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In an Aging Nation, Single-Payer Is the Alternative to Dying Under Austerity

Truthout – By Mike Ludwig – June 14, 2017
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Photo: (Maxlkt; Edited: LW / TO)

This piece is part of Fighting for Our Lives: The Movement for Medicare for All, a Truthout original series.

Every day about 10,000 people turn 65 in the United States, and the number of people over the age of 85 will more than triple by 2050. As a result, the demand for long-term health care services and end-of-life care will surge in the coming decades, increasing pressure on a system that is already suffering from high costs and workforce shortages. Unless policymakers make serious changes to how we fund and operate the health care system, the process of confronting chronic illness and death in the United States could become increasingly expensive and difficult for everyone but the very wealthy.

This isn’t just bad news for the aging baby boomer generation, which is expected to increase the number of people over the age of 65 in the US from 48 million to 88 million by 2050. In the decades to come, many millennials may find themselves navigating the current health care system’s complicated mix of government benefits, out-of-pocket costs and private insurance offerings with their elderly parents.

Meanwhile, the Republican plan to repeal the Affordable Care Act (ACA) that passed the House last month would gut ACA provisions that kept insurance companies from gouging older customers and cut $839 billion from Medicaid over the next decade. The bill would increase private insurance rates for older people with lower incomes and leave 5.1 million people between the ages of 50 and 65 without insurance by 2026, according to the Kaiser Family Foundation. Despite the popular misconception that Medicare covers all of seniors’ health care needs, millions of Americans over 65 are also enrolled in Medicaid. Elderly people would certainly suffer if the program saw deep cuts.

The proposed cuts to Medicaid are generally unpopular, and the Republican House bill has slumped in the polls. The repeal effort has recently stalled in the Senate due to deep divisions among Republicans. However, reports now indicate that Senate Majority Leader Mitch McConnell has been hammering out a compromise on Medicaid behind closed doors, with the goal of holding a vote on a Senate repeal package before a July 4 recess. A repeal is not a given, but it will take a sustained push from those who value affordable health care for low-income and working families to prevent a repeal while the GOP has a majority in Congress.

Amid this crucial resistance, a renewed push has also emerged for the creation of something different: a single-payer system. A House bill for a “Medicare for All” health plan has more co-sponsors than ever among progressive Democrats, and grassroots activists are rolling out campaigns across the country. When it comes to the issue of how to best serve elderly patients, advocates say guaranteeing health coverage for everyone would help prepare the system for an aging nation.

Medicaid and Elderly Americans

“The profit-seeking in end-of-life care is the real problem, and we could get rid of it,” said Dr. Andy Coates, an assistant professor of internal medicine and psychiatry at Albany Medical College in New York and a member of Physicians for a National Health Program (PNHP), the group of doctors and reformers backing single-payer legislation in Congress.

Coates told Truthout that many patients facing terminal conditions receive “palliative care,” which focuses on treating symptoms of serious illnesses, and then “hospice care” at the very end of life. Palliative specialists consider difficult questions posed by life-threatening illness: What treatments may be necessary or desirable, and what treatments would a patient want to avoid even if they could prolong life? How is the patient managing pain? What does the patient still need to get done in life before they die? Palliative specialists focus on both symptom management and psychological wellbeing.

New strategies for delivering care and reforms to Medicare under the ACA show promise for lowering costs and improving palliative and hospice care by empowering patients to take greater control of their medical decisions. Yet patients with chronic and life-threatening conditions are still bounced between providers and experience high rates of expensive and preventable hospitalizations.

While older people often juggle a number of medical expenses they must pay themselves, most also depend on the government’s main health programs for at least some of their care. Medicare provides insurance to people age 65 and older, and 8 out of 10 people who died in 2014 were in the program. Beneficiaries in their last year of life accounted for 25 percent of Medicare spending that same year.

While Medicare is the largest insurer of health care provided in the last year of life, Medicaid is the nation’s largest provider of long-term care services for elderly, chronically ill and disabled people. Medicare coverage tends to focus on short-term care that is medically necessary, such as providing devices after an accident or a nursing home stay for less than 100 days. Many older people in need of long-term care at home rely on Medicaid, often after spending off their personal assets on out-of-pocket costs in order to qualify. In 2011, 10 million people were enrolled in both programs, according to the Kaiser Family Foundation.

In a single-payer system, the government guarantees health care to everyone through a universal insurance program. In many countries with single-payer systems, private insurance is still available but tightly regulated, and many providers remain private. Together, Medicaid and Medicare already pay for the majority of long-term and palliative care services in the US, so some might say that the US has almost achieved “universal” coverage when it comes to end-of-life care — but without added benefits that could support low-wage workers and keep elderly folks from falling into poverty.

“We’re paying for a single-payer system, and we’re not getting it by any stretch of the imagination,” Coates said.

PNHP supports a single-payer proposal known as “Medicare for All,” but that doesn’t mean a transition to a single-payer system wouldn’t change things for seniors covered by Medicare. The single-payer legislation currently in the House, entitled the “Expanded & Improved Medicare for All Act,” would create a single, streamlined public agency that would pay health claims, rather than a profit-driven bureaucracy of competing insurance firms. “Expanded and improved” Medicare would mean that everyone, regardless of age, would be covered for all medically necessary services, including dental, vision and types of long-term care that Medicare does not currently cover.

Such a system would simplify how the nation pays for health care, and PHNP expects single payer to save hundreds of billions of dollars in administrative costs created by the insurance bureaucracy. These savings would be used to eliminate out-of-pocket costs such as copays and deductibles and provide patients with more freedom in choosing a doctor, according to PNHP.

“The country has the potential to have a great health system — truly great,” Coates said. “Instead, we have a mediocre health system and a bureaucratic mess, and everyone knows that.”

Low Wages and a Growing Shortage of Caregivers

As the nation ages, more people are trying to stay out of nursing homes as long as possible, and the government now promotes home care and assisted-living models as less costly alternatives. As the ACA expanded Medicaid, the Obama administration offered states waivers to spend Medicaid dollars on “home and community-based” services for those in need of long-term and palliative care. These programs allow families to hire home-care workers and nursing assistants or support themselves while caring for loved ones. This support is crucial for members of working families who often struggle to care for elderly and disabled relatives while maintaining low-wage jobs.

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Posted by Teri Perticone

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