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Making Seniors on Medicare Have More Skin in the Game


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The movement is growing, it seems, for making people who rely on Medicare have more skin-in-the-game. In the minds of some, seniors and the disabled pay too little for their health care and their Medicare benefits and have been feeding at the public trough for too long. Making Medicare beneficiaries pay more will stop them from going to the doctor so much. Voila! The nation’s medical bill will drop.

According to this theory, beneficiaries themselves should be the ones responsible for bringing down the costs of Medicare. Never mind that the program has always had trouble saying “no” to doctors who wanted more money or drug companies that wanted this drug or device paid for by the government program, or that Congress has prohibited the government from negotiating prices for prescriptions it pays for under the drug benefit.

Bruce Vladeck, who headed the Medicare agency under Bill Clinton, says the single, most sensible thing that would lower costs for the government and beneficiaries would be to require sellers of the Medicare drug benefit, often called Part D, to buy medicines at the Federal Supply Schedule price used by the Veterans Administration, Defense Department, and safety net hospitals and clinics.

But few people want to talk about an option that steps on the toes of the drug makers. Instead, new voices pushing the skin-in-the-game approach are getting a lot of press. One is David Goldhill, the CEO of GSN, a multimedia entertainment company whose website notes that its cross platform content “gives game lovers the opportunity to win cash and prizes.” Goldhill was a featured speaker at the recent meeting of the Association of Health Care Journalists and has penned op-eds in the Washington Post and New York Times.

In the Times, Goldhill argued that Americans’ ignorance of the real cost of health care, “results in a lack of discipline that allows for pervasive excess care and exorbitant prices.” If people knew what they were paying, they would insist on greater control of health care resources, he added.

Goldhill wants everyone to have insurance but wants that insurance to cover very little — “only the most major needs — for example, cancer, stroke, and trauma — would be paid out of insurance.” Everyone would have to pay for routine and expected medical treatment including expected end-of-life care.

But what would be expected care? What about a heart attack or a detached retina or pneumonia or a premature infant that most people don’t expect? In Goldhill’s scheme, would people be on their own for those kinds of kinds of medical problems?

What if they had no money to pay for these conditions? We already have rationing by price for the under and uninsured in this country. We would just have more.

Goldhill appears to have earned his health care bonafides as a business man who pays for his employees’ insurance, as an observer of his father’s experience with the health care system, and as the author of Catastrophic Care: How American Health Care Killed My Father and How We Can Fix It. He’s no Medicare expert, but that hasn’t stopped him from attacking Medicare in his Washington Post op-ed.

He claims “the explosion of ‘care’ under Medicare is an assault on the very bodies of our seniors.” Health care often can be a “real benefit,” he says, but there are too many adverse events from treatment under Medicare. You can make the same argument for health care in general, and perhaps that is a rationale in Goldhill’s mind for doing away with much of health coverage for the rest of the population. He says Medicare’s low administrative costs aren’t an accomplishment, “they’re a refusal to discipline excess care, even dangerous care.”

About the same time Goldhill was getting ink in two of the country’s biggest dailies, three advocacy groups for seniors — the Medicare Rights Center, the Center for Medicare Advocacy, and California Health Advocates — submitted written testimony to a House Ways and Means subcommittee. They were not invited to testify. No group representing beneficiaries was. These groups have not been as successful as Goldhill in getting their observations into influential newspapers or getting the attention of journalists for that matter. No reporters called to ask about the press releases that described how changes to Medicare might affect beneficiaries.

In fact, there has been a serious lack of good reporting on Medicare.

The messages Medicare advocates sent Congress: “Most Medicare beneficiaries cannot absorb more costs without facing significant hardship. Medicare beneficiaries already have too much skin-in-the-game, and as a group are very aware of the high cost of health care services based on the bills they receive and Medicare’s summary notice of payment.”

The advocates also told Congress that the increased cost sharing pushed by many members of Congress “poses significant financial risks for beneficiaries, particularly for those living on low and moderate incomes.” It also limits access to necessary medical care. What’s necessary to a senior may not be necessary to Goldhill, and in his scheme, who would decide? Bean counters functioning as real death panels would be one way.

In 1963, in a special message to Congress, President Kennedy paraphrased the historian Arnold Toynbee, saying, “A society’s quality and durability can best be measured ‘by the respect and care given its elderly citizens.’” Today’s question is: what kind of respect and care, if any, do we want them to have.

More Blog Posts by Trudy Lieberman

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Trudy Lieberman, a journalist for more than 40 years, is an adjunct associate professor of public health at Hunter College in New York City. She had a long career at Consumer Reports specializing in insurance, health care, health care financing and long-term care. She is a longtime contributor to the Columbia Journalism Review and blogs for its website,, about media coverage of health care, Social Security and retirement. As a William Ziff Fellow at the Center for Advancing Health, she contributes regularly to the Prepared Patient Blog. Follow her on twitter @Trudy_Lieberman.

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Medicare   Health Care Cost   Pay for your Health Care  

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