The incredible expense of getting old in America

The Kaiser Family Foundation has recently done some excellent reporting on the out-of-pocket expenses faced by seniors on Medicare. Using data from the 2016 Medicare Current Beneficiary Survey (MCBS), they found that the average Medicare beneficiary pays $5,460 out-of-pocket each year for health related expenses such as co-pays, medical supplies, or medications. This spending amounts to 12% of these seniors’ total income, reducing the amount of money they have available for food, housing, or transportation.

Elders have struggled with these costs, resorting to putting their health at risk by skipping doses of necessary medications or delaying necessary medical care.

Working in primary care, I see this brutal self-rationing all too often. Elder patients who cannot talk to their grandchildren because they cannot afford hearing aids, who cannot eat the foods they enjoy because they cannot afford dentures. It’s devastating.

For seniors that require long-term care services such as a rehab or skilled nursing facility, average out-of pocket spending was $23,045 or 79% of their income. For context, 70% of people over the age of 65 spend at least some time in a skilled nursing facility. For seniors who need full-time nursing care which is not covered by Medicare, the average cost is $102,200 per year.

Because our current Medicare program does not cover long-term care, seniors are forced to spend-down, essentially selling off all of their assets to pay medical bills until they are impoverished enough to qualify for Medicaid. The majority of people in nursing homes end up in this situation.

Access to needed medical services need not impoverish us in our later years when we should be spending our time and energy with the family and friends that bring meaning and joy to our lives.

Bernie Sanders’ Medicare For All plan addresses all of this. It removes cost-sharing for medical care and expanding benefits to cover hearing, dental care, and long term care services.

The specific proposal to make long-term care services a covered benefit of Medicare is quite popular in polling. Even with a negative framing, Data For Progress found that 60% support while only 27% oppose this benefit expansion.

Seniors are understandably anxious about politicians messing with Medicare. After all, Republicans have tried again and again to reduce Medicare benefits and increase medical costs for seniors. However, single payer Medicare for All makes the program more generous for seniors, while giving all Americans access to the same high quality level of care.

A Public Option Is Not Enough: The Pain of Narrow Networks

During the Democratic primary campaign, several candidates have come out in support of a public option as their preferred strategy for improving the American healthcare system. While details are scarce in candidates’ proposals, generally speaking a public option is a federally-administered insurance plan that competes with but does not replace commercial insurance plans.

With a public option, people have the choice to pay a premium to be insured under the federally-administered plan. Others would remain insured on commercial plans through employers, unions, or the individual marketplace. This is the supposed draw of the public option, the “if you like your plan, you can keep it” appeal.

However, what a public option does not address is network limitations which are the source of much of the frustration with our current health care system. Network limitations are the reason that you can only see certain doctors or visit certain hospitals with your insurance plan. If you go out-of-network, you have to pay a higher co-pay or even the full cash price just to see the doctor you prefer.

However, networks are renegotiated every year. Just because a doctor is in your network one year is no guarantee that they will be in your network the next. If you have been seeing your same primary care doctor for twenty years and value that relationship, out of nowhere they can inexplicably be declared “out of network” and you’ll be forced to find a new one or face hefty fees to have continuity with a doctor you trust.

If you get insurance through your employer, they can also choose arbitrarily to switch commercial insurance plans without your input or consent. Right now, this sudden change in coverage happens to one in four people every year. If you like your current PCP, you better hope your boss isn’t feeling fickle.

If you go to a hospital or emergency department that is in your network but one of the doctors who takes care of you there is out-of-network, you will still get stuck with a surprise medical bill which currently happens with 42% of all hospital admissions, sticking patients with an average bill of $2000 over and above what they would have paid otherwise.

Similarly, each insurance plan has their own formulary–a list of medications organized by how large of a co-pay you must contribute to have your prescription filled. Every year, insurance companies will renegotiate their formularies and without your input declare a medicine that you’ve been taking for years to be “non-preferred” leaving you again to stop or switch medications lest you be hit with a heavy fine. If your doctor determines that a non-formulary medication is actually the best treatment for you, there is often nothing they or you can do about it.

Again, if you get your insurance through your employer and they decide to switch plans or you change jobs, you can easily be thrown off of the medications you need for your health.

If it isn’t abundantly clear from the above, much of the frustration of our current health care payment system is caused by the presence of narrow networks and limited formularies in which your choice of doctors or medicines is not based on your medical needs, but on the backroom dealings of business executives. With a public option, none of this changes.

Health care is expensive in America because it profits those with power

In this excellent review of the late Uwe Reinhardt’s book “Priced Out,” Dr. Adam Gaffney lays out in cogent terms why we cannot understand rising health care spending in America in simple terms of either over-utilization or insurer-provider price negotiation.

This writing is especially impactful to me because I became interested in health care due to frustration with how high health care prices were keeping people in poverty from getting the care they needed, and was initially very persuaded by super-utilization arguments. I followed the work of people like Jeffrey Brenner because at the heart of it, I saw compassion for patients harmed by lack of preventive care and social services. However, I also absorbed the subtle patient-blaming aspects of this approach.

