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Posted on Sun, Jul 31, 2011 : 7:01 a.m.

Extending Medicare to everyone makes good economic sense

By Guest Column

In yet another attempt to bridge the debt ceiling impasse by reigning in entitlement spending, President Barack Obama recently proposed raising the eligibility age for Medicare from 65 to 67. As we pass Medicare’s 46th anniversary on July 30, I propose that rather than raising the age for Medicare, we consider lowering it instead. In fact, let’s lower it to zero.

This is not as offbeat as it sounds. Expanding and improving Medicare -- essentially creating a Medicare-for-All national health insurance program -- would eliminate the administrative duplication that pervades the private insurance industry, capture economies of scale, and use more of the health care dollar for actually improving health and preventing illness.


Dr. James Mitchiner

Medicare-for-All would create a system providing universal and portable health care so that all Americans could receive the same health benefit package regardless of where they lived, and one that would follow them if they relocated. An expanded Medicare system would embody a uniform set of rates and fees for hospitals and physicians, and medical records for patients, all supported by a universal health information technology platform.

Employers would have the health insurance monkey off their backs, allowing them to better compete in the global marketplace. And a national health program modeled on Medicare would allow the U.S. to join the ranks of other advanced democracies that provide health insurance to all their citizens.

Since its creation, Medicare has turned out to be an enormously successful program, as measured by universal access to benefits, portability, minimal administrative costs, and overall popularity among its 47 million current beneficiaries. And relative to private for-profit insurance, it has done a better job in pooling risk, bending the cost curve, and making timely payments to doctors and hospitals. Yet Medicare as it exists now is by no means perfect.

The average Medicare recipient is finding it increasingly harder to afford the growing out-of-pocket costs of health care. Many will skimp on necessary care, or just go without. And Medicare’s looming insolvency, currently projected to occur in 2024, is deeply concerning to beneficiaries, government actuaries, Congress and health policymakers alike.

Expanding Medicare to cover everyone would address these problems. Since young and middle-aged adults and their families are healthier than current Medicare beneficiaries, and therefore have lower health care expenses, an expanded risk pool under Medicare-for-All would have an average per-beneficiary cost that’s much less than the current cost for seniors (over $10,000 per current enrollee). And since expanded revenues would be greater than projected expenses,

Medicare’s Trust Fund could be replenished, and personal out-of-pocket costs could be minimized. Of course, financing an expanded Medicare program would require the non-elderly to pay an increased tax on income, but this would be modest, progressive, and a fraction of the exorbitant private insurance premiums they’re paying now.

To my critics who would decry a universal Medicare program as “government-run health care” with its implied rationing and restrictions, think about how the for-profit insurance companies control your choices now. Then recall the image of the health care townhall protestor in 2009 who shouted, “Keep your government hands off my Medicare.” Can you think of a better testimonial to the non-intrusiveness of the federal government in individual health care decisions? And as a physician, I find it much easier to deal with Medicare than with managed care plans.

It is clear that reducing government spending and thus forcing beneficiaries to pay more out-of-pocket will not by itself preserve Medicare and keep it sustainable for the baby boomers. Rather, what needs to be done is to find a better way of financing this important social insurance program so that it remains viable and available to future retirees. The solution is a single-payer national health insurance program modeled on the success of Medicare. That would be the icing on the Medicare birthday cake.

Dr. James Mitchiner, an emergency medicine physician, is the former president of the Washtenaw County Medical Society, and a member of Physicians for a National Health Program.



Sun, Aug 7, 2011 : 1:14 a.m.

hahahahahaha.. pause. hahahahahaha. oh wait. you're serious. You think that if you give everyone what no one can afford the world will be better. Did you notice that we just got a credit downgrade for that kind of idiocy? Good luck with your fantasy world.


Mon, Aug 1, 2011 : 3:29 p.m.

Rather than "medicare for all", I think that the government should draft all doctors and nurses into the army, set their salaries at a low enough level, make each doctor serve as a primary care physician at least two days a week, and set all prices for each and every medical procedure. That would work to reduce the cost of healthcare.


Sun, Jul 31, 2011 : 11:18 p.m.

Conservatives will call this " socialized medicine" and it is "too expensive" and "look how the government has screwed up Medicare". The truth is any health care plan would be expensive if the only participants were all over 65 years of age. I believe that large organization that currently provide health insurance to their employees would be thrilled to have their premiums decreased by 40% ( and that is what universal care would do). What most Americans care about is that the cost of living is within their budget not how much tax they pay. What would you rather pay 12,000$ in taxes ( for health care) or 20,000$ to the health insurance industry? Conservatives should conserve not throw money out the window.


