Republican Vice Presidential pick Paul Ryan isn’t the only one Democrats are piling on this week. The knives have come out for Senator Ron Wyden, the Oregon Democrat.

I guess that isn’t a surprise. If Ron Wyden is right on Medicare then so are Paul Ryan and Mitt Romney.

The fundamental problem here is that the Democrats have decided that their best path to victory in the November elections is to say that the Republicans want to destroy Medicare as we know it and that the Democrats can preserve it.

The truth is that no one can preserve Medicare as we know it. There isn’t a prayer that your father’s Medicare will be around in 10 years. There is a legitimate policy debate going on about the direction we will have to go with it.

There is just plain going to be less money to spend on senior health care than there would have been if we let the program continue on its present unsustainable track. Health care providers and patients are going to have less money.

The question is who will control that money.

Conservatives generally want consumers to be in the driver’s seat—give seniors a defined contribution and let them decide on which health plan, and on which health plan’s approach to health care management, they want to spend it.

Progressives generally want to continue the defined benefit approach—guarantee everyone a benefit and use the regulatory power of government to make the dollars stretch to pay for it.

Both directions would lead to a Medicare program that looks very different than the open-ended entitlement we have today—one that because of its open-ended nature and the huge number of baby boomers about to retire will bankrupt us.

Late last year, Ron Wyden and Paul Ryan came along with a compromise—I will suggest an elegant political compromise.

First, they both agreed the current system is unsustainable—perhaps Ron Wyden’s real sin in an election-year when the party-line is that Medicare as we know it can be preserved and Republicans need to be defeated because they will kill it as we know it.

Then they found a way to craft a plan that took key elements from both the Democrat’s defined benefit and the Republicans defined contribution philosophy. For the details, see my post, Paul Ryan and Ron Wyden Blow the Medicare Reform Debate Wide Open!

At a time most Americans are upset that Republicans and Democrats can’t find a way to solve the big problems we face, Wyden and Ryan did just that on Medicare—they found a way to preserve the defined benefit baseline Medicare entitlement Democrats are insisting on while giving Republicans the consumer-centered defined contribution approach they want.

It was really elegant policy. But also inconvenient policy because Democrats had already decided they were going to make this election about their preserving Medicare while charging Republicans want to kill it.

So, with Ryan now the apparent Republican Vice Presidential nominee, the imperative to target Ryan’s approach to Medicare reform becomes all the better target and with him Wyden. Because if Wyden is right then the Democrats are wrong—or worse not telling the truth about Medicare.

That may be a necessary political strategy for Democrats during this election season, but my money is still on Wyden.

After November comes January.

My bet is that there are likely only two outcomes come January:

  1. Romney wins the White House and with it the Republicans capture the Senate and hold the House. In this case, the Wyden-Ryan Medicare reform proposal will be on top of the new administration’s agenda and Ron Wyden will be in the catbird seat. Republicans saw what happened to Democrats when they passed health care reform without a single Republican supporter. Republicans will be willing to round a lot of edges to keep Wyden on board and perhaps get a couple more Democrats.
  2. Obama wins but the Republicans take the Senate and keep the House. While a Republican victory in the Senate isn’t a certainty, the odds look a lot better than not. Now, either Republicans and Democrats compromise on the key issues or the political gridlock, and financial uncertainty that accompanies it, continues doing lots of damage to the economy. How will both sides eventually compromise over the key Medicare issue? There is only one path to Medicare compromise on the table—Wyden-Ryan.

Ron Wyden’s solo effort to actually find common ground and fix things now puts him in a very lonely and uncomfortable spot—until about the first Wednesday in November.

Maybe actually trying to be bipartisan and telling the truth will have a payoff after all.

Robert Laszweski has been a fixture in Washington health policy circles for the better part of three decades. He currently serves as the president of Health Policy and Strategy Associates of Alexandria, Virginia. Before forming HPSA in 1992, Robert served as the COO, Group Markets, for the Liberty Mutual Insurance Company. You can read more of his thoughtful analysis of healthcare industry trends at The Health Policy and Marketplace Blog, where this post first appeared.

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67 Responses for “The Coming Battle for Medicare”

  1. brimcmike says:

    This is Within-the-Beltway, Gilded-Age resurgent, Big Lie. We do have choices: stop fight unnecessary and unfunded wars, tax the rich and corporations at Eisenhower-era tax rates, reinvest in our infrastructure, take care of our young, our infirm and our elderly.

  2. Dave says:

    Wow, brimcmike, you’ve got a bad case of liberal talking point palilalia.

    Stopping the wars and confiscating 100% of the wealth of the private wealth in this country would not even fix the fiscal cliff we’re headed for. Research that for a while and then attempt to make an intelligent comment.

    • Craig "Quack" Vickstrom, M.D. says:

      Not 100%, just 90%. It worked for Ike.

      • Mark says:

        No, it didn’t. Nominal tax rates are not the same as effective tax rates. The 50s tax rates included enormous provisions for deductions and allowed for tax shelters. Most of these were eliminated in the Reagan tax reform. The actual effective rates were not greater than today’s and if you look at tax revenue as a % of GDP it was around 18%, about the same as it has always been. This was also at a time before Medicare, Medicaid and the explosion in Social Security spending so that the Federal budget was less than $100 billion compared to over $3 trillion today. Increasing taxes will raise more revenue in the short-term but it will not come near to balancing today’s budget and it will not solve the long term entitlements problem.

        • Craig "Quack" Vickstrom, M.D. says:

          Cut the military budget by 90%. Take the cap off Social Security taxes, as well as benefits. Make corporate tax rates and investment income tax rates equal to payroll tax rates. Make income tax (payroll, investment and corporate) heavily progressive. Maybe not has progressive as Ike’s but much more so than today. Nationalize health care, eliminate insurance companies, seize their assets. Ration the health care along standards of need, not standards of greed we currently have. Problem solved.

          • Keith says:

            Craig,
            You need to go read up on Clemente Atlee, and the vast nationalization of multiple sectors of the UK economy following WW2, along with the progressive taxation they imposed. Those policies were a key part in the decline of the UK economy.

            As to your comment about making corporate tax rates equal to payroll tax rates. Do you mean to lower them to the current payroll tax rate of 12.4%? Or did you mean to say raise them? Current US corporate tax rates are one of the highest in the world.

            You need to go study some economics first. You may have an M.D., but your knowledge of econ is based upon a seeming hatred/envy of those you consider well off.

  3. Pat S says:

    Although Ryan-Wyden pays lip service to the preservation of conventional Medicare as an option, that option would be of increasingly little worth for two reasons.

    First, conventional Medicare would be the most attractive option for people with high medical costs, as it is now. This would tend to drive the cost of true Medicare up relative to other programs, since without a very elaborate system of actuarial analysis private insurers would tend to seek and draw lower utilizers.

