Medicare: one size really does fit all

[eridani]

http://jama.jamanetwork.com/multimedia.aspx#AuthorInterviews

Uwe E. Reinhardt, PhD, economics professor at Princeton: On this point, I'm very disappointed that we Americans couldn't even get the exchanges right. As Atul said, an exchange is really just like the personnel benefit department at General Motors. It's just an electronic market to buy health insurance. I could show you the Swiss or the German exchanges. We have now made a horrendous mess of these exchanges. It cost close to a billion dollars to implement the California exchange, and heaven knows what's happening in the other states. I was thinking if this generation of Americans had to plan the Normandy invasion, I think they would never have gotten there, or by the time they got there, the Russians would have been there. It is just unbelievable what an administrative nightmare the Affordable Care Act has become. Americans always tell me - I'm just an immigrant trying to learn about this country - they always tell me, oh, one size doesn't fit all. Well, tell that to McDonald's or to the Holiday Inn. In fact, Americans invented the idea that one size fits all, and built great industries on it - the auto companies, the food services, the hotels, the department stores - they're all one size fits all.

Ed Livingston, deputy editor of JAMA: You mentioned that companies like McDonald's and Holiday Inn have been very successful in building large industries with uniformities, but those are private industries. Is the problem that when the government tries to take on something this complex they just can't seem to get it done?

Uwe Reinhardt: Well, it's for the reason that Atul mentioned, that somehow we give enormous respect to regional variations, and, because we do, we make everything enormously complex. Imagine if you ran the U.S. Army that way. Soldiers from every state could pick their own rifles, and so on and so forth. Sometimes you have to do national things. I recently wrote a Health Affairs piece and said, every American is a dual citizen. He has citizenship in the state that they live in and citizens in America. And it really depends when you draft federal legislation, which citizenship do you make supreme.

Typically you find Democrats put American citizenship up on top. The idea being that a baby in Mississippi should have the same rights to access to health care as a baby in Massachusetts, because they are both Americans. I think more on the Republican side they would say, no, what happens to a Mississippi baby is up to the people down there, and you can do what you want to a Massachusetts baby up there in Massachusetts. Now, that's a different conception, neither right or wrong, but I'm saying on some issues we really, in my view, should have national policies because it would be much more easy to administer. After all, that's what we said in Medicare. We said no matter where the elderly live, they should have the same deal in health care, and we created Medicare. Has Medicare been that much of a disaster?

Comment by Don McCanne of PNHP: Hmmm.

"It is just unbelievable what an administrative nightmare the Affordable Care Act has become."

"...they always tell me, oh, one size doesn't fit all. Well, tell that to McDonald's or to the Holiday Inn."

"...but I'm saying on some issues we really, in my view, should have national policies because it would be much more easy to administer."

"We said no matter where the elderly live, they should have the same deal in health care, and we created Medicare. Has Medicare been that much of a disaster?"

So can we draw the conclusion that we should adopt the administrative simplicity of a national, one-size-fits-all Medicare that gives everyone the same deal in health care? Seems like a really good idea.

[MannyGoldstein]

1. "Make no mistake... only through complexity can we find simplicity. "

Flaming bag of poop!

[Honeycombe8]

2. Except that McDonald's & Holiday Inn are not "one size fits all" businesses.

They are like exchanges, where there is a basic level of food/room, and from there customers have a range of choices and options and purchases at their disposal. Do you want one double bed or two twins? Smoking or non-smoking? Two double beds? A Queen? Facing the poolside or the front vista? Room by the vending area for convenience, or at the end where it's quieter? Second floor or first floor?

Do you want fries with that or one of these other side orders? Double burger or single? With or w/o cheese? Triple decker? Salad bar? Want a dessert with that? Or maybe the box lunch with double burger, fries, and dessert - you get 50 cents off if you order the box lunch. Or do you want chicken McNuggets? 6 or 12 nuggets? What sides? Dessert with that? Eat here or to go? Wanna a drink? Which of these 6 beverages do you want? Or do you want a shake? Will that be vanilla or chocolate or strawberry shake?