Mon, Aug 1, 2011 : 12:56 p.m.

Donbee go to the WHO ( World Health Organization) website and look at the per capita spending, country by country. You will find that we are paying almost double what the rest of the industrialized world is paying. I was being nice by lowering costs by 40% it should be 50%.


Mon, Aug 1, 2011 : 11:43 a.m.

Tim - I would love to see the source of your "premiums decreased by 40%" comment. Please provide the link to the study. I cannot find it on the internet anywhere. I can find a number of advocate sites that quote this number, but no supporting research. Same for the $20,000 and $12,000 numbers.


Mon, Aug 1, 2011 : 2:12 a.m.

Where will Canadians go for heart surgery if the U.S. goes to single payer? The Canadian health care system rations care and is some provinces are trying to privatize there system due to cost over runs. We get upset if we wait for 5 minutes to get a coffee at Starbucks, how will people react if they have to wait a year for a knee replacement?


Sun, Jul 31, 2011 : 11:04 p.m.

As a poster pointed out, we need a system where health care providers can provide quality healthcare at a profit. We don't need a healthcare insurance industry that adds no value and takes 35% of the dollar. This is where Medicare can help. Heath Insurers are the leaches of the health care industry. They provide no value. None. None. None.


Mon, Aug 1, 2011 : 2:08 a.m.

What do you mean by "takes 35% of the dollar"? The vast majority of premiums are used for claims. Under Obamacare insurance companies now have to pay 80% of premium to claims leaving 20% for administration and profit. The insurance company is not the cost driver.


Mon, Aug 1, 2011 : 12:59 a.m.

I think you need to spend a day in a doctor's office watching the billing people try to get paid. One of the hardest programs to figure out and code for, according to a friend is Medicare, the second is Medicaid. They spend a significant amount of time in the office dealing with billing.


Sun, Jul 31, 2011 : 9:51 p.m.

Same old stuff we have been hearing, lacking what is real. No country in the world has HC that is efficient other than perhaps small oil rich countries. Britain has a NHS and they have lots of problems: <a href="" rel='nofollow'></a> And I suppose we would have to drop the &quot;cover those with pre existing conditions&quot; mantra: <a href="" rel='nofollow'></a> The problem is that HC is expensive. It cannot be made inexpensive and to extend it to all would require a large spike in taxes to the 50% of Americans who pay taxes, many of which believe that their current HC costs are expensive. Many Drs do not accept Medicare and Medicaid patients because their practice cannot get buy on what the govt payments are, so they do not take or limit how many patients under the plans they will take. But under the plan presented here, I guess all Drs would work for the govt. That is what they do in Britain and by the way, the pay is much lower. That is going to go over real well with our Drs. <a href="" rel='nofollow'></a> Comparing US health care to any other country is a bit of a stretch. Few if any countries are as large or as populous as the US. The sheer size of the country is a major issue. It requires far more facilities and personnel. One key area where this is a big issue is in general practice. There is a shortage of general practice physicians, partly because it pays far less than specialties and is somewhat &quot;unattractive&quot; in comparison to specialties. And we need many more non urgent care general practice offices, which will be a huge expense My point here is not deny the need for improving HC, but that it is a far larger problem with many issues that have to be addressed rather than changing how it is paid for. Another major problem is we do not insist on responsibility. Any HC initiative should require healthy living, not putting up with unhealthy behavio


Sun, Jul 31, 2011 : 4:58 p.m.

Medicare for all is universal health care, which is badly needed in the US. This was thrown out in the discussions during the health care debate a couple years ago due to the powerful health insurance lobbies who have bought off the congress. Nothing good will ever come from Congress regarding health care reform as long as the insurance industry owns the senators and representatives. Everyone should have basic health care paid for with taxes. If you want to add a higher end policy to that, pay out of pocket. But no one should be denied health insurance or have to declare personal bankruptcy because of obscene health care costs.


Mon, Aug 1, 2011 : 12:57 p.m.

Your so right!


Sun, Jul 31, 2011 : 4:15 p.m., not enough content to fill the &quot;paper&quot;? Is this a reprint from earlier? I am sure I have read this same article before. Even the Dems do not want single-payer/medicare for all. (except J. Dingell). The Dems had 60 votes in the Senate, the majority in the House of Rep. and a far left President and still could not pass it. Instead we got stuck with Obamacare that drives up cost and hires IRS agents instead of doctors.


Sun, Jul 31, 2011 : 2:32 p.m.

