by Edwin Quinabo
Americans want affordable healthcare. At least that’s what polls have shown in the last two national elections.
And a majority of both Democrat and Republican voters also support Medicare – the US national health insurance program – as an institutional feature of government to be improved on and protected.
While lawmakers at this time are not prepared to deliver on the first part, to make major changes to the US healthcare system via Medicare for All, Democrats are now prepared to go full speed ahead on the second, less dramatic part to expand Medicare services and lower the program’s age eligibility.
The expansion proposal aims to add dental, vision and hearing to original or traditional Medicare (not currently available unless purchased through supplemental private insurance).
The proposal to lower Medicare eligibility age would go from 65 to 60 years old. Should this push through, health insurance would at least be more affordable to 25 million new enrollees to Medicare, proponents of this measure say. It would also make good (partially) on President Joe Biden’s campaign promise to provide more Americans with health care they can afford.
Neither of these proposals to Medicare is a done deal as Republicans and Democrat Senator Joe Manchin are still not sold on the price tag. Changes to Medicare are only part of a $3.5 trillion budget proposal known as the Reconciliation bill. Democrats want to move the Reconciliation bill along together with the Infrastructure bill (that already has bipartisan support).
Either they both pass, or they both fail, this is the current position most Democrats have placed on the negotiation table. The Reconciliation bill must receive yes votes from all 50 Democrats in the Senate to pass since no Republican is on board with the bill as it stands.
Rey Gozar, Aiea, 55, says he supports both the expansion and lowering of Medicare age eligibility. As a federal employee for over 26 years, he says he plans to continue his Federal Employee Health Benefit (FEHB) plan. He believes his FEHB is excellent and will cover his health needs through retirement.
“But I also plan to enroll in Medicare when I’m of age. I can have both. The Medicare Part A, I don’t believe any retirement plan can match that. So I will enroll in Medicare primarily for that. As far as what is not covered in Medicare, my FEHB should be that added insurance to cover other medical services.
Cost and Coverage of Traditional or Original Medicare (Parts A and B)
Medicare Part A covers inpatient hospital stays at 100% (after a deductible of $1,484) for the first 60 days. Beyond 60 days, there is a copay (patient’s share) of $371 daily through the 90th day. There is no out-of-pocket cap for Part A.Medicare Part A also covers short-term stay in a skilled nursing facility and hospice, and some home health care services. Most Medicare beneficiaries do not have to pay a premium (monthly bill) for Part A if they have contributed at least 40 quarters of Medicare-covered employment.
Medicare works with FEHB to maximize coverage. But if retired federal employees decide to keep FEHB, they must continue to pay the employee portion of the premium.
“My parents have taught me to be a compassionate person. I understand many people do not have quality retirement benefits as federal workers. Some seniors are struggling to pay for their prescription drugs. If they are sick and must go to the doctors a lot, that also becomes expensive. Not everyone can afford private supplemental insurance. So this is why I support dental, eye and hearing to be a part of basic Medicare coverage. At least this will help our seniors who cannot afford these services,” said Gozar.
Medicare Part B (which all Medicare enrollees qualify for along with Part A) covers only limited outpatient prescription drugs. It also pays for doctors’ visits (outpatient) after a deductible ($203 annual). There is a standard premium for Medicare Part B ($148.50 each month, for 2021).
Medicare Part D (additional coverage, not included in traditional or basic Medicare)
To get prescription coverage, enrollees must buy Medicare Part D (average is about $44 per month in 2021).
So, the cost of Medicare Part B and D comes out to about $200 a month for only premiums.
Part D only covers 5% of brand-name drugs and 75% of generic drugs. Enrollees may still be responsible to pay for copayments and coinsurance each time they need to fill a prescription.
For seniors with chronic illness, prescription drugs alone even with Part D could run into hundreds of dollars monthly, separate from the $200 monthly premium. Without Part D, that same senior with the same illness could pay thousands monthly.
These costs for basic care covered in Parts A and B, and prescription drugs, does not include eye, dental or hearing medical services that many seniors need but go without due to cost.
According to the Kaiser Family Foundation, about half of Medicare’s 60 million beneficiaries have no dental coverage at all. More than half of Medicare beneficiaries have not seen a dentist in the last 12 months.
Lucille (last name withheld), Waipahu, 77, lives on a tight fixed income. She says her eyesight has been getting worse over the years. Her dental care has also been ignored as far as visits to the dentist. “It would be a big help to have Medicare pay for my eyeglasses and dental visits.”
As for lowering the age eligibility, she prefers it be 55 years old.
The original lowering of age eligibility floated around earlier this year was 55 years old, that were being pushed by progressive Democrats. But President Biden said he would support a lowered age of 60.“I hope Medicare lowers their age of eligibility to 55. My daughter is nearing that age soon and I hope that she will be able to receive Medicare benefits as well. It will be a big help to secure our family’s medical future,” said Lucille.