    Second, the plan is structured to base its voucher payments on the cost of low cost programs, which would mean that users of conventional Medicare — or of any other insurance program providing relatively comprehensive benefits for truly sick people — would gradually pull away over time, requiring a greater and greater enrollee out of pocket payment above the level of the vouchers.

    The only way to make a voucher program work would be to either use very elaborate — and costly — underwriting to set the worth of vouchers based on potential need of the insured, or to develop systems to set both the price of insurance and the price of health care services so that all insurance programs public and private start on an even footing and cherry picking is prevented.

    The second approach is the approach used by many European and the Japanese systems, and in fact does — unlike Ryan-Wyden — represent a true fusion between the desires of the right and the left, but requires far too much supervision and control for the taste of the current right in the US. The fact that it works extremely well and results in health care systems that not only provide better health care, as measured by outcomes, than the US, but also cost anywhere from 25% to 60% of the costs of US health care, potentially putting an end to the entire US health care crisis in one go, does not seem to impress most of those paying lip service to the idea of repairing not only Medicare and Medicaid but also the rapidly imploding private insurance system as well, but who seem to be most intent on gradually creating a system to ration health care by price to an even greater extent than we have now.

  4. Barry Carol says:

    I generally agree with Pat’s take on this.

    We should remember that in any given year, the healthiest 50% of Medicare beneficiaries account for only 4% of program’s costs or less than $1,000 for each of those 24 million people while Medicare overall spends roughly $10,000 per member annually. I think the Medicare program would cost even more if healthy people were allowed to take their voucher, find a low cost insurance plan and pocket the difference. At the same time, most of those with high healthcare costs would adverse select into standard Medicare.

    People who want something different from standard Medicare can already choose a Medicare Advantage plan and some 26% of them have done so. Medicare Advantage insurers receive risk adjustment payments but I’m told that it generally takes about 12-24 months from the time a member ages in to Medicare for the risk adjustment to begin to reflect the member’s true health status and it is never completely accurate in any case. While the risk adjustment mechanism gets decent marks from insurers, in the end, it overpays for the healthy and underpays for the sick. As an aside, I was surprised to learn on Humana’s most recent earnings conference call that the average risk score for its Medicare Advantage population is 0.65 with average risk for the total Medicare population scored at 1.0.

    I think we would be better served if we put our efforts into trying to change the culture of how medicine is practiced. Our culture tends to favor aggressive interventions even when they are unlikely to do much good. I think doctors could do a better job of honestly describing the options available to patients and families and the quality of life implications of each. Patients, for their part, should at least discuss with spouses, adult children and other family members what care they want and don’t want in an end of life situation, especially Alzheimer’s, dementia and advanced cancer. Sensible tort reform could reduce defensive medicine and I think there is more that could be done to combat fraud. Moving away from the fee for service payment model in favor of bundled payments for surgical procedures and capitation where feasible would also be helpful.

    I don’t think the Republicans’ faith in the private insurance marketplace will work here. Democrats, for their part, don’t seem to know how to do anything other than squeeze provider payments which can only be pushed so far before more providers drop out of the program. The U.S. is likely to always have the most expensive healthcare system in the world but there is plenty of room for improvement. Much of the leadership, though, probably has to come from doctors and hospitals.

  5. DeterminedMD says:

    Really folks, how much more of disingenuous, insincere, and plain fraudulent dialogue by both sides of the failed aisles of this political system can you tolerate before the reverse peristalsis of projectile vomiting will overcome those just fed up? Medicare has passed the zenith of it’s potential, and now is just a bloated beast of excess access for minimal gain.

    Again, we are seeing what the entitled narcissistic expectations of the boomers will force on the rest of America and just bankrupt us all financially, politically, and spiritually until the system collapses under it’s bloated weight. Are any of you just shouting out for more of the same paying attention to what is going on in Greece, Spain, and other European cultures of “gimme that, it’s mine”?

    Blind faith, wow, it truly is sensory deprivation at its finest!

  6. Beautifully and thoughtfully put. I couldn’t put it better. Here is how the poet in me puts it.

    Don’t Let Them Mediscare You

    The first and great commandment is. Don’t let them scare you.

    Elmer Davis (1890-1958), But We Were Born Free (1954). Elmer Davis was a well-known news reporter, author, and Director of the United States Office of War Information in World War II and a Peabody Award recipient.

    August 14, 2012

    Don’t let those Obamacare folk scare you,

    No matter how they say it or what they do.

    Under Paul Ryan’s most recent proposal,

    You’re not headed to the Medicare disposal.

    The proposal won’t affect you if you’re over fifty five.

    You can stay on Medicare as long as you’re alive.

    You can choose to remain on traditional Medicare,

    You can choose a cheaper private plan if you dare.

    Don’t believe that nasty unfounded riff,

    That Ryan pushes Grandma off the cliff.

    Or that a price support voucher

    Is the work of a political poacher

    Ryan’s proposal repeals the health care law,

    Which sticks in many a skeptical senior’s craw.

    Obamacare cuts $710 billion from Medicare.

    That already places Medicare in disrepair.

    Under Obamacare, Medicare as you knew it,

    Will soon be gone no matter how you view it.

    The Ryan plan restores the $710 billion cuts,

    It proposes the same Medicare growth rate,

    As Obamacare says it would choose to inflate.

    It switches willing seniors on vouchers, no if ands and buts.

    And it issues block grants to states to administer Medicaid,

    The states can then administer their own budgetary bandaid.

    Don’t let them scare you.

    With stories apocalyptic

    Remember the alternative.

    A bankruptcy nightmare.

    For Medicare.

    Tweet: The Ryan budget plan is to head off Medicare bankruptcy by offering either traditional Medicare or private premium support voucher options.

    • You can’t just “choose to remain on traditional Medicare”, Dr. Reece. You’ll have to pay the difference between that and the second cheapest plan, which is going to be increasingly more money.

      And since lots of seniors are on Medicaid as well, or will soon be, those block grants are certain to affect them in a nasty way.

      And why is this supposed to start in 10 years and not 10 months? Does it have anything to do with appeasing voters?

      Is the new modus operandi now that one party passes one law and then the other party repeals it and passes its own law and then the first party repeals that and passes something else, all of which is scheduled for doomsday in the future and in the interim we do nothing?

  7. Bill Springer says:

    Just as we criticize public employee unions for extracting outrageous fringe benefit and retirement packages from our elected officials, we should aim the same type of barrage at CMS for what it has done with Medicare. Medicare was intended to provide health care for the elderly at a time when many were unable to afford basic care. How did it now evolve into the massive pay for everything program? We need to get back to what it was intended to do, namely, provide reasonable care for the elderly, not give them carte blanche for anything that the FDA has not rejected.

