It will be rare, I expect, that I will agree with our new HUD Secretary Dr. Ben Carson so I begin with a reprint of a paragraph I revised in my recent post A Spoonful of Sugar since some readers may have missed his exact words:
What is driving the financial struggles for Medicare is not that it is a government run program, which in fact is its strength, rather it is the reality of the rising expectations we collectively have for extending our individual lives, regardless of quality, at great costs. As one who is likely, as my friend Lloyd Snow would say, playing in my final quarter, I can say that we do need to have an honest national discussion about the amount of scarce resources we are devoting to end of life treatments. Call it “death panels” or say it like Dr. Ben Carson did recently to HUD employees when he honestly expressed his belief that his skills as a brain surgeon were more appropriately used to “operate 12, 18 or 20 hours on a young child and, if successful, you might be rewarded with 50, 60 or 80 years of life, whereas with an old geezer they die in five years or something else, I like to get a return on my investment.” Regardless of the blunt language (though maybe 6 months instead of five years), if we want to control health care costs, it is a genuine way to do so, unlike so-called “market” and “private competition” proposals that will exacerbate the lack of access to care for our younger and economically marginalized citizens.
Linda and I are headed out for a few days to take more Thinker photos so before boarding the plane I wanted to leave you with a couple more thoughts about our nation’s health care challenges, including my rescue by fellow Econ Robert Samuelson (he’s a real economist, I’m just a wannabe) from being an “old geezer” yet. A rational discussion about our national goals for health care needs to begin with whether or not we keep the Emergency Medical Treatment and Active Labor Act (EMTALA) which requires every hospital that receives Medicare or Medicaid payments from the federal government and that provides emergency room services, to treat anyone and everyone who shows up at the emergency room, regardless of ability to pay. You see as long as we keep it, meaning we won’t allow emergency rooms to deny treatment to our fellow humans in this country based on their ability to pay for the treatment, we already have universal health care coverage. It’s just that if EMTALA is the only game in town for millions who are uninsured then we will have more of our working age population who are sicker, more medical cost-shifting to those who do pay, more insurance premium death spirals, etc., because the uninsured are going to get treatment in a very cost-ineffective manner that simply exacerbates the problems with our crazy quilt system of medical care.
We could move to the South African alternative (per Trevor Noah’s story I retell in A Spoonful of Sugar) where the dying can be turned out onto the street if they can’t pay. Or there’s the Oklahoma Council of Public Affairs alternative, the wonderful marketplace for emergency services, best summarized in this cartoon from this week’s New Yorker Magazine with the caption
“I’ll go shop around for a doctor.”
The cartoonist is among the many of us who “knew health care could be so complicated” and is demonstrating the folly of those, like the OCPA, who primarily advocate “market” and “competition” based solutions to our nation’s health care challenges. As I pointed out in A Spoonful of Sugar there is too often a disconnect between the buyer (man unconscious on the sidewalk) and the seller (whatever medical provider eventually comes to his aid). Unlike our common purchases of food, clothing, entertainment, etc. much of what we spend on health care is not always for a service for which we can effectively plan, much less shop among providers (like the OCPA’s silly example of discretionary cosmetic surgeries), to be sure we are making the best choice. Even when we can prepare, often the pricing is obscured and far from fully knowable in advance. A health care system reliant on third party payments, i.e. insurance, is just not like most markets.
If we are truly serious about making health care affordable and available to all, then we cannot rely on simply providing mandated access to emergency room treatment (EMTALA) and greatly subsidized care (Medicare) for the old who, however deserving, are our least productive, i.e. geezers. Samuelson’s recent Tulsa World column Making Medicaid Great offers an important perspective on the role of Medicaid, i.e. federal/state financed health care for the destitute, in our health care system. Most mention of Medicaid in the current national discussion is about how Obamacare expanded Medicaid coverage (in the 31 states that agreed to participate; 19 including Oklahoma did not) to provide insurance to millions more Americans. In fact three quarters, per Samuelson, of Medicaid recipients are working age poor adults and children, a population some seem willing to cast aside or marginalize as unworthy of assistance. The other quarter are the disabled elderly, think nursing homes, and younger disabled determined unable to support themselves. In other words, this part of Medicaid is our nation’s go-to answer when our elderly parents run out of money, think $70,000 per year in nursing home costs, to pay for their own full time care, AND we choose to let the government pick up the tab instead of taking care of them ourselves.
In my law practice I counseled many clients about these choices—especially the reality that the survivor of Mom or Dad couldn’t qualify for nursing home Medicaid until the family house was sold for his/her care. Many adult children curiously viewed this as the government taking the house. Still today, to qualify for Medicaid assistance, a person’s assets can total no more than $2000. Most elderly receive their health insurance through Medicare, but it does not pay for long term nursing home care—that comes either out of the family pocket, rolling the dice with long term care insurance, or Medicaid (sell the home first). That part of Medicaid, including care for the younger disabled, is two-thirds of the total expenditures, per Samuelson.
Now here’s how Samuelson saves me from being an old geezer, and his proposal—a good one I think. The huge costs of Medicaid for the elderly are predominantly for those age 85 and over–a population set to explode due to medical advancements and aging baby boomers (I’m on the leading edge, born in 1947). This is likely the same population Dr. Carson had in mind. So I’ll make no more claims to being an “old” geezer for now (next 15 years), but do proudly consider myself a “geezer”. Samuelson’s proposal is to replace the current federal/state sharing, approximately 60/40, for all Medicaid expenditures with a system where the federal government will assume the costs of providing for the elderly in nursing homes, and the younger disabled, while the states take care of health insurance for low income adults and children. This shifts the riskiest and fastest growing part of Medicaid costs entirely to the federal budget and would leave states better able to invest in improving health care for the working poor and children. Something to think about.
As always lunch is on me for the first to ID the photo location.