Medicare and "YouPays"
-- Dan Keller's Healthcare Blog

October, 2020 -- I am 66 and I've had Medicare for a year. My parents (may they rest in peace) had it, too (as do most 65+ Americans) and were pleased although, in his last two days of life, my father was not afforded a private room in the hospital (Mt. Sinai in New York City which we dubbed Mt. Cyanide) and we -- an endless stream of family paying last respects and we three his distraught offspring -- had to tiptoe and whisper so as not to disturb the saintly heart patient in the other bed. Medicare is no Rolls Royce.

And it's complicated! Ok, I get the distinction between Parts A (hospital), B (doctors), C (Medicare Advantage, mentioned below) and D (drugs). But that's just the beginning. You can get "Original" Medicare from the federal government. They deduct the small premium (around $125) from your Social Security check. But it doesn't cover everything so, if you're not dead broke, you pay extra for a policy from a private company (United Health, Health Net, Kaiser, Humana, Cigna, Blue Cross, and more), either Medicare Advantage (also called Part C) or Medicare Supplement (you can't have both). Medicare Advantage fills some (not all) of the gaps in Parts A and B. Medicare Supplement (which I chose) is colloquially Medigap -- it covers more than Advantage (as far as I can tell) and comes in versions A, B, C, D, F, G, K, L, M, and N (yup, no E, H, I, or J). I have G. You have to get Advantage (you can't have Supplement) if you're a Kaiser member but that's ok since Kaiser is pretty comprehensive. But I don't like Kaiser anymore.

Then there's Part D, the drug plan. You have to know what drugs you take. But who can predict what you'll need when someday you're sick? Insurance is by definition a gamble, you vs. the insurer. Nobody wants to pay. Drugs are grouped in "tiers" (six of them) depending on whether they are generic or fancy or a bunch of other factors. You must understand them -- oh yes, and predict the future -- if you are to make a wise choice. The different tiers have different copays (i.e. youpays).

Then there are deductibles. These are another youpay. In theory, once your payments add up to the deductible amount, the insurance pays. But it's not so simple, and it's not always true. Different tiers (and different services in medicare Parts A and B) have different deductibles. Some things count toward your deductible (which in theory should not exceed some guaranteed maximum but there are all those exceptions). If you get healthcare things that don't count toward your deductible, your bill could get astronomical. And it resets every calendar year so you get to hemorrhage all over again starting next January 1st. No wonder the most common cause of bankruptcy in the USA is medical bills.

And wait, there's more! These policies advertise a MOOP -- maximum out-of-pocket -- which (again, in theory only) sets an upper limit on your medical expense. But there are different MOOPs for different categories of expense, and some expenses are exempt (i.e. don't count toward your MOOP) so you better know what surgeries, drugs, services, etc. you'll someday need so you can choose the right policy. Hah! It's a game you can't win.

Equally dismaying is the army of insurance agents, claims adjusters (i.e. claims deniers; doctors hate them because they must often fight to get paid), bureaucrats, functionaries, and corporate fat cats with private jets. They all draw paychecks that, of course, are ultimately paid by us, and they produce nothing of value.

Then there are the endless glossy brochures, inch-thick manuals and web sites and "help" (read: sales) lines describing policy coverages, benefits, and limitations. And all those slick advertisements on TV and in newspapers. Ultimately it is we who pay for those, too, with our insurance premiums. It is a very profitable business.

How about all the cards I must carry in my wallet and produce in mad profusion at various points of care? There's the insurance company card for Medicare Supplement, the insurance company (a different insurance company) card for Part D, a pharmacy frequent flyer card, and more.

Don't get me wrong, I think Medicare is great and everyone should have it, not only we oldsters. Medicare for all! When I turned 65, my health insurance premiums went down by a factor of 6.

Still, the decision-making process is absurdly confusing and the bureaucratic waste contributes to the vast overpricing of our healthcare. Anywhere from 15% to 35% (depending on who you read) of our healthcare dollars go to feed this paperwork monster. It's time for single-payer!

Why single-payer? Because when there are multiple payers (insurance companies, government, and you) each works to stick the others with the bill. Hence the bureaucracies. And the suffering Americans.

Go single payer!


Dan Keller RN MS © 2020

Updated Wednesday, 21-Oct-2020 12:29:57 MDT

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