    • Peter1 says:

      Bill, when part of ACA “reasonable” was living will consultation, Repugs screamed “DEATH PANELS!”. Until we get away from extreme political base tribal camps there will be no “reasonable”. Reassurance of elderly that “their” Medicare won’t change will only carve out younger, voucher coverage groups as targets of scare-care tactics.

      Don’t forget it was GOP who vowed to only defeat Obama, not work to “resonable” long term solutions that would give political cover to both sides.

    • BobbyG says:

      “How did it now evolve into the massive pay for everything program? … give them carte blanche for anything that the FDA has not rejected.”
      __

      Grossly overstated.

  8. Bill Springer says:

    BobbyG, you might feel otherwise about gross exaggeration if you see the number of terminal elderly patients put on ventilators without “DNR” orders. Patients and families don’t think twice about the cost of care when they’re allowed to play with “house money”.

    • BobbyG says:

      Look, I just recently finished up YEARS of next-of-kin POA/Legal Guardian duties for my late parents, both of who had Medicare — as well as VA, and Tricare. None of which were “carte blanche.” Moreover, I shelled out about $300k cash across the 4 years of my Ma’s long-term care. My Dad was in LTC with dementia from 1991 ’til he died in 2008. His disabled WWII combat vet VA coverage, while adequate, was not a blank check.

      None of which is to deny that there are systemic problems. Just that gross overstatements don’t add anything useful to the debate.

  9. Barry Carol says:

    “And why is this supposed to start in 10 years and not 10 months? Does it have anything to do with appeasing voters?”

    Margalit –

    People who are on Medicare now or will be going on it within 10 years are counting on current system as part of their retirement planning. Even Ryan recognizes that. Younger people, by contrast, have time to adjust to and plan for a modified system. As I noted above, though, a hybrid system for the under 55 population won’t work because the sicker people will adverse select into standard Medicare. A voucher approach would have to apply across the board and insurers would need risk adjustment payments like they get now under Medicare Advantage.

    That all said, the important thing to understand about Ryan is that he’s a supply sider as opposed to a deficit hawk. His proposal wouldn’t balance the budget until 2040 even if his aggressive economic growth assumptions materialize which they probably won’t. His focus is mainly on tax cuts for “job creators” (meaning the wealthy) in order to stimulate economic growth. Eliminating taxes on interest, dividends and capital gains is outrageous on its face and I say that as one who would benefit materially from that if it happened because much of my income in retirement is from investments. I thought we got taxation right in 1986 when the top marginal income tax rate was 28% and all income including capital gains and dividends was taxed at that maximum rate.

    The Ryan and (probably) Romney economic program are losers because both will be seen, correctly I think, as grossly unfair to the middle class. At the same time, if Obama “wins ugly,” he will alienate the other side who then won’t cooperate with him and he won’t have a mandate to do anything other than raise taxes on the wealthy unless he puts forth a viable alternative plan, campaigns for it and wins.

    • Barry,
      If as Bob writes above this “elegant” compromise does nothing more than put Consumers in the driver seat, what is there to prepare for? Do people need over a decade to ponder whether they should stay in traditional Medicare or opt for one of those spiffy private plans that will end up saving them boatloads of money?

      There is no integrity left anywhere….

  10. maggiemahar says:

    Bob–

    Medicare spending has already slowed, thanks to the ACA.

    As Peter Orszag has pointed out Growth of Medicare spending has already
    slowed to an affordable rate. WE have 2 1/2 years of data.
    Hospitals, in particular, are anticipating the new payment systems and are cutting costs, thus submitting lower bills to Medicare.

    I quote Orszag in my most recent THCB post here http://thehealthcareblog.com/blog/2012/08/09/breaking-the-curve-of-health-care-inflation/

    Republicans have already lost this war. The law passed, and it’s beginning to work.

    And the parts oif the ACA that will reduce spending further haven’t even begun to kick in:

    –Accoutnable Care Organizations,
    –Patietns receiving care at community health centers (ACA doubles capacity)
    rather than ERs,
    – patient homes that keep patients out ot hospitals
    –Many ways of paying for quality, not fee for service
    –Reduced fees for overvalued services, much as Medicare has already
    reduced fees for CT scans and MRIs done outside hostpials;
    –Medicare will be shaving annual inflation increases in payments to hospitals
    and nursing homes by 1% a year for 10 years–this is a major reason why
    hospitals are already tigheting their betls, reducing preventable readmissions, etc.

    Meanwhile, with Ryan on the ticket it appears more and more likely that Obama
    will enjoy a landslide victory.

    If so, the coattail effect for Democrats running for Congress will be significant.

    Once in office, in his second term, OIbama is going to veto anything that shifts
    costs to Medicare beneficiaires

    Finally,American voters are very, very tried of hearing conservatives insist on
    continuing to debate health care reform.The legislation passed. Let’s see
    how it works.

    In the meantime, voters want to hear how Republicans will create jobs for
    teachers, firemen, construction workers repairing infracture. We need public sector jobs.

    Obama and Democrats know that tax rates for the wealthiest 5% are at historic lows. They will increase those taxes, take a look at inheritance taxes,
    corporate tax loopholes, etc. .

    Republican candidates who continue to fight the last war by going on and on about turning Medicare into a defined contribution plan will be punished at the
    polls.

  11. DeterminedMD says:

    “Republican candidates who continue to fight the last war by going on and on about turning Medicare into a defined contribution plan will be punished at the
    polls.”

    Really. Like your political agenda is going to save America. Wow, the rhetoric between these two parties is so pathetic. The status quo ain’t gonna work people, and pandering to a clueless, dependent base is not going to drive that 30% independent voting block to reflexively go with either party just because of scare tactics.

    Entitlements are not answers, just delays to inevitabilities. You want to live indefinitely, yet can’t handle the truth. Again, per MASH episode with Ron Howard and Hawkeye’s friend dying on the table, “rule #1, people die, and rule #2, doctors can’t change rule 1″.

    But for the sake of political gain, let’s sell the public said rules can be excepted. I don’t know who is worse, the rich guy who wants another title, or a political thug who will demean and defame while projecting his own ugliness onto his opponent.

    Ugly election tactics. Yeah, at who’s expense in November? Oh yeah, the public’s. Wait until we watch Democrat PAC ads showing Ryan impersonators mowing down people in hospital corridors.

    Sounds stupid and obscene? Welcome to the crossfire of politics!

  12. Peter says:

    Why don’t we give back to each person all the money they have put into Medicare with interest and then you are on your own. People get way too much out of this program in comparison to what they have put in it.
    Or cut off the benefits once a person has used up all they have contributed.