Dr. Mitchiner, While your article makes perfect sense, sadly, I fear the US is not ready for it. Why? Many who would benefit from a Universal care program have been convinced to vote against it. Alas, the Republican party works miracles on it's followers. Of course, everyone knows rising health care costs are strangling the US economy and crushing American workers. It's the single most serious threat to American businesses today. Long term, it is the most important issue the US congress must deal with. Providing affordable access to health care for all Americans and moving the burden of this from the private sector seems like a no brainer. But to simply enroll more people in the same costly health care system is not enough. We need to drive cost out the health care system. Here are a few options. - cut patent coverage from 20 to 7 years on pharma products - increase $$ to the FDA to speed the import of foreign generics - eliminate the need for prescriptions for a host of drugs, equipment and supplies - increase the $ of foreign doctors in the US to put wage pressure on doctors - allow mail order of pharm products - treble the number of US students in medical schools to increase competition for business - make doctors and hospitals post their prices online - require hospitals to give written cost estimates ahead of time - reform medical liability laws - set up a tiered licensing system so that more of the routine medical work can be performed by lower cost nurses, practitioners, etc. - eliminate the need for private insurance companies. Set up non provide state entities

Craig Lounsbury

Sun, Jul 31, 2011 : 2:19 p.m.

There is no built in inherent reason why a national plan has to be expensive and/or inefficient. It can be whatever &quot;we the people&quot; want it to theory. The only thing standing in the way is politicians and the special interests that throw bags of money at them. There are inherent reasons why a national plan can be as good and cheaper. It can be as good because we can demand it to be. It can be cheaper because it would remove profit as a cost and consolidate the upper management that runs the mired of insurance company's we have now. For those concerned about &quot;the Government&quot; in charge of your health care I would present two retorts. First that doesn't have to be a bad thing, again it can be (in theory) what &quot;we the people&quot; want it to be. Second the people in charge right now see you as an &quot;asset&quot; on their ledger books as long as your premiums paid exceed your billing for services received. As soon as you get seriously ill, or some one in your family does, you become a liability on their ledger books. At that point I guarantee somebody in the hierarchy of the organization is looking for ways to mitigate that liability (you or your loved one)

Craig Lounsbury

Sun, Jul 31, 2011 : 5:18 p.m.

I fail to see your point. The last time I was in the secretary of state office I was out in an hour. I'm out more often in 45 minutes than I am an hour and a half. The last time I was in the emergency room, with insurance, I didn't see a doctor for 6 hours. My dad spent 7 hours in the waiting room at the hospital 13 days before he died. It was 2003 well before so called &quot;Obama care&quot; became a cliché. He too had plenty of private health insurance. On my score card the secretary of state is hands down more efficient than the private health care system.

Will Warner

Sun, Jul 31, 2011 : 3:04 p.m.

Three words: Secretary of State's offices.


Sun, Jul 31, 2011 : 1:32 p.m.

Dr. Mitchner, With all due respect sir, as a fellow health-care professional, I am certainly in no hurry to have the government control all the choices regarding health care (yours, mine, ours...). I agree that Medicare is a useful plan that has benefited many, but it is just not practical to have it serve a capitalistic country of 300 + million people. Medicare Part D, which has provided assistance for millions for their prescription drug medications, has been costing the nation far more money than projected, and with the 10 year anniversary of Medicare D approaching, you can bet that the government will be looking to take back a lot of the money that it has spent by conducting mass audits. Medicare will be closely inspecting claims and looking for i's that are not dotted and t's that are not crossed. If claims do not meet their guidelines and satisfaction, not only will the government reclaim any money for those claims, but will hit us with fines. Even worse, health-care professionals who do not treat their patients according to what the government states as guidelines may end up on the exemption list, barring that professional from working in an environment that bills Medicare (thus effectively ending their medical career as long as that person is on the list). You stated that you find it easier to deal with Medicare than the managed health care plans. You, or the system that you work for, have the option of not renewing a contract with the third parties that you find difficult to work with. You would not have that option if the government ran the only health care system. The health care system is flawed - yes. But more moderate steps (tort-reform, using medication therapy managments, patient incentives, etc...) seem more reasonable rather than taking a leap to the extreme.


Sun, Jul 31, 2011 : 1:29 p.m.

Yes Dr. Mitchiner we are all waiting for the answers to DonBee's questions. Please enlighten us. Or forget your pie in the sky mumbo jumbo!


Sun, Jul 31, 2011 : 1:14 p.m.

