Why doesn’t Medicare cover the services so many older people need?
Sorry, Joe Namath. Despite what you keep saying in those TV commercials, under Medicare, the elderly are not “The right to waive co-payments and to obtain dental care, dentures, glasses, prescription drug coverage, home helpers, unlimited transportation and meals at home, all without additional costs ”. But if Democratic congressional lawmakers have a say, seniors may soon qualify for some of these services.
Namath’s ad sells private Medicare Advantage plans, which often offer benefits that traditional Medicare doesn’t – in exchange for being limited to certain doctors and hospitals. “Traditional” health insurance does not cover many of the benefits used heavily by its beneficiaries, including most vision, dental and hearing care, and drug coverage is only available by purchasing a health plan. separate insurance – Medicare Part D.
But Democrats in the House and Senate plan to try to change that as early as this fall. On Monday, Senate Majority Leader Chuck Schumer released a preview of an upcoming budget bill which includes a directive to the Senate Finance Committee to expand Medicare “to include dental, vision and hearing benefits”. The catch – all Democrats in the Senate and almost everyone in the House will have to agree on the entire budget bill for it to become law.
Yet this raises a question about Medicare: Why has it taken so long to add such clearly needed benefits?
As with almost everything about the American health care system, the answer is complicated and a combination of politics and politics.
“Medicare is the kind of program where you expect benefits to be expanded over and over again. It’s popular and the benefits expansions sound good, ”said Jonathan Oberlander, professor of health policy at the University of North Carolina-Chapel Hill and author of the book“ The Politics of Medicare ”. “This is one of the big puzzles of Medicare policy: Why have extensions of benefits been so rare? “
In fact, in the 56 years since Medicare became law, only a few perks have been added to the package, which was created to mimic a 1965 Blue Cross / Blue Shield plan. During the 1980s and 1990s, some preventive care was added, such as pneumonia vaccines and mammograms. Republicans spearheaded the addition of prescription drug coverage in 2003, when they controlled both Congress and the White House. But they decided to separate this coverage from the traditional benefits of the program.
Other efforts to expand benefits have not worked so well. In 1988, a bipartisan effort in Congress produced the Disaster Health Insurance Act, which would have added drug coverage to traditional Medicare and also filled a hole: the fact that there is no limit on the amount that patients can be billed for their share of covered services. This law, however, was repealed just a year later after older people rebelled against being asked to pay most of the bill for the new benefits through a new “surcharge”. Today, Medicare beneficiaries still face the risk of unlimited spending.
Medicare is funded by a combination of money paid directly to the government from paychecks and taxes paid by American workers and their employers. This brings us to another big reason why the Medicare benefit package has not been stepped up further – the cost of the current program.
“When Medicare was created, its architects took charge of the expansion, both in terms of population and in terms of later benefits,” Oberlander said. “They hadn’t foreseen the shift to the right in US policy, and they hadn’t foreseen that Medicare would be labeled a tax problem and that policymakers would be more concerned with avoiding the next trust fund deficit. than to extend the benefits. “
In fact, in the 1980s and 1990s, spending on health insurance was more often restricted than increased. A series of budget reconciliation bills wiped out millions of dollars from Medicare, usually at the expense of paying doctors, hospitals and other health care providers.
Medicare has remained popular over the years, but it has become less generous than most private insurance policies. However, many Medicare patients have been able to find additional coverage to cover what Medicare does not cover, through private “Medigap” policies, employer-provided pension plans, or Medicaid for low-income people. . In recent years, Medicare managed care plans, now known as Medicare Advantage, have grown in popularity in recent years and were first authorized in 1982 and often offer additional benefits to members.
All of this “relieved some of the pressure” from lawmakers to expand the program, Oberlander said. And one final reason why vision, hearing and dental care has not been added to standard health insurance is that they are far from the most critical gaps in all of insurance benefits. -disease.
For example, Medicare does not cover long-term care – the type of non-nursing personal care that provides assistance with activities of daily living such as bathing, dressing, eating, going in or out. from a bed or chair, using the bathroom or preparing food. On-call care tends to be both very expensive ($ 50,000 to $ 100,000 per year or more) and needed by a large number of beneficiaries, especially after the age of 80. Efforts over the years to create a government long-term care benefit have been largely unsuccessful. A very limited program, the CLASS Act, was part of the Affordable Care Act in 2010, but has been repealed before it could take effect because its funding was deemed insufficient. President Joe Biden has called on Congress to include billions of dollars for caregiving in the infrastructure package Democrats will be working on this fall.
Also, as mentioned earlier, traditional Medicare does not include any limits on patient cost sharing – the percentage or amount of a medical bill that a beneficiary must pay. His basic inpatient benefit expires after 90 days, and the 20% coinsurance (the percentage for which patients are responsible) on outpatient care runs indefinitely.
So why is dental, vision and hearing coverage in the foreground now as lawmakers consider stepping up the program? Some can be selfish for lawmakers tasked with allocating funds. The three advantages “are cheaper than [adding] retirement home, ”said Oberlander.
But much of it is political. During the election campaign, Biden promised to lower the age of eligibility for Medicare from 65 to 60 years old. Advocates of “Medicare for All” like Senate Budget Committee Chairman Bernie Sanders (I-Vt.) promised to try to do the same, and lowering the age of eligibility is included in the plan that Schumer shared with Senate Democrats as an option.
But lowering the eligibility age is opposed by hospitals and other health care providers, who fear losing money if people currently covered by higher-paying private insurance are instead covered by Medicare. This makes expansion of benefits the much easier choice for Congress.
That doesn’t mean it will happen. the Congress Budget Office said the vision, hearing and dental benefits included in a bill passed by the House in 2019 would have cost around $ 358 billion over 10 years. But it is the closest measure that benefits have come close to since the inception of Medicare.
HealthBent, a regular feature of Kaiser Health News, offers policy and policy insight and analysis from KHN Washington Chief Correspondent Julie Rovner, who has covered healthcare for over 30 years.
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