Medical Professionals Opinion on Medicare Expansion
Liz Martin, registered nurse, Ewa Beach, supports the proposed Medicare expansion. “Seniors shouldn’t have to worry about having to pay out of pocket for visual or hearing aids, which could be quite costly. Dental health should also be covered under Medicare. The lack of dental coverage through Medicare results in poorer preventative outcomes. For example, there is a strong correlation between poor dentition and heart disease. Dental coverage through Medicare may not only be preventative, but also diagnostic.”
A Mayo Clinic article addressed the connection between oral health and overall health. “Studies suggest that oral bacteria and the inflammation associated with a severe form of gum disease (periodontitis) might play a role in some diseases. And certain diseases, such as diabetes and HIV/AIDS, can lower the body’s resistance to infection, making oral health problems more severe.”
Tessie Bagtas Marcos, retired health manager, said she’s for adding dental, vision and hearing coverage to Medicare. She also supports lowering Medicare eligibility age to 60. Marcos has original Medicare A and B, but she also has secondary health insurance (TFL Tricare for Life ) from her husband who retired from the US Navy. Like Gozar’s FEHB, Marcos says her TFL coordinates benefits with Medicare on all physician visits, outpatient and inpatient services, including ancillary services.
She says she is content with her health insurance. “My husband and I pay $148.50 each month which is automatically deducted from our Social Security benefits.”Marcos hopes that Medicare will cover services outside of the US.
“My take on this is for Medicare to offer 90 days off-island medical coverage from the time an individual leaves a place of residence in the US or territories and would need medical care output or input including any diagnostic or surgical procedures. I would want Medicare to cover expenses, if not in full coverage, at least at an 80/20 cost co-sharing.
At the moment, Medicare does not cover medical costs for services outside the US.
Elvie Gabriel, retired physical therapist, Mililani, says adding dental, eye and hearing coverage is essential medical coverage and she supports the proposed expansion. She’s also in favor of lowering the eligibility age to 60.
“I wish age eligibility was 60 at the time I retired, I would have retired sooner in that case.”
Gabriel has Kaiser Senior Advantage that includes vision, dental and hearing. She says it covers almost all medical services that she needs.
“There is copayment for certain services like medicine, diagnostic procedures and imaging,” said Gabriel, who pays $114 plus $88 for Kaiser senior advantage plus. She is satisfied with her health insurance and calls her premium “just fair.”
What Gabriel would want in reform to Medicare, “I wish that there will be less paperwork that medical providers need to do to encourage more quality providers not to opt-out of treating Medicare patients.
According to the Centers for Medicare and Medicaid Services (CMS), 1.3 million health care providers take Medicare. And, less than one percent of health care providers opt out of Medicare.
What Traditional or Basic Medicare (Parts A and B) Does NOT cover
*Vision, dental or hearing coverage (that a majority of seniors need).
*If you plan to travel, as many seniors hope to do in retirement, Medicare will not cover medical costs should you get injured or sick outside the US.*Additional home health care from health aids or nursing care.
*Long term care at private nursing health facilities.
*Drug coverage is minimal.
*Most therapies like physiotherapy, occupational therapy, speech therapy, eye therapy, chiropractic services, podiatry or psychology services.
Most health experts say original or traditional Medicare without some sort of employer insurance plan is not adequate for special health needs and it is not a comprehensive insurance plan.
Medicare Advantage Plan or Part C
The alternative to original or traditional Medicare is to purchase a comprehensive health insurance plan or Medicare Advantage Plan (Part C). This is private insurance and the cost is generally higher as the enrollee adds more coverage. It’s flexible and can be catered to what the enrollee’s health needs, lifestyle, or income. If you have a chronic illness, you might want to buy more insurance for prescription drugs. If you’re generally healthy, there could be areas of coverage to reduce and save. There are many insurance providers for Part C and it’s encouraged to shop around for the best rates.
Mariasol Madla, retired, has Medicare Advantage United healthcare through her husband Roro’s insurance with Pfizer. “Right now, we are paying almost $150.00 /per person for the Medicare B that does not include what we pay to Pfizer $250.00 for premium, plus $200.00 for dental and glasses, etc. So, we pay in total for premium almost $600 for both Medicare and Pfizer.
“I am Happy with Medicare Advantage plan of United Healthcare, In and out of network plan is better than HMO. HMO is cheaper but 100% precertification is needed.”
Madla recommends getting coverage for what you need. “Everybody needs to address their medical needs. Medicare offers choices in plans. It’s your responsibility to find which one fits your needs.
“To keep Medicare costs down, preventative wellness programs should be implemented and be mandatory. This helps to catch medical conditions early before they get blown up to be more chronic health problems,” said Madla.
As for the current proposals to Medicare, she believes expanding dental, eyes and hearing coverage could make it harder for doctors by adding more paperwork. “Medicare is now adding star coverage to their plan — hearing aid, vision and dental.”
Madla says lowering eligibility to 60 or 62 is better than the current age.
