CHICAGO (Reuters) – The COVID-19 pandemic has put a bright spotlight on weaknesses in many of the systems designed to protect Americans from risks. But with older people more susceptible to serious illness and death from the virus, the problems in our Medicare system that were evident pre-pandemic have come into especially sharp relief.
Medicare reform will be on the agenda in Washington after the pandemic recedes – if nothing else, the looming exhaustion of the Hospital Insurance trust fund in 2026 must be addressed (https://reut.rs/2X3JRyf). But there also is growing support for a post-pandemic drive for Medicare for All, or at least to expand Medicare by reducing the current eligibility age of 65 (https://reut.rs/3gzmcxA).
With that in mind, this is a good time to consider how Medicare could be improved.
Medicare plays a critical role regulating and funding nursing homes, paying for care in skilled nursing facilities for up to 100 days during each spell of illness. During the COVID-19 crisis, the rules for covering care