. But, also in 2003, as part of that legislation, Congress prohibited Medicare from negotiating lower drug prices (and individuals from buying drugs in other countries with lower prices), resulting in drug prices 40 to 50 percent higher in the U.S.

Yet, despite providing a wide range of benefits, the overhead of Medicare - always low - in the past three years has been less than 2 percent. Compare this to the 10 to 20 percent of most private insurance companies.

It was envisioned, in 1965 when Medicare was passed, that Medicare would eventually be expanded to include all age groups and all people living in the United States.

However, ideological differences and political divisions have impeded that reality. The Affordable Care Act (passed in 2010) is an attempt to expand health care coverage, but it will still leave 30 million uninsured when fully-implemented and is unlikely to control rising health care costs.

How can we really improve Medicare? How can we live up to the original vision?

A bill currently in Congress (HR 676) proposes “improved and expanded Medicare for all.” This would expand Medicare to all those living in the U.S. and would provide - in addition to all inpatient, outpatient, emergency room, drug coverage, mental health, and physical therapy services - drug and alcohol rehabilitation, vision care, dental care, and long-term care.

All of this would be without co-pays, co-insurance, or deductibles. How would this be possible? Because such a program would negotiate for lower drug and medical device charges, require hospitals to be nonprofit, and eliminate $400 billion/year in unnecessary overhead and profits in the current multi-payer system.

As Martin Luther King, Jr., said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

Dr. Nick Anton practiced internal medicine in Santa Rosa for 34 years before retiring in 2009. He is a member of Physicians for a National Health Program.