Dr. Mitchiner - I am sorry, I disagree. The paperwork, the overhead, the reimbursement rates, and other issues with Medicare and Medicaid make them non-starters in my mind. The level of waste and fraud in the system also bothers me. Help me understand how you would address these issues, in a manner that makes it very easy for me to walk into any doctor's office, pay my deductible and see any available doctor, and I am listening. So long as doctors decline to take new patients on the various federal programs, wait list people and can opt out to do &quot;private practice&quot; only, I am not interested. Watching my friends from Canada come to the US for new knees, heart surgery, and other procedures tells me that Canada is not perfect. Listening to CBC a couple of weeks ago, there was a story on the wait times for some procedures - upwards of 2 years for people who are off work because of reconstructive issues. During that time they are on a disability payment that is more over the wait time than procedure costs. Tell me how we will not have these issues and provide open access for everyone.


Mon, Aug 1, 2011 : 12:54 a.m.

Sallyxyz - Many Canadians I work with, dread the US going to a Canadian type system, they own insurance that lets them come to the US for anything beyond a cold or flu. Craig - Canada, the UK, Sweden, Australia, and all the other countries I travel to have similar issues. If not a system similar to what other countries have, then what?


Sun, Jul 31, 2011 : 5:04 p.m.

If the Canadian system is so bad, why don't we hear about Canadians clamoring to change their system to the US system of privatization, exorbitant premiums, 15 million uninsured that we all pay for, and denial of insurance based on pre-existing conditions?

Will Warner

Sun, Jul 31, 2011 : 3:30 p.m.

Craig, re your post farther down... Why aren't the Canadians demanding and getting the kind of health care they want?

Craig Lounsbury

Sun, Jul 31, 2011 : 1:55 p.m.

dragging in Canada is a straw man argument. It assumes in a manner that is &quot;the other option&quot;.

Bob Carlin

Sun, Jul 31, 2011 : 12:58 p.m.

Medicare for all makes sense. The US's health care system is going to bankrupt the country. We're well on the way to that now. A significant amount of the cuts in police, fire and other city services occur because of health costs. It's too expensive to hire permanent employees because their benefits cost too much.


Sun, Jul 31, 2011 : 12:47 p.m.

This is kind of like a bricklayer saying all houses should be made of brick because it is cheaper in the long run.( And it keeps the bricklayer employed) @Hot Sam You are right! It is a hard enough pill to swallow when you get the bill for that 10 minute visit. But then you are still getting bills months later! The money saved in paper alone would pay the bill.

Hot Sam

Sun, Jul 31, 2011 : 12:31 p.m.

I posted this on another blog, but I feel it is relevant to this conversation as well... I recently had two short trips to the doctor for a couple of very minor things. I received a bill and via the instructions went on line, created an account, and paid the bill. No problem? I kept getting bills, so I called and was told &quot;the UM system bills the facility and doctors separately, and only one of them is on line&quot; To be noted, is that the first payment I made on line was more than enough to cover a ten minute doctor consultation and the writing of a prescription. Yesterday I went through my file and found that I have 24 pieces of correspondence relating to two ten minute doctor visits. The bureaucracy, excessive management and other nonsense has added untold amounts of money to what should be a much easier process We can afford the health care, what we can't afford is the health care industry...


Sun, Jul 31, 2011 : 5:01 p.m.

Your experience is the kind of insanity that the health care industry has created. It's appalling.

Will Warner

Sun, Jul 31, 2011 : 12:19 p.m.

"...Medicare-for-All would create a system providing universal and portable health care so that all Americans could receive the same health benefit package " I don't want the same heath care as everyone else—whatever a monopoly decides to furnish me. I want the freedom to buy better health care for myself offered by people who have to make me happy because they know I have choices. "...And a national health program modeled on Medicare would allow the U.S. to join the ranks of other advanced democracies that provide health insurance to all their citizens." It's pointless to compare America with other advanced democracies. America is unique. It was founded as a bastion of individual liberty (yes, I know, except for the slaves) and therefore has different priorities. "...Of course, financing an expanded Medicare program would require the non-elderly to pay an increased tax on income, but this would be modest..." Rather a glib statement, that. I'm not sure how we know it would be modest. And as I look at our long term debt problems, it seems there is an urgent need to REDUCE entitlements, not expand them. "The solution is a single-payer national health insurance program" My biggest fear: the existence of national health insurance will permit people to credibly argue that since others are paying for my health care, others should have input on my lifestyle choices that (possibly) affect my health. You may be OK with that, but I'm not.


Sun, Aug 7, 2011 : 2:21 p.m.