[eridani]

3. And with Medicare, you can go to any doctor with opening in his/her practice n/t

[HiPointDem]

4. they are businesses where the product is mass-produced and you can buy whatever's on the

menu.

like medicare.

rather than being able to buy different things depending on which fast-food or hotel joint you've personally contracted with and what your personal physical/social/emotional profile is -- as in the "subsidy to health insurers" program.

[customerserviceguy]

6. People buying the full price sandwiches at McD's

subsidize those buying the ones off of the dollar menu. Folks who pay full rack rate for a Holiday Inn room subsidize the corporate and other discounted rates.

Kind of like Medicare.

[dennisbyron]

5. Yes, Medicare is a disaster

One of the authors cited said:

"After all, that's what we said in Medicare. We said no matter where the elderly live, they should have the same deal in health care, and we created Medicare. Has Medicare been that much of a disaster?"

The author -- another Princeton economist -- is making an argument for federal vs. state regulation of health care using Medicare as a proof point. On this point he is incorrect relative to Medicare (he is also wrong overall but that is for another discussion). Medicare varies widely for every state and in many cases for every county.

-- Medicare is the limited fee for service (FFS) backup for many seniors (40% of us) that have employee retiree insurance as our primary protection. That retiree insurance follows the rules of the state insurance departments in the state where the employer is based and is tuned to retired employee needs. (This category includes union retiree insurance.)
-- Medicare offers capitated financing for a growing number of seniors (30% of us) that pays state-based HMOs and preferred provider organizations to integrate a senior's health care. In general these are not even state based but are tied to a specific county (at least in determining the payment amount if not in actually limiting the breadth of the network). There is nothing "federal" about them and they could not provide their integration benefit if "federal."
-- Most seniors that do not fall in one of the two above buckets (15%-20% of seniors overall) buy supplemental insurance to protect themselves against the terrible insurance that is "federal" Medicare. This supplemental insurance varies state to state and is regulated by the states in which it is sold (some of the plans are the same in multiple states but each is still regulated by the state in which it is sold and the price typically varies).
-- About 10% of seniors are not eligible for or cannot afford one of the three options above. they go on state Medicaid and get free "federal' Medicare as well as many more state-specific benefits. (Another about 10% of seniors get some state Medicaid assistance but not total Medicaid. They almost always use their Medicaid assistance -- the Princeton economist would call it a voucher -- to buy the capitation insurance or supplemental insurance mentioned above.)

Only less than 5% of seniors use "Federal" Medicare as the Princeton economist describes it for their health insurance because it is such bad insurance. Presumably most of those are very rich and do not want to pay the penalties Medicare imposes on them for being rich. Some I am sure have also fallen through the cracks despite the 25,000 volunteers trained by the Federal government to get the other 95% of us seniors signed up for some local "state-based" insurance to replace the terrible insurance that is "federal" Medicare.

[SammyWinstonJack]

7. ...

[eridani]

8. The "supplemental" insurance is for doctors

Medicare A does only hospitalization. My own situation has dramatically improved since I turned 65. Interesting that Medicare is so terrible that the Repukes cleaned our clocks in 2010 by pretending to "defend" Medicare. How would they have done that if seniors didn't like it? Peddle your bullshit neocon talking points elsewhere.

[Wounded Bear]

9. IMHO, the root of the problem is treating medical care like a hamburger...

The US has let the corporate mindset establish healthcare and insurance as commodities to be profitized and commercialized, instead of necessities that should be guaranteed and subsidized with government assistance as needed by the people, but provided on a non-profit basis.

I don't give a flying fuck if McDonald's is somehow classified as a "one size fits all" commodity or not. It is apples and oranges to medical treatment. Much as we can categorize dietary requirements for survival, we should be able to assign and assume medical care requirements and guarantee through community action that everyone gets it.