    • John Ballard says:

      …give back to each person all the money they have put into Medicare with interest…

      Splendid idea except that Medicare, like Social Security, is a pay as you go plan. Since when is any federal or state program into the business of giving back anything? Last I looked both state and federal elected officials are in the business of collecting money and spending it right away. And when there isn’t enough to do what they want done, they borrow on behalf of the electorate — “bonds” they are called.

      In other words, the “money they have put into Medicare” is not there any more. It’s gone. Spent. Nothing. Nada. Your suggestion would be clever if it were not so transparently ignorant, unless, of course, you are suggesting ending the program at once and letting everybody sink or swim according to how long they can survive on whatever private assets they may have.

  13. Barry Carol says:

    Margalit –

    While I’m not an insurance expert, I’ll offer my opinion anyway.

    I think any private insurance plan would include a limited provider network as is the case with Medicare Advantage plans because that’s one element of their effort to control costs. As I understand the Ryan proposal, insurers would bid in each region and the value of the voucher in that region would be set at the price of the second lowest cost plan. The only potential savings available to a beneficiary would be the difference in cost between the lowest cost plan and the value of the voucher. Beneficiaries could pocket that difference if they chose the lowest cost plan. Those who choose higher cost plans than the value of the voucher would have to pay the difference themselves.

    Assuming insurers could not turn anyone down who applies for a policy and can pay any difference between the premium and the value of the voucher, the approach cannot work without risk adjustment payments as some insurers will wind up with sicker members than others. This is how it works it Germany, Switzerland and the Netherlands. If standard Medicare remains an option, it’s a virtual certainty that the sickest patients will choose it (adverse selection) because they will want maximum provider choice especially as it relates to hospitals. Without risk adjustment payments, either standard Medicare will become unaffordable or, if Congress provides for an additional subsidy to cover costs in excess of premiums received, it won’t save any money. Moreover, to the extent that healthy people who choose the lowest cost plan are allowed to pocket the unused portion of the value, the overall program could wind up costing more than the current system of standard Medicare plus Medicare Advantage. I think this proposal has cost overruns and unintended consequences written all over it.

  14. Bob Hertz says:

    The Ryan plan for Medicare is extremely gentle, at least on my first reading of it.

    Everyone over 65 can stay with Medicare until they die.

    Everyone 55 or over today can stay with Medicare until they die.

    Therefore, between 2012 and 2022, Medicare spending will grow to about $1.2 trillion a year just on demographics and mild medical inflation.

    No one will be on the Ryan plan in 2022, as I understand it.

    Between 2022 and 2032, some of today’s elders will still be alive and on traditional Medicare, and most of today’s 55 years olds will be alive and on traditional Medicare.

    The number of people on the Ryan plan from 2022 to 2032 will be growing by about 2-3 millon a year, as today;s 55 year olds hit age 65.

    This is budget dust, more or less.

    Remember that the entire Federal government took in about $2.2 trillion in revenue during 2010. Between 2000 and 2010 there was almost no growth in federal revenues, per David Cay Johnston.

    it would certainly seem that a budget crisis will hit America long before the
    Ryan plan has any real effect.

    • Pat S says:

      “The Ryan plan for Medicare is extremely gentle…”

      True. In fact, it is so gentle that it will actually increase the deficit substantially for the first 25 years, according to the CBO analysis — by $6 trillion in ten years, due to the fact that the tax cuts start immediately while the savings are phased in over time. Ryan even concedes that it will increase the deficit for the first 15 years, then says that the tax enhancement from the feverish economic growth he envisions will put the budget in the black.

      The main reason for the delays in implementation of the Medicare cuts and some other cuts is that they will result in very substantial increased costs to individuals, and that current retirees and near retirees would largely refuse to tolerate that and use their votes to express their opinions. The hope is that people who are 10 and more years from Medicare will be less interested in the topic and more interested in other things, like tax cuts, and will not be motivated to vote the issue.

      However, make no mistake, the Ryan budget will ultimately have a very pronounced impact on the many people, including many seniors, who according to the CBO will have very large (from $2000 to more than $10,000 a year) new out of pocket payments for health care depending on their health status. The budget will also impact many low income people, who will be eliminated from programs like Medicaid, food stamps, housing aid, the earned income credit, and unemployment, as well as many young people who will be eliminated from educational aid and job training programs. All those programs are due to be severely contracted or eliminated long before the onset of the Medicare changes.

      Of course, many if not most of Ryan’s fans would say that that is exactly as it should be.

  15. Barry,
    I think we’re in general agreement on this. Just wanted to point out that in those countries you mentioned, the plans are not allowed to profit on the basic and rather generous package, so there goes another 15% to 20% savings and since the provider prices are uniformly negotiated, there are probably even more savings, compared to the free-for-all contemplated here.

    I think Bob Hertz is right too and this “plan” from Mr. Ryan is not really a plan to accomplish anything except the ultimate removal of the social safety net, which is rather flimsy to start with, and a return to the good old gilded days eventually.

  16. Bob Hertz says:

    Thanks Pat S for the insights. The view of Ryan that you suggest is what used to be called ‘voodoo economics’ in the Reagan 1980′s………..i.e. goose the deficit now to get rid of the deficit later.

    According to David Stockman, the whole Reagan economic platform was a lot of smoke and mirrors with one and only one goal — lower taxes. Everything else was policy pablum.

    Actually the Ryan Medicare plan would work, if people would save a lot more money. In theory, a person who works 40 years should have enough capital so that paying $2,000 or even $5,000 a year on top of a voucher should not be terrifying.

    Here is where the Republicans trip on their own principles. Republicans have sponsored the right of businesses to offshore jobs, slash pensions, and lay off older workers. As a result,you have millions of senior citizens who are as poor as church mice.

    A winner take all economy will necessarily produce quite a few poor people. The Republicans would rather not think about this difficult problem.

  17. Barry Carol says:

    “A winner take all economy will necessarily produce quite a few poor people.”

    Bob –

    With all due respect, Switzerland has plenty of wealthy people among its population of seven million and its share of lower income people as well. There is no such thing as Medicare or Medicaid in Switzerland. Everyone, including the elderly, is covered by private health insurance but fully 45% of the population qualifies for a government subsidy to help them afford the premium and, at the population level, 30% of healthcare costs are paid for out-of-pocket vs. about 12% in the U.S.

    A portion of hospitals’ operating costs are paid for with general tax revenue which moderates premium costs somewhat. Doctors earn less than they do in the U.S. and prices per service, test, procedure or drug are lower on average. As their former health minister admits, though, they do not have good data about the overall quality of their healthcare but it’s perceived as good.

    If we’re really interested in lowering healthcare costs in the U.S., our focus should be on the medical culture from physician practice patterns, including end of life care, to patient expectations. Smaller issues include the lack of the widespread use of interoperable electronic records, too much defensive medicine, fraud and poor management of many patients with chronic conditions. Insurance companies and competition among them is the wrong focus, in my opinion.