How's that &quot;freedom&quot; working for you now? How about for the 40 million uninsured people in the country? If you have an employer-paid plan, as do most people with private coverage, the insurance company doesn't compete to make you happy. It competes to make your employer happy, or doesn't compete at all. Our current non-system of health care has contributed to the US having the poorest health care outcomes markers of its peer nations. And as for your reflexive fear of universal health care, Cuba's outcomes are excellent, especially considering its relative poverty. The US can learn from other systems. Apparently we just don't want to. Jingoism doesn't create good health care.

Lamont Cranston

Sun, Jul 31, 2011 : 12:19 p.m.

Wow, frankly I am amazed of the timing of this posting. Our country is facing a debt crisis. We have record debt that is pushing our country at risk of default, and this guy is promoting nationalizing health care. You got be kidding me. I have not seen one nationalized health care program that saves money and improves quality. What i see are citizens from nationalized health care countries visit the United States when they want health care. Why? Because their countries' is of lower quality and is rationed. They can't get the needed health care Good idea, give the government control and it will improve quality and reduce costs (note sarcasm). Isn't that the same federal government that buys $600 hammers and $400 toilet seats. Government run and save money do not fit in the same sentence.

Bryan Mitchiner

Mon, Aug 1, 2011 : 2:31 a.m.

Lamont - I think there has been one critical detail of this piece that has been overlooked. The detail speaks directly to the cost to our nation as well as us individuals. Right now those of us that are fortunate enough to have health insurance are paying a certain fee to our private health insurers. Let's call it 'Cost A.' Cost A is comes directly out of our pocket. And with medicare for all the costs for the government would surely go up. However, to pay for this, as dr. Mitchiner noted, personal income tax would have to go up, thus increasing the federal tax revenue and therefore not increasing the ntional debt. That tax is Cost B. But it's definitely not in addition to Cost A. That is, if cost B existed (we installed a medicaire for all program) cost A would not. The authors point is that through the economic principles of scale and less administrative costs, Cost B would be less than Cost A. How's that: less costs for us, and less debt for Uncle Sam.


Sun, Jul 31, 2011 : 10:33 p.m.

pest: What you are arguing for, and what would make more sense potentially, is having patients pay the doctors directly for the service provided. You would know the cost upfront and, if you so chose, could then ask an insurer for reimbursement. Sounds good for office visits, but it might not work out well in the ED or hospital.


Sun, Jul 31, 2011 : 9:23 p.m.

I am aware that it works poorly. More and more doctors and hospitals have begun to not accept medicare and/or medicaid. Basically, medicare tells the doctors/hospitals what they will pay, making the medical professionals accept less for their service. Also, medicare is notoriously a slow payer and has even stiffed people on what they owe them. Almost impossible to get hold of anyone in billing - trust me on this.


Sun, Jul 31, 2011 : 1:09 p.m.

I'm not sure you really are aware of how Medicare is run. Although there is a central organization (Centers for Medicare and Medicaid Services) that determines national coverage policies and implements congressional directives, the program is &quot;run&quot; through local Medicare carriers (usually private companies) that have contracted to control the program in certain regions. Dr. Mitchiner's point about increasing costs are related to recent estimates of trends that appear to indicate that per unit pricing (i.e. hospital and physician costs) are part of what is driving up the cost of healthcare. A single entity with large negotiating power would be able to help reduce that aspect of rising costs.


Sun, Jul 31, 2011 : 12:15 p.m.

Dr. Mitchiner, Extending Medicare to everyone would not necessarily mean a healthier populace, although it would mean you would be more likely to be paid for the work you do in the Emergency Department. Economically, extending the current version of Medicare to all is unaffordable. The way to do it would be to refashion Medicare as catastrophic care, allow it to negotiate pricing with drug and device manufacturers and then let the consumer purchase a secondary insurance plan (which should be much more affordable). Having the consumer bear some of the costs of healthcare might also serve as incentive to live a healthy lifestyle (ie. stop smoking, lose weight, exercise, wear sunscreen, wear helmets, wear safety belts, brush/floss their teeth, etc).

Craig Lounsbury

Sun, Jul 31, 2011 : 11:35 a.m.

how 21st century of you sir. It would take a miracle of sorts to make it happen. To actually have the United States of America fall in line with the rest of the &quot;civilized&quot; world.

Joe Hood

Mon, Aug 1, 2011 : 12:37 a.m.

Seriously? Have you been following what the British have been going through with their national healthcare lately (and most of Europe)? I would lump them in the &quot;civilized&quot; world. I hope we don't FALL in line.