In medical school at UPenn, I got involved in excellent research by Heather Klusaritz through which I had the opportunity to interview patients who had been labelled at super-utilizers due to frequent visits to emergency departments. In these conversations, I was forced to confront my internalized bias against these patients who were described as “inappropriately” visiting emergency departments for complaints that were not true emergencies. Through these conversations, I gained a deeper understanding of the inadequacy of our health care, public health, and public welfare infrastructure. If frustration with these systems led me to medical school, it was in medical school that I saw just how bad things really were.

With faculty like Zeke Emanuel providing our health care systems lectures, I initially bought into neo-liberal arguments that these were simply failures of incentives. Part of me believed that if enough Ivy League technocrats crafted just the right policies–Rube Goldberg-esque as they might be–private insurers and for-profit hospitals would provide for the health care Americans needed. However, over time I began to see how market forces would never be sufficient to guide health care allocation and development, and it will only lead to ever-rising health care spending at the expense of everything else in our budgets.

For both the private insurers and profit-driven hospital systems, increasing health care spending is just more cash in their pockets. Your deductible is their kid’s private school tuition payment. Health care isn’t expensive in America because of utilization. Health care is expensive in America because it profits those with power. There is exactly one real policy solution to the fact that we now pay nearly $11,000 per year for health care in America compared to an average of $4,000 per year in OECD countries and that solution is single-payer Medicare For All.

High health care spending in America means lower wages for Americans. It means high deductibles, frequent medical bankruptcies, and families rationing health care because they need some money for groceries. It is inhumane and we’ve tolerated it for far too long. As long as private insurers are the payers in the American health care system, there will always be insurance trolls whose priority is to deny cancer patients their chemotherapy or to put huge paperwork burdens in front of patients and doctors to discourage necessary care. As long as private insurers are the payers, hospital systems will spend enormous amounts of money on flashy branding and sleek buildings to attract wealthy patients as if a person’s income determined the value of their life.

So read Adam Gaffney’s piece and vote only for those politicians who support Medicare For All because it is truly our only way to a better future for health care.

Medicare For All: An Update

A little over a year ago, I made my personal case for Medicare For All. In that post, I argued that the American health care system has intolerable financial toxicity on patients and that a transition to a single payer system, such as Medicare For All, was the only feasible way to achieve true universal health care coverage in which a person’s economic status was not the main determinant of the health care they receive.

Since then, Medicare For All has continued to gain momentum with many of the leading contenders for the Democratic presidential nomination like Bernie Sanders, Elizabeth Warren, Kamala Harris, Cory Booker, and Kirsten Gillibrand explicitly in favor of this approach.

Pramila Jayapal (my very own congressional representative) has released an updated house bill (H.R. 1384, summary here) with 108 cosponsors, to implement Medicare For All. This operates as a companion bill to Bernie Sanders’ Medicare for all bill (S.1804) with 16 cosponsors in the Senate.

As coverage has increased, I’ve seen some important points about Medicare For All go missing from the popular discourse, so I would like to highlight a couple of points here.

What will the quality of coverage be like?

Although I feel that overall “Medicare For All” is a great slogan, it sometimes creates confusion because many assume that this means that the current Medicare plan would simply be extended to all Americans. However, the Jayapal and Sanders bills both outline a heath insurance payment system that is far more generous than current Medicare. For that matter, it’s far more generous that most commercial insurance. We’re talking no copays, no deductibles, unlimited network, vision benefits, dental benefits, and long-term care benefits. For the patient, this means that if the health care is medically indicated there are zero financial barriers to you receiving it.

How are we going to pay for it?

Many commentators have brought up that the budget allocation for a Medicare For All bill, by nature of paying for all Americans’ health care, is quite large. However, when compared to current national health care spending, the increase is marginal. For example, using estimates from The Urban Institute, annual health spending would increase from $2.8 trillion per year to $3.5 trillion per year.

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That additional $500 billion gets 34 million more Americans medical coverage, 75 million more dental coverage, and 167 million more vision coverage. That is in addition to upgrading every American’s health care coverage as described above. There are a variety of ways to pay for this including repealing Trump-era tax cuts ($230 billion per year) and implementing a wealth tax ($275 billion per year). Matt Bruenig has also laid out how to capture current employer health insurance spending through payroll taxes.

Advocacy versus legislative action

It’s worth emphasizing that Medicare For All is still in the advocacy stage, not in the legislative stage. Although a majority of Americans already support Medicare For All, activists and advocates are working to build upon that strong momentum and build enthusiasm amongst legislators who can bring Medicare For All into reality. Not every nitty gritty detail is going to be exactly worked out at this stage and that’s okay. Good quality legislation takes time to build and refine. It often requires ongoing amendment after passage. We as a nation have proven ourselves capable of this in the past and we can continue to be capable of it as long as we remain committed to universal, comprehensive health care coverage that is free at point of service.

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The U.S. government spent 50 million dollars on research which showed that Truvada, an HIV medication, was safe and effective at preventing HIV transmission when taken by people who did not have the infection. As a result, the government received a patent on this application. However, they have never enforced their patent to collect royalties for its use.