  18. John Ballard says:

    …quite a few poor people,

    ►Understatement of the week

    Don’t forget that Social Security is also on the chopping block, although nobody is saying much about that these days. The vanishing employer-contribution retirement plans (already few and far between) are now obsolete and will likely be replaced by employee-contribution plan(s) of some sort.
    The most realistic option I have heard is an “opt-OUT” plan added to the current system which may also be means tested. But that’s still way up the pipeline.
    (If either side dares mention Social Security prior to the election we’re apt to see civil unrest… we’re not all that distant from Euro-style “austerity.”)

  19. DeterminedMD says:

    I came back to this site because this debate about Medicare is so ridiculously shallow and misdirective, we all know what is going on with this entitlement program that is sucking the finances out of our culture. Obama is a fraud, and the Republicans are equally not invested in real change for the better.

    Again, for the umpteenth time, what are you looking for, alleged invested voters? People who are either about abandoning the middle class, or, just trying to enslave it? This isn’t about a vote to save the country, just who will destroy it less slowly. Entitlements do not help us in the end. No one of alleged substance and concern would argue the status quo is fine. Nor would anyone of character and investment in the well being of America as a whole would demand serious change without the wrath of clueless and selfish citizens who have no idea what the concept of future is.

    We are doomed with the majority of voters as they are. And this site just reinforces the stupidity of what constitutes the typical voter. Democrap or Repugnacant. Third party choice is minimized and avoided. Again, good luck America, you do not deserve it with the alleged ‘choices’ that await us.

    Think about it, irregardless of who is president come November 7, you all vote for the same lame incumbent jerks for congress, what really will be different come January 2013. Only a new fourth digit at the end of the designated year. And 90% of the usual suspects here just sell the outcome with their partisan commentary!!!

  20. Simon says:

    A really good article. We speak with several medical professionals daily and I will forward this blog onto them for their opinion….

  21. Bob Hertz says:

    Several points from the last few posts:

    1. Robert Samuelson had an excellent piece in the Washington Post on the phoniness of the Ryan Medicare plan. Samuelson takes the position that we need some cuts right now, but both political parties are afraid to alienate senior citizens on anything.

    We could someday be three days away from national bankruptcy, and some politicians will still be running on a platform of ‘no change.’ We are seeing that in Greece right now.

    2. Barry, I would be cautious about using Switzerland as a health care comparison for the USA.

    One big reason is that I believe Switzerland’s labor market is like Germany or Sweden, in that there is less inequality. Retail, food service, and hospitality employees are much better paid than in the US, whereas these are the core sectors of our uninsurance problem. I do not think that any Swiss waitresses work for $3 hr plus tips.

    Bill Maher once quipped that the true mission of the Democratic Party was to drag the hillbilly half of America into the 21st century. We’ll see.

  22. DeterminedMD says:

    “We could someday be three days away from national bankruptcy, and some politicians will still be running on a platform of ‘no change.’ We are seeing that in Greece right now.”

    Gee, how many more trillions in debt before we get to that 3 day notice? I guess we wait for the riots for validation.

  23. bob hertz says:

    Riots can occur when a government has made extravagant promises, but can no longer borrow money to satisfy those promises. In the USA this may happen first at the city and state level.

    Based on interest rates, it would appear that the US federal government can go on borrowing money for a long time.

    Our federal government can also slash defense spending, if and when health care promises become too expensive to maintain. In Canada, health care is about 43% of the provincial budget, and that nation stays prosperous. The same is true in varying degrees across northern Europe.
    It helps to have a tiny army.

  24. Barry Carol says:

    Bob –

    While there is undoubtedly room to cut the defense budget, especially once the war in Afghanistan winds down, I think it’s unlikely that defense spending will shrink below 4% of GDP anytime soon vs. a bit over 5% now. BTW, it was close to 10% when JFK and LBJ were presidents. Within reason, given the importance of the rule of law and of keeping us safe, I would rather see the defense budget be a little too big than a little (or a lot) too small. I prefer to have a margin of safety in this area.

    While most other developed countries spend less than 1% of GDP on defense and they spend a considerably lower percentage of GDP on healthcare than the U.S. does, they spend a lot more for unemployment benefits and other safety net programs. Unemployment rates are persistently higher than ours in most of the other developed countries because their labor markets are much more rigid and their tax burdens are significantly higher. Economists will tell you that Europeans make a conscious tradeoff of more economic security (broad safety net) and less inequality at the cost of lower long term economic growth and less opportunity. The U.S. makes the opposite tradeoff which reflects, I think, our different history and culture.

    Finally, Canada’s current relative prosperity stems mainly from high commodity prices. There have been times in the past when commodity prices were low and their economy really struggled.

  25. Pat S says:

    “Unemployment rates are persistently higher than ours in most of the other developed countries because their labor markets are much more rigid and their tax burdens are significantly higher. Economists will tell you that Europeans make a conscious tradeoff of more economic security (broad safety net) and less inequality at the cost of lower long term economic growth and less opportunity. The U.S. makes the opposite tradeoff which reflects, I think, our different history and culture.”

    Back in the 80′s that was pretty much true, but recently the trend has reversed.

    Of the established developed countries — including the old EU and Northern Europe, Canada, Australia, and Japan — unemployment is now lower than the US in all except France (and perhaps Britain, as their current economic program crushes the economy,) and actually has been for the best part of a decade. Economic growth has equalled or exceeded ours in all but Japan — in a permanent recession for two decades now.

    Even in the past, while our rate of growth exceeded theirs in the second half of the 20th century, unemployment is more difficult to compare since unemployment in the US is far different from unemployment in those countries with far better safety nets of all sorts, including unemployment pay. Many economists suggest that the U6 measure of unemployment in the US, which includes discouraged workers who have withdrawn from the labor market, people working part time who desire full time work, and significantly underemployed people — i.e. IT people working as WalMart greeters. Unemployment benefits in those countries require reporting as “ready to work” for much longer periods of time — indefinitely in some cases — and discourage people from seeking part time or low wage work that does not provide income above the level of unemployment and associated benefits. U6 right now is near 15% in the US, nearly twice U3, the official rate, and has been in double digits or very near double digits since the fourth quarter of 2001.

    It is especially interesting to note that countries like Canada, Sweden, Germany, Denmark, the Netherlands, Norway, etc. have been able to weather the current recession much better than us, with higher or much higher rates of growth despite their high rates of safety net spending. It is also interesting to note that Greece, the usual example for the nightmare of overspending on social support, actually spends and has spent a lower portion of their GDP on social support than any of the major old EU countries except Britain — the problem with Greece has been a combination of wholesale corruption leading to much lower tax receipts and very high government employment in what are essentially make work — or no work — jobs, and government borrowing to support those habits. These two things have been features of the Greek economy since the dictatorship period of the second half of the 20th century, and actually may date back to the Ottoman era, when the combination of making being a tax official an entrepreneurial venture and rulers using government employment as a tool to suppress unrest became a way of life.

