Thoughts on Medicare’s 50th Birthday

by Emily Kirchner

“What the patient really needs is better insurance.”

The physician said it abruptly, matter-of-factly. Her comment was not meant to evoke empathy in the rest of the medical team. She stated it like a diagnosis.

The recommended care was out of the question because of the patient’s insurance. Two seconds later, the discussion had moved on — how to address our patient’s other medical problems, or maybe when the patient could be discharged from the hospital.

I, the lowly third-year medical student, was still stuck on the doctor’s words: “What the patient really needs is better insurance.”

Today, Medicare turns 50.

Medicare, the federal health insurance program that insures adults age 65 and older as well as younger people with permanent disabilities, currently covers 55 million Americans — that’s 17 percent of the population.

Before Medicare, senior citizens delayed or forewent medical attention. In 1959, a retired Detroit autoworker named John Barclay described why for the Senate Subcommittee on Problems of the Aging or Aged :

“…the retired person must pretty much exhaust any savings he has before he can get free hospitalization. This is a constant source of worry. Many of my acquaintances will not visit a doctor for minor illness because they have no money to pay for drugs. After they exhaust their savings they go on welfare to get medical aid, but then, in many cases, it is too late.”

About half of our seniors did not have hospital insurance and one in four seniors went without medical care because of cost concerns. The cost burdens of health care and hospitalization meant that the elderly were the group most likely to be living in poverty. In 1965, 1 in 3 seniors was considered poor.

The 1963 Survey of the Aged concluded that “Many aged persons never recover from the economic effects of a single hospital episode. Unfortunately, the heaviest burden is likely to fall on those with the least resources. Those with insurance are better able to absorb the blow than those without such protection, but even for the insured there is no present guarantee against dependency in old age caused by catastrophic medical expenses.”

Prior to Medicare, segregation policies in many hospitals legally and routinely denied African Americans and other marginalized racial minorities access to medical care. To receive Medicare reimbursements, institutions were required to see patients of all races. Government officials oversaw desegregation programs to ensure that hospitals could collect Medicare payments.

After it was signed into law by President Johnson in 1965, Medicare enrolled 19 million seniors and covered their 1966 medical expenses for a cool $867 million in today’s dollars. (To put that in perspective, it took over $6 billion for enrollment costs alone in the first year of the Affordable Care Act.) Congress extended Medicare coverage to younger individuals with permanent disabilities in the early 1970s.

And yet a half-century after this landmark legislation became law — the first step, in the eyes of its proponents, toward universal coverage under a national health insurance program — I am treating many patients whose biggest problem is not their medical diagnosis, but their insurance status.

The statistics about health care costs in the U.S. are frightening. Sixty-two percent of all personal bankruptcies in the U.S. are linked to medical bills or illness, and three-quarters of those people had health insurance when they got sick.

Even after the expansion of coverage promised by the Affordable Care Act, about 31 million people will remain uninsured in 2023. High out-of-pocket expenses, including copays, deductibles, and coinsurance, still plague tens of millions of Americans who are technically “insured” but in reality underinsured.

The U.S. spends more on health care than any other country in the world, $3 trillion annually — about 17 percent of our GDP. For all of the money that we are spending on health insurance premiums, out-of-pocket expenses, and taxes to sustain our health care system, we aren’t getting very good care. The U.S. was ranked 37th out of 191 countries in the 2000 World Health Report. We haven’t done much better in any ranking that has emerged since then.

As Medicare turns the big 5–0, it is as good a time as any to consider what our country could look like with improved, expanded Medicare for everyone — i.e. a single-payer national health program.

A publicly financed, improved Medicare for All would allow patients to go to the doctor or hospital they prefer. Coverage would no longer be tied to employment. Financial barriers to care such as premiums, copays and deductibles would be removed.

A single-payer system would cut down on bureaucratic waste for hospitals and physicians and, with its strong bargaining power, cut the costs of drugs, equipment, and services. Universal coverage would encourage more preventive care, keeping everyone healthier for longer. Not only do I want this system for me and my family, I want it for my patients.

Improved, expanded Medicare for all is not out of reach. The political climate and lobbying powers of insurance companies and pharmaceutical companies make it challenging but not impossible to attain.

The American Medical Association backed an extraordinary campaign against Medicare in the early years of the Kennedy administration. The AMA tried to tie Medicare to the bogeyman of “socialized medicine” and an imminent threat of communism. But the scare campaign failed, Medicare was enacted, and our nation has been bettered for it.

There’s no doubt that well-financed scare campaigns by the health industry remain a threat to bringing about more fundamental health reform. But today a majority of physicians support universal coverage, and a majority of Americans do, too.

When we talk about the health care system, we often talk about money. But underlying these arguments are people: the waiter with the flu, your mother-in-law’s shoulder pain, a coworker’s shortness of breath. Whether these are minor events or serious health crises, everyone should have access to good health care.

There is an economic argument and a moral argument to be made for deeper reform, and both point to the same answer: We need to go beyond the Affordable Care Act to an improved Medicare for all.

Emily Kirchner is a third year medical student in Philadelphia, PA. She has blogged for Medical Students for Choice and Students for a National Health Program. Find out more about improved, expanded Medicare for All and blow out the birthday candles for Medicare with other supporters.

Photo: Bill McChesney

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