Monday, February 25, 2013

Fwd: qotd: TIME: Steven Brill's "bitter pill" should wake us up

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Subject: qotd: TIME: Steven Brill's "bitter pill" should wake us up
Date: Mon, 25 Feb 2013 08:56:52 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

February 20, 2013
Bitter Pill: Why Medical Bills Are Killing Us
By Steven Brill

The Way Out Of the Sinkhole

"I was driving through central Florida a year or two ago," says
Medicare's (Jonathan) Blum. "And it seemed like every billboard I saw
advertised some hospital with these big shiny buildings or showed some
new wing of a hospital being constructed … So when you tell me that the
hospitals say they are losing money on Medicare and shifting costs from
Medicare patients to other patients, my reaction is that Central Florida
is overflowing with Medicare patients and all those hospitals are
expanding and advertising for Medicare patients. So you can't tell me
they're losing money … Hospitals don't lose money when they serve
Medicare patients."

If that's the case, I asked, why not just extend the program to everyone
and pay for it all by charging people under 65 the kinds of premiums
they would pay to private insurance companies? "That's not for me to
say," Blum replied.

In the debate over controlling Medicare costs, politicians from both
parties continue to suggest that Congress raise the age of eligibility
for Medicare from 65 to 67. Doing so, they argue, would save the
government tens of billions of dollars a year. So it's worth noting
another detail about the case of Janice S., which we examined earlier.
Had she felt those chest pains and gone to the Stamford Hospital
emergency room a month later, she would have been on Medicare, because
she would have just celebrated her 65th birthday.

If covered by Medicare, Janice S.'s $21,000 bill would have been deeply
discounted and, as is standard, Medicare would have picked up 80% of the
reduced cost. The bottom line is that Janice S. would probably have
ended up paying $500 to $600 for her 20% share of her heart-attack
scare. And she would have paid only a fraction of that — maybe $100 —
if, like most Medicare beneficiaries, she had paid for supplemental
insurance to cover most of that 20%.

In fact, those numbers would seem to argue for lowering the Medicare
age, not raising it — and not just from Janice S.'s standpoint but also
from the taxpayers' side of the equation. That's not a liberal argument
for protecting entitlements while the deficit balloons. It's just a
matter of hardheaded arithmetic.

As currently constituted, Obamacare is going to require people like
Janice S. to get private insurance coverage and will subsidize those who
can't afford it. But the cost of that private insurance — and therefore
those subsidies — will be much higher than if the same people were
enrolled in Medicare at an earlier age. That's because Medicare buys
health care services at much lower rates than any insurance company.
Thus the best way both to lower the deficit and to help save money for
people like Janice S. would seem to be to bring her and other near
seniors into the Medicare system before they reach 65.

Meanwhile, adding younger people like Janice S. would lower the overall
cost per beneficiary to Medicare and help cut its deficit still more,
because younger members are likelier to be healthier.

If that logic applies to 64-year-olds, then it would seem to apply even
more readily to healthier 40-year-olds or 18-year-olds. This is the
single-payer approach favored by liberals and used by most developed


Yet while Medicare may not be a realistic systemwide model for reform,
the way Medicare works does demonstrate, by comparison, how the overall
health care market doesn't work.

Unless you are protected by Medicare, the health care market is not a
market at all. It's a crapshoot. People fare differently according to
circumstances they can neither control nor predict. They may have no
insurance. They may have insurance, but their employer chooses their
insurance plan and it may have a payout limit or not cover a drug or
treatment they need. They may or may not be old enough to be on Medicare
or, given the different standards of the 50 states, be poor enough to be
on Medicaid. If they're not protected by Medicare or they're protected
only partly by private insurance with high co-pays, they have little
visibility into pricing, let alone control of it. They have little
choice of hospitals or the services they are billed for, even if they
somehow know the prices before they get billed for the services. They
have no idea what their bills mean, and those who maintain the
chargemasters couldn't explain them if they wanted to. How much of the
bills they end up paying may depend on the generosity of the hospital or
on whether they happen to get the help of a billing advocate. They have
no choice of the drugs that they have to buy or the lab tests or CT
scans that they have to get, and they would not know what to do if they
did have a choice. They are powerless buyers in a seller's market where
the only sure thing is the profit of the sellers.

Indeed, the only player in the system that seems to have to balance
countervailing interests the way market players in a real market usually
do is Medicare. It has to answer to Congress and the taxpayers for
wasting money, and it has to answer to portions of the same groups for
trying to hold on to money it shouldn't. Hospitals, drug companies and
other suppliers, even the insurance companies, don't have those worries.

Comment: Steven Brill's TIME article, "Bitter Pill: Why Medical Bills
Are Killing Us," seems to be awakening those who have, until now,
accepted the very high prices of health care as an inevitability for
having a technologically advanced health care system here in the United

In his 36 page article - which will surely be required reading in many
health policy courses - Brill makes it clear that we no longer need to
take the "bitter pill" of medical bills that are killing us. Clearly,
Medicare already has several tools to control costs and has the
potential for further improving value in the nation's health care

At the end of his article, Brill seems to be advancing a non sequitur
when he writes, "The real issue isn't whether we have a single payer or
multiple payers. It's whether whoever pays has a fair chance in a fair
market... We don't have to scrap our system and aren't likely to." This
certainly does not follow from what he had to say as the central theme
of his article.

He then recommends some tired or inadequate remedies that would have
very little impact on the problems that we face in health care. What is
ironic is that he has built a tremendous case for the logical solution -
an improved Medicare for all - and then he seems to dismiss it. You
cannot read his article and escape the conclusion that a single payer
national health program is an absolute imperative, that is, if we really
do want affordable care for everyone.

Download this article (the full 36 pages is available for free at the
link above), and share it with others. But put a Post-it note on it that
states: WARNING! For the health of our nation, ignore the section at the
end titled "Changing Our Choices" (that's the tired remedies section),
but concentrate on what an improved Medicare system could do for all of us.

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