    Unfortunately, the steady drumbeat of propaganda from some sources has given most Americans as poor an image of how the economies of other countries work as of how their health care systems work. The fog surrounding both is a significant impediment to arriving at health care and economic decisions that really work.

  26. Pat S says:

    Also, on Canada.

    Canadian resource exploitation has benefitted and continues to benefit the economy, and has especially helped their balance of payments, but the real driver of growth in Canada has been NAFTA. Canada is the huge winner of the NAFTA world, and has successfully recruited a ton of US manufacturing — everything from autos to software — due to lower costs (partly related to employers not being responsible for health care,) a skilled and motivated work force that speaks English, and much more liberal immigration rules which allow wholesale recruitment of skilled people from Asia and Eastern Europe. Canada is now running into some trouble as its currency gains on and passes the US dollar in value, making some pay scales and prices less advantageous, but the Canadian economy continues to grow faster than ours.

    Where I live we have been treated for many years to the sight of Canadians flocking to our shopping areas to load up on stuff that is much cheaper than in Canada now that their currency has increased in value. I have a relative in Bellingham, Washington (an hour’s drive south of Vancouver) who tells me they are trying to pass regulations requiring stores like Costco and Target to have certain times of the week or day when only Americans can shop there, since the stores are otherwise overrun with Canadians eager to take advantage of bargains in our depressed economy.

  27. Barry Carol says:

    “Unfortunately, the steady drumbeat of propaganda from some sources has given most Americans as poor an image of how the economies of other countries work as of how their health care systems work. The fog surrounding both is a significant impediment to arriving at health care and economic decisions that really work.”

    Pat S. –

    Aside from higher taxes on the wealthy, which I support, what would those economic decisions that really work be? I’m genuinely interested in your opinion.

    Regarding healthcare, Japan spends only about 8% of GDP and enjoys the highest life expectancy in the world but its economy has been in a funk for two decades as you noted and their public debt to GDP ratio is the highest in the development world by far. They don’t seem to have any answers either.

    Some of the European countries you referenced have a much higher percentage of their population that is 65 and older now than the U.S. does. While that drives up costs for pensions and healthcare, it also mitigates the unemployment rate from what it might be if the population was younger on average.

    • Pat S says:

      We would be way off topic on this site to get into a discussion of economics apart from health care, but I would recommend checking out a couple blogs: Brad De Long’s “Grasping Reality with Both Hands” and of course Ezra Klein’s Wonkblog. There are a bunch of others, most of which are regularly linked on De Long’s blog. Any ideas I have are second hand from places like that.

  28. bob hertz says:

    There is a lot of good information in these posts, but personallyI am going a little nuts on measuring the quality of national health care by mortality rates

    I know that journalists have to use something to measure health care, so this is not a personal diatribe in any way.

    But let me be blunt.

    A child with a hole in his heart might live 15 extra years if he gets into the Mayo Clinic.

    At the end of this period. the health care plan which covers his family might be charging $2,000 a month.to all orhr employees.

    Or else his parents have declared bankruptcy.

    Are we ahead from this gain in mortality?

    I have my doubts. Heroic medicine is overrated, in my view.

    In the USA , a 94 year old like Gerald Ford could be scheduled for bypass surgery. He died before the scheduled operation.

    This could legitimately have helped Mr Ford, an outstanding person in many ways, to live to age 98.

    Big deal, in my view.

    :Longer mortality costs society money. David Cutler says otherwise but I
    question his assumptions.

    For me, I would measure national health system based on how many families are deeoly in debt from health care.

    Canada, Britain, Germany and France win hands down on this scale.

    I could not care less about mortality rates.

    I may not be right — comments are welcome!

    Bob Hertz, The Health Care Crusade

    • DeterminedMD says:

      I agree with the above. While quality of life is individual specific, there has to be boundaries at least with those over 65.

      Really, organ transplants for 70 year olds like Cheney!? My only hope is the immunosuppressant meds do the damage they often do even in healthier younger patients. And this is not just a political swipe, look at liver transplants for addicts. But, people can’t handle the truth, eh?

      • John Ballard says:

        At least one well-known investment guru might take issue with the age 65 cutoff. He was older than that when he got a hew heart and is still going strong at 83.
        http://www.cnbc.com/id/48635888

        • DeterminedMD says:

          Ok, but who would have been next on line for that heart who was younger, that could have contributed as much if not more, watched his/her children grow up, that could spread the word of appreciation better?

          Let’s face it, people getting major organ transplants don’t deserve it, they pay for it, and let’s face it even more brutally candid, don’t understand their time is done. Is this the face of Medicare come the next decade: oh, so an organ failed, we’ll just put someone else’s in you to live another 3-5 years and have more chronic problems to cost the system even more to keep a greedy life present longer?

          Gimme a break!

  29. bob hertz says:

    Just forgetting about any morality considerations, let’s look at the economics.

    An 83 year old who gets a transplant of any kind is out of the work force.

    He will never pay any payroll taxes again. He will pay income taxes if his income is over about 40K a year, given current deductions for seniors.

    It is not an accident that socialist countries used to deny transplants or, for that matter, dialiysis, to persons over age 65. This was true in Poland and a number of other nations.

    Tbere is certainly nothing wrong with younger workers chipping in payroll taxes to make life longer and better for older persons.

    What is starting to grind in America is that these younger workers have what in Yiddish is called ” bupkes” for their own health insurance. (i.e. nothing.)

  30. DeterminedMD says:

    Why are morality considerations irrelevant, oh, I get it, because it may bring some clarity to the issue. Why are we considering prolonging the lives of people who have lived a reasonable period of time? Because the needs of the few outweigh the needs of the many.

    That certainly is the mantra of the Republican party, and Democrats just blur it with the superficialness of claiming concerns for the downtrodden, but, their party elders mirror the mentality of Republican well off brethren and try to avoid being caught saying “screw the poor, they work for us!”

    You can’t really be arguing containing Medicare costs and include organ transplants, dialysis indefinitely, and full court ICU stays for people with end stage chronic illness.

    If you do, disingenuous at least, clueless most likely, or just partisan to whatever special interests trump realities of cultures with 300 million or more citizens. Numbers don’t lie in the end if used responsibly!

  31. DeterminedMD says:

    And by the way, it is nothing less than disingenuous in this alleged argument the young owe the old in being mandated to have health insurance. No one younger than 55 is out there pushing this failed premise. To the general readership, you think it is bad now, wait ’till more than 25% of boomers are older than 65, then entitlement cries will make jet take offs sound like bedroom white noise machines!

