Medicare for All(most)

by, Dr. Bill Thomas

Journalist Steven Brill’s recent long piece on health care costs (Time) and its exposé of $1.50 acetaminophen pills and $77 boxes of gauze has stirred controversy and even some outrage. While the article did a great job arousing righteous indignation, it also touched on a wonderfully counter-intuitive idea. In a time when politicians and deficit hawks are advocating raising the eligibility age for Medicare two years to 67, we should actually be pressing for lowering the Medicare eligibility age. What would happen if that age was lowered to, say, fifty?

People between the ages of 50 and 64 will make up twenty percent of the US populations by 2015 and their needs are actually well aligned with the kind of care that Medicare does best. According to a report issued by the National Prevention, Health Promotion, and Public Health Council, 70 percent of these folks will already be diagnosed with at least one chronic condition and nearly half will have two or more. Research has shown that preventive care is especially valuable for this population and that such services save money. The researchers conclude: “Despite the cost-effectiveness of many of these services, the percent of adults who are up to date on receiving them is low.”

They need Medicare now. And Medicare needs them.

Adding post-50 adults to Medicare would not only provide them with financial and health security and peace of mind, it would reduce the overall cost-per-beneficiary to Medicare and help cut the deficit by greatly increasing the number of healthy people on the rolls. As Brill rightly points out, “That’s not a liberal argument for protecting entitlements while the deficit balloons. It’s just a matter of hardheaded arithmetic.”

Now, it’s easy to blame politics for protecting the status quo of our broken health care system. I have advocated in the past for single-payer universal healthcare — Medicare for all. Politically, that’s a nonstarter. But if just lowering the eligibility age a bit really would cut the deficit while benefiting older adults, why is no one talking about it?

To understand the true reason why Medicare for fifty-year-olds is “off the table,” we need only look at our nation’s scandalous approach to the flu. Geriatrician Jack Rowe summarizes our alarmingly wasteful approach to vaccination with a clever fable:

“In the midst of a typical seasonal influenza epidemic, an extraterrestrial being walks into a hospital emergency room teeming with acutely ill older adults. Turning to the head nurse, he says, ‘There must be no prevention for this illness.’

‘We have an effective vaccine.’

‘Then the vaccine must be in very scarce supply,’ he counters.

‘Oh no,’ she replies, ‘We have lots of it. It’s in those bottles on that shelf.’

Puzzled, he suggests, ‘Well,it must be very expensive.’

‘No, it is very inexpensive, often free.’

He replies, ‘Well, can you explain to me why you don’t prevent this disease in these people?’

And to that, the head nurse replies, ‘No I can’t, I just can’t.’”

Influenza will take the lives of 36,000 Americans– and most of these cases could have been easily prevented. We could change this, but we haven’t.

Here’s why.

We are willing to pay often outrageous prices for the pills, equipment and facilities that maintain the health care system’s status quo, but we invest almost nothing in new models of care that promise to change that system. Lowering the Medicare eligibility age would actually strengthen our health care system and improve the health of millions of people. We don’t lack vaccines– we lack a system for ensuring that people get the immunizations they need when they need them. Our supposedly innovative health care system actively resists innovations that challenge conventional practice and overpays for what we already have, even when those treatments have been shown not to be effective.

This year marks the 10th Anniversary since I began working with an incredible team to develop, refine and validate a new approach to the long term care of frail older people. It’s called the The Green House Project and independent research has shown the approach to caring for elders with complex needs pioneered by adopters of the model has the same median cost as traditional nursing homes but delivers consistently better clinical and satisfaction outcomes. A detailed economic analysis has shown that Green House homes save Medicaid and Medicare between $1,300 and $2,300 per resident per year compared to traditional nursing homes. A system that overpays for so much would surely leap at the opportunity to reduce costs while improving quality, right? It’s the health care equivalent of a walk-off grand slam home run. Except, it isn’t.

There are now 146 Green Houses in 22 states and the model is heralded as a big success. But… there are more than 16,000 nursing homes in the United States and significant resistance to change within the industry. In the coming years we will continue to spend billions of dollars on brand name prescription drugs that are no better than what is already on the market and at that same time insist that it is just not feasible for our elders have access to a higher quality, lower cost model of long-term care. The real scandal here is that our health care economy aggressively protects the interests of the existing systems and limits change to minor matters related to pills and treatments.

This state of affairs is, of course, unsustainable — we need a new health care delivery system, one that is centered on people rather than insurance companies, hospitals and long term care facilities. To get there we will need to launch a health care revolution that brings forth new models of person-centered, community-based care.

I look forward to the day when Dr. Rowe gets to tell the story of a visiting Martian who takes a look at our health care system, nods his little green head and says, “Nice work humans. Well done indeed.”