Prefer the Original (by Richard Quinn )

 

MEDICARE GETS A LOT of criticism these days. Some view it as socialized medicine. Others fret over the hospital trust fund, which covers Medicare Part A and is expected to run out of money by 2036.

Meanwhile, some policymakers want to cut back on traditional Medicare and promote privatization through Medicare Advantage plans, otherwise known as Part C. That reflects the philosophy that health care costs, access and quality will be improved if we obtain health care as we do other goods, by shopping for the best deal and choosing from among many competitors.

I vehemently disagree. Health care isn’t like obtaining and paying for other goods and services. The current system is working well.

Connie and I have been enrolled in Medicare since January 2010. Over the past 14 years, we’ve been admitted to both public and private hospitals, gone to labs and imaging centers, and seen both primary care physicians and specialists.

I’ve had one surgery since 2010, while Connie has received several types of surgery, both on an inpatient and outpatient basis. One procedure required her to continue treatments in Massachusetts while we were on vacation. She received highly specialized treatment for an eye injury when we self-referred to Wills Eye Hospital in Philadelphia. Over the past 14 years and through various treatments:

• We’ve never been confronted with a non-participating provider who wouldn’t accept the Medicare fee allowed.
• We’ve never been prevented from obtaining the care we chose or needed.
• We’ve never been required to obtain preapproval for care.
• We’ve had Medicare limit treatment only once, and that was a chiropractor.
• Our out-of-pocket costs have been limited to our annual Part B deductible because we have Medigap Plan G.

From this patient’s point of view, Medicare works very well. It’s not socialized medicine or government-run health care. Instead, it’s government-run, taxpayer-funded insurance.

This is not to say there are no problems. It’s a bureaucracy, after all, and its ability to control costs is limited. But it works for more than 60 million Americans like Connie and me.

No doubt many players in the health care system and some individual providers would not share my positive sentiments, especially regarding Medicare’s fees, rules, regulations and requirements. Yet similar issues are true of private insurance as well.

Medicare isn’t cheap, especially if you’re subject to the premium surcharges known as IRMAA, or income-related monthly adjustment amount, that apply to higher-income people. And, as noted earlier, I must buy a Medigap policy to supplement our Medicare coverage.

For many, the cost of health care coverage after age 65 will likely be higher than it was with their pre-retirement employer-funded coverage. Some try to save money with Medicare Advantage, or Part C. More than 50% of Medicare-eligible beneficiaries enroll in Part C. The attraction is lower out-of-pocket costs and added benefits. Maybe.

The question that often isn’t asked is, how can a Part C plan charge a modest or no premium, add extra benefits and still make money? It can’t—not without some significant differences from original Medicare. Part C plans employ various forms of managed care. Here are three examples:

Limited network. Unlike traditional Medicare, which allows you to visit any doctor or hospital accepting Medicare, Medicare Advantage plans often restrict your network to contracted providers. This might limit your choice of doctors and specialists.

Prior authorization. Certain Medicare Advantage plans require prior authorization before specific treatments or procedures are covered. This can lead to delays in care.

Less flexibility. Switching doctors or plans mid-year can be more cumbersome with Medicare Advantage compared to original Medicare.

While Medicare Advantage is popular and growing, behind the scenes there are issues. The Department of Justice and the Office of the Inspector General have been looking into Medicare Advantage plans, including concerns that some plans use prior authorization requirements to limit care and deny claims.

If you don’t mind playing by all the rules, a Medicare Advantage plan can be a good deal. Yet, having managed various forms of health plan during my career, including health maintenance organizations, I’m sticking with original Medicare. If you decide differently, take a close look at your choices before you enroll.