  32. Bob Hertz says:

    To Determined MD — you may want to read a libertarian economist named Robin Hanson on health care.

    His position is that health care is a ‘signal’ of our altruism. People and countries support health care as a way to show others that we care about them. In Hanson’s view, this emotion is stronger than economics or rational policy.

    • John Ballard says:

      Of course one must subscribe to the idea that altruism is a virtue in order to appreciate ideas like that.

    • DeterminedMD says:

      Altruism with a blind eye to boundaries like cost and efficacy of treatment does not serve dispenser nor receiver of services well, much less the whole community that is invested in the process too.

      I think people use terms a bit too liberally at times to try to paint opinions like mine are insensitive or impolite. Yet, docs like me are the ones front and center who have to explain where things lead, the bean counters and political hacks who just tell us how it “should be” never jump in to substitute and make it easier, neither for physician nor patient. And that is why people like me are so outraged we have politicians and accountants try to tell us what the future will be when they can’t even be attentive or honest what the damn present is like now!

      Again, don’t quote us what the AMA or AARP have to say, they do not represent the majority of people who could belong to these groups. You know why we don’t hear about polling from doctors in general or seniors over 70 as a whole? Because either the pollsters are deterred by the powers behind the scenes to not get the truth, or, the respondents are too afraid to speak the truth or just hang up or walk away when propositioned to participate in a poll. Frankly, I don’t blame them for either response.

      God knows no one really wants to hear the truth these days, and god also knows polls are only as good as who is getting the data anyway!!!

      Hey, if Medicare is so great, why don’t you poll general private practice physicians and ask them if they take new Medicare patients, and how much administrative time they have to pay for in using that program if they do participate? Do you really want to publicize those numbers?!

      • Pat S says:

        “Hey, if Medicare is so great, why don’t you poll general private practice physicians and ask them if they take new Medicare patients”

        Done! :http://content.healthaffairs.org/content/31/8/1673.abstract

        Turns out that more physicians will accept new Medicare patients than will accept new private insurance patients.

        This, by the way, is a real scientific survey, not a web or fax survey by a physicians recruiting firm with a voluntary response rate of less than 5%.

        As to the admin time, my experience as a private practice physician has demonstrated that the overhead expenses of dealing with Medicare are not just lower, but much lower, than private insurance. In fact, our billing agent calculates that billing private insurance costs her seven times as much as billing Medicare, and results in much slower payment times.

        • DeterminedMD says:

          Yeah, until you have an audit for accusations of fraud for using the wrong CPT codes. Ask those same physicians about that issue looming over everyone’s heads. And maybe I am living in a place that is exempt from this poll’s results, but I do not hear even 50% of colleagues in my region taking new patients at least, that going on for the past couple of years now. So who do you believe? Me, I believe what people tell me to my face that are in the middle of the pit, battling for survival not only for themselves, but their patients too.

          Oh, yeah, maybe ask patients looking for new providers that same question, how many calls did you have to make before finding a provider who not only would take Medicare, but see you in a timely fashion. Did the poll ask that too?

          And by the way, to Pat S your link that I could access was about Medicaid, so unless you mislinked the article and could give us an access password to read the whole thing, ahh, I don’t see your rebuttal so directly.

          • Pat S says:

            READ THE WHOLE ABSTRACT, NOT JUST THE TITLE. The article title is about Medicaid, but the article, as the abstract makes entirely clear, reports a survey that included physicians’ willingness to accept new patients with Medicaid, Medicare, and private insurance. The results show that while 17% of doctors would refuse new Medicare patients, 18% would refuse new private insurance patients.

            To spell out the math, 83% of physicians indicated they would accept new Medicare patients.

  33. Bob Hertz says:

    Hanson’s position is that all societies have altruism. Sometimes the altruism is restrictred to one’s own tribe or race or religion, but altruism is ever present.

    I think you were hinting that some of our Republican social darwinists have no altruism. Hanson would disagree. They are in fact altruistic to other Republicans.

  34. DeterminedMD says:

    To debate Medicare as is and see no real limits to extended care that only prolongs life, and does not really improve quality of life, is an empty argument and only self serving to a population over 60 that isn’t accepting the boundaries of life.

    Everything involved in health care is finite, costs included. The proponents are already fully accepting of what will be IPAB as it stands, oh, but as long as they do not mess with the proponent group and their cronies.

    Anyone who thinks this IPAB is benign and beneficial to society, how does that sand taste in your mouth? I know you haven’t seen light since March 2010!

    • Peter1 says:

      “To debate Medicare as is and see no real limits to extended care that only prolongs life, and does not really improve quality of life, is an empty argument and only self serving to a population over 60 that isn’t accepting the boundaries of life.”

      Empty argument!? Empty how – you mean no patient involvement? Who are you going to delegate to make those decisions FOR THE PATIENT? Is this part of the GOP “Patient Centered” health care?

      Determined, were you part of the “DEATH PANELS” crowd? And who would you like to make your decision for YOU?

      • DeterminedMD says:

        It is amazing what people infer from one’s writings, and just making shallow, false allegations will attempt to just shut one up for having the unmitigated gall to not walk goose step in line with the Democrat “PPACA is supreme” mentality some just spew here!

        Uhh, reality call, not supporting PPACA does not make one a Republican hack, as I have clearly called out that failed party as well for their repeated shortcomings. No, we here in the middle find both extreme sides of the aisle nauseating and pathetically limited in trying to help this country out of problems. If we had a viable third party candidate, we would actually see unity from the Republocrats and see their vile attack dogs unite on said third party candidate. Can’t upset that false premise of choice for voters, eh!?

        And really, who here who is not a partisan hack does not see IPAB become a potential death panel-type process, not ordering deaths as these Democrat blind loyalists want to falsely proclaim the process would be, no, just setting choice with a financial price tag that will exclude those who don’t have the finances. You all really think PPACA will make for a one system process for health care? Wow, anyone who proclaims that makes the Wizard of Oz character a true god!

        No, we will still see at least a 2 tiered system, and guess who NEVER will stand in line with us, your politicians, big business leaders, and others who have fleeced and manipulated the public out of funds in their greedy zeal to keep the addiction of money flowing in their proverbial veins. That’s why Nancy didn’t want her cronies to read the bill, because truth is not part of the process that the Democrats forced on the country. Just like the Republicans did in forcing the ongoing wars in Afghanistan and Iraq on us 10 years ago.

        So, put your blind faith in callous, selfish and soulless politicians, and now watch them spin the Medicare debate where it will not really go, into the laps of voters, because politicians do not want you to realize that there is not enough money to keep all your mommies, daddies, grandparents, Aunts and Uncles, and anyone else over 70 you hold so near and dear to live another 10 or more years,that death is not an option for Americans to consider.