Medicare Advantage could be costly and more coverage than needed. To supplement original Medicare, enrollees often purchase Medigap (Plan F) which is designed to “fill the gaps” where they are needed that Medicare Parts A and B fall short in coverage.
Other possible future changes to Medicare NOT included in the Reconciliation Bill
Belinda Aquino, Ph.D., professor emeritus at the University of Hawaii at Manoa, has Medicare A and B, plus insurance from HMSA as a retiree from the State of Hawaii.
What she would want in Medicare reform is better prescription drug coverage. “There should be more coverage for prescription drugs particularly since they seem to be increasing with every drug that is prescribed for me by my primary doctor and other doctors. They are usually increasing from 1 to 15 percent as the years go.”
Changes to Prescription Drugs and Medicare. AARP is pushing for three policy changes: Medicare price negotiations, Inflation-based rebates and Out-of-pocket cap.
*Medicare price negotiations. Allow the program to negotiate the prices of prescription drugs and allow private insurance plans to have access to those lower prices.
*Inflation-based rebates. Require drug manufacturers to pay a penalty when their prices for prescription drugs covered by Medicare parts B and D increase faster than inflation.
*Out-of-pocket cap. Creates a hard out-of-pocket spending limit for Medicare Part D prescription drug plan enrollees.
In President Joe Biden’s address to Congress in April this year, he promised to give Medicare the power to negotiate lower prices for prescription drugs. This was not included in the current Reconciliation bill, but it could be on Biden’s future agenda.
Medicare for All. It was the buzz in the 2020 election for a few progressive presidential candidates. But Medicare for All (a Single-Payer System) is still a political “Hail Mary” with no one on the receiving end to catch the ball and score a touchdown.
The concept of having everyone medically covered for free and for everyone to pay less or nothing in medical services is an idea almost universally accepted. But the process of how this would be practical and achievable leaves many cold to the idea of a single-payer system.
Madla is against a single-payer system. “[It would] drive competition away and premiums could be manipulated in a single plan. It might turn out to not be affordable. I’ve worked with an insurance company. With all of them [in the industry], when the premium is not enough to provide services, it goes up. Without competitors, it will not be affordable and people will have no choices to pick services. A single plan can do whatever they want according to profitability and affordability.”
Under a single-payer healthcare system or Medicare for All, the single part refers to the government which would be the only entity paying for coverage that everyone would receive. Government would not have the same “for-profit” goal but focus on the program’s solvency. Under such a system, the goal would be to keep medical care as affordable as possible without the pressures to constantly improve profit margins each year as private insurers have.
Medical access in a single-payer system would be comprehensive for everyone, regardless of the individual’s ability to pay. Funding for the program would largely come from taxes, mostly from billionaires and the highest income earners and corporations, proponents of Medicare for All say.
Marcos believes the cost under such a system could actually be higher than what people are paying now.
Gabriel said of Medicare for All, “I think it will solve a lot of problems with regards to being able to find good providers of care.”
Martin said, “If the government has the financial infrastructure to support a single-payer system, it could be beneficial in terms of finally making healthcare accessible for all.”
She makes the point that under our current healthcare system, “our private insurance model, there already is health insurance for everyone to be eligible for. For example, the unemployed or low income are eligible for coverage under Medicaid, retirees under Medicare, and the working, middle class through private employers.”
She adds, “it is important to point out, however, that having healthcare eligibility does not make healthcare coverage accessible.”
Medicare for All advocates say there are programs people are eligible for but cannot realistically pay for access at times. There are people who earn too much for Medicaid but cannot pay for individual private health insurance. There are seniors eligible for Medicaid, but due to special needs and poor health, often they cannot afford access to the medical care they need specifically for their situation. As for workers (even full-time workers), in many states providing health insurance to employees is optional and not extended. But because they are working, their income disqualifies them from Medicaid. And the last alternative of buying an individual health insurance plan is very costly, well over several hundreds per month.
Martin’s point between the difference of eligibility and access underscores the reality that some health policy experts make: what may look like credible options and choices in the programs currently available, do not always turn out to be practical or even possible in real-life situations.
Lucille said, “It would be great to only pay for one insurance and that being the government-funded one. However, I have a feeling that it will take a long time before the country will adopt a Medicare for All system. I don’t even think I’d still be alive when that happens. But I am hopeful that future generations will have access to this.”
The Fall Medicare Open Enrollment period to join, switch, make changes or drop a plan in the Medicare program will start October 15 and end December 7, 2021.
For new Medicare enrollees, you must sign up for the program within a 7-month period (any time three months before turning 65 and any time three months after turning 65).
Medicare specialists encourage enrollees to assess their health needs each year and make changes as needed. If you anticipate an upcoming surgery, adjustments should be made, they say. If your doctor wants to start you on a new medication or you’ve already started one earlier in the year that could impact your financial situation, adjustments to your plan should also be made.
Insurance specialists say researching plans and making adjustments could save Medicare enrollees potentially thousands in out-of-pocket costs.
by Edwin Quinabo