Meanwhile, Gilead Pharmaceutical, the corporation that manufactures this drug, charges up to $2000 a month for this treatment. Since they started manufacturing this medication in 2004, they have collected 36.2 billion dollars in revenue from patients and their insurance companies.

Since the government owns the patent, public health experts are arguing that they can and should enforce the patent to require that Gilead lower the price of the drug (a one month supply of which is estimated to cost $6 to manufacture) to promote more widespread availability and reduce healthcare costs. Alternately, the government could collect royalties from the patent and use that money fund other HIV prevention and treatment efforts.

Either way, the government clearly has leverage to make HIV prevention more accessible and affordable and should absolutely use this power.

Read more here.

Care Of Vulnerable Adults: Balancing Independence and Safety

Last night, I watched ProPublica and Frontline’s excellent documentary, Right to Fail, about New York’s struggle to find the balance between independence and safety in the care of people with disabling mental illness.

Finding this balance between independence and safety is something that I struggle with in primary care frequently. Most of the time, you can find a balance by bringing family members into the conversation and focusing on harm reduction and quality of life. But sometimes it’s not enough.

I took care of a gentleman in the emergency department the other day whose blood oxygen was dangerously low because of a condition called aspiration pneumonitis that he got because he was choking on the food that he was eating. He had neck surgery a couple months prior and the muscles that coordinated his swallowing reflex had not fully recovered. I advised him to come into the hospital until his lungs recovered enough that he wouldn’t need supplementary oxygen or we could arrange to have an oxygen tank delivered to his home. I told him I was worried that with prolonged low oxygen levels, his brain, heart, and kidneys may start to be damaged or fail. He declined admission, but couldn’t really repeat back to me an understanding of the risk he was taking by leaving against medical advice. I offered to call a family member on his behalf, but he didn’t want to worry them. I was stuck…

As someone with a strong professional and emotional drive to protect people from physical harm, it hurts me to see people suffering because of a limited capacity to take care of themselves. I often feel the impulse to say, “well let’s just have someone else take care of you.” I’m not alone in that. I think most people, when they seem someone on the street who is clearly unwell and in distress, feel suffering on that person’t behalf.

Many people with disabilities are glad to have assistance when that assistance is provided with compassion not condescension and supports of positive sense of self. I strongly believes that we need much better programs to support people with disabilities to maximize their capacity to live independently. But for those who who expose themselves to significant harm by rejecting assistance while having a questionable capacity to understand the risks and benefits of that decision, it gets difficult.

Institutionalizing someone against their will can be traumatic and harmful and must be a last resort. That being said, I do think it is sometimes the right thing to do, and it needs to be an option on the table.

In summary, 1) watch Right To Fail, 2) support programs that help people with disabilities live independently with dignity, and 3) consider that there are (rare) situations where loss of agency can be a net benefit to an individual with severe mental illness.

Closing the Racial Wealth Gap

The Samuel DuBois Cook Center on Social Equity and the Insight Center for Community Economic Development put out a great report titled “What We Get Wrong About Closing the Racial Wealth Gap.

You can read a short editorial summarizing a few of the findings here.

The report presents ten myths regarding the racial wealth gap and then gives the evidence again each of these myths:

  • Myth 1: Greater educational attainment or more work effort on the part of blacks will close the racial wealth gap
  • Myth 2: The racial homeownership gap is the “driver” of the racial wealth gap
  • Myth 3: Buying and banking black will close the racial wealth gap
  • Myth 4: Black people saving more will close the racial wealth gap
  • Myth 5: Greater financial literacy will close the racial wealth gap
  • Myth 6: Entrepreneurship will close the racial wealth gap
  • Myth 7: Emulating successful minorities will close the racial wealth gap
  • Myth 8: Improved “soft skills” and “personal responsibility” will close the racial wealth gap
  • Myth 9: The growing numbers of black celebrities prove the racial wealth gap is closing
  • Myth 10: Black family disorganization is a cause of the racial wealth gap

Pertinent both to our discussions on theft of black wealth and the conversation about reparations in Seeing White, the authors in this report give a detailed argument about why behavioral interventions to close the racial wealth gap are doomed to fail.

“We challenge the conventional set of claims that are made about the racial wealth gap in the United States. We contend that the cause of the gap must be found in the structural characteristics of the American economy, heavily infused at every point with both an inheritance of racism and the ongoing authority of white supremacy.

“As a result, blacks cannot close the racial wealth gap by changing their individual behavior –i.e. by assuming more “personal responsibility” or acquiring the portfolio management insights associated with “financially literacy” – if the structural sources of racial inequality remain unchanged. There are no actions that black Americans can take unilaterally that will have much of an effect on reducing the racial wealth gap. For the gap to be closed, America must undergo a vast social transformation produced by the adoption of bold national policies, policies that will forge a way forward by addressing, finally, the long-standing consequences of slavery, the Jim Crow years that followed, and ongoing racism and discrimination that exist in our society today.”

Questions to consider
  • How many of these myths are only plausible due to racist prejudice against black people?
  • Why are explanations of inequality that “blame the victim” more appealing than explanations that place some burden of responsibility on me? How can I counter-act this bias?
More reading on the racial wealth gap