        And any physician who can’t look you in the eye and tell you that he/she cannot cheat death, that human beings were NOT meant to live past 70 or so without much heartache and pain is not only culpable for this tragedy being forced on this country, they are co-conspirators.

        How’s that for a retort rant? The hypocrisy from both Presidential candidates alone could choke a room of 1000 thinking people and not even be phased when it runs out to find the next room when done. Threads like this are not about debate at the end of their runs, just who can shout down and win applause from their partisan brethren, who would then sell you out for getting up the ladder tomorrow.

        Now that is politics!

        • Peter1 says:

          “How’s that for a retort rant?”

          Yes, just a useless rant. You can either write to express an opinion or you can’t put logical thought into plain english then claim others interpreted it wrong.

          • DeterminedMD says:

            Almost as useless as you alleging I am a Republican hack and advocating for death panels. This is a heated debate even outside the partisan jockeying, because it is about limits in care. Threads like this amount to nothing just spouting statistics and academic drivel that just wants status quo to be maintained.

            Take care of a patient for a couple of months and get back to me!

            No one seems to attack my occasional comment about realistic limits to our lifespan being about 70-75 with a realistic quality of life thereafter. While that is good because there really is no argument against it, it does strike me as odd that no one wants to extrapolate from it.

            Personally, I hope this Medicare debate burns both Obama and Romney, and puts the current older population right in the crosshairs of the rest of the population that needs the reality check!

  35. DeterminedMD says:

    And by the way, to the above discussion about altruism, where’s the altruistic nature of our elderly population in saying without much hesitation that they have had a hopefully fair share of opportunity to get to the age they are now ,and at least for organ transplants make a spontaneous, realistic choice to not take an organ that someone else might make last a sizeable longer period of time then what someone over 70 could do?

    Again, using a term or a stat to just favor one side of an argument is not so strong and indefensible, when the other side could use it as rebuttal, hmm? There is no black-white line in this debate, but you let Republocrats run the debate, you’ll end up saying what you denied 5 minutes earlier.

    Face it, Medicare was not created for a population that is now seeing a sizeable percentage live past 75 years old. Who is going to argue this point is false!?

  36. DeterminedMD says:

    Oh, and by the way, probably a minute point to the Medicare argument as a whole, but what of the minority sized population on Medicare as disability patients, who could be on Medicare supports for 3 or more decades depending on what disability gained them access in the first place? And the fact that more people are getting disability determinations of late, coincidence on Obama’s stay in office (?), so what do we do should this population become a sizeable faction for the country?

    Sorry, I do not subscribe to this ridiculous adage that health care “is a right”, but care should never be refused for casual and selfish reasons either. You never really hear responsible health care advocates who say that everyone should get the full level of care irregardless of cost, because, hey, responsible people don’t say stupid things like that! There has to be boundaries, limits, time to say stop or no more! It is almost always people who have the least to lose and the least to personally offer in the health care system who advocate for this infinite expectation with care.

    And too many idiots listen to them and believe it!

  37. DeterminedMD says:

    Wow, just got home and read this at a site who, full disclaimer here about the link is a radio commentator who hates PPACA as much if not more than me, and is the story revealing, again to me mostly, of how much a hypocrite and projector of his poor judgment, even if moreso by wife Michelle, Mr Obama really is at the end of the day:

    http://www.americanthinker.com/printpage/?url=http://www.americanthinker.com/articles/../2012/08/romney_really_needs_to_fight_back.html

    Well, you read it and decide for yourselves.

    Cheers.

  38. Bob Hertz says:

    I used to live in Hyde Park in Chicago. That area is filled with limousine liberals, who say that they are advocates for the poor, but want nothing to do with the poor people who live next to them.

  39. Henry Markant says:

    An actual decrease in life expectancy due to obesity in the developed world could be the shock the public needs to become concerned about health habits. In order to stave off an imminent crisis, “universal” programs will have to be paid for by substantial new taxes, increased federal debt or individual health insurance savings accounts that will emphasize preventive medicine financed by nontaxable deductions from gross income—or a combination thereof. The only alternative is to slash benefits. According to its board of trustees, Medicare will be insolvent before 2019 since its so-called “Trust Fund” is already used to compensate for monthly shortfalls.

    Before 2017, Medicare payments will amount to 15 percent of GDP and require 24 percent of all federal income taxes if changes are not made in 2012. The situation is clearly unsustainable. Of the federal budget 84 percent is non-discretionary, consisting of the following: Defense, 23 percent; Social Security, 20 percent; Medicare & Medicaid, 19 percent; interest on the national debt, 5 percent (and going up substantially); plus “other mandatory,” 17 percent. These figures do not include TARP (Troubled Asset Relief Program) bailouts, Quantitative Easing, or emergency funds for foreign aid or natural disasters. There is absolutely no hope of paying our national (and state) debts. This charade of solvency of the “Ponzi Scheme” cannot end well.

    If we were to spend 15 percent of GDP today, that would take 95 percent of federal revenues that are already at 19.5 percent of GDP. In addition, Medicare is $29.9 trillion (plus) underfunded; how much more depends on the cost of the Medicare drug benefit. A Heritage Foundation report estimates the unfunded liabilities for the three parts of Social Security will be $10.4 trillion, Medicare $61.6 trillion, and the new Medicare drug benefit will add $16.6 trillion—or $88.6 trillion total. Without a new universal health care plan somehow fully paid for, current Congressional Budget Office estimates are that the US budget deficit just for Medicare will be 82 percent of GDP by 2019—truly unrealistic!

    You can buy this book now on any of the following websites:

    Strategic Book Publishing Rights Agency: http://sbpra.com/HenryMarkant/

    Amazon Books: http://www.amazon.com/Coming-Crises-Their-Solutions-ebook/dp/B00A2WZ4CK/ref=sr_1_1?s=books&ie=UTF8&qid=1357573018&sr=1-1&keywords=coming+crisis+henry+markant

    Barnes and Noble Books: http://www.barnesandnoble.com/w/coming-crises-and-their-solutions-henry-markant/1113749628?ean=2940015922875

  40. bob hertz says:

    Good points, and I look forward to your book.

    However, Medicare is only underfunded if the current benefits package never changes.

    The Ten Commandments did not mandate that Medicare pay for every hospital visit, or that Part B even exist.

    I do not want the government to cancel Plan B, but it could and then what would be underfunded?

    Our defense budget is also underfunded by trillions if we assume we must have over 100 foreign bases.

    We could have no foreign bases next month if we wanted to. Now that might hurt innocent nations, just as slicing off parts of Medicare would hurt innocent seniors.

    But these deficits are not a force of nature!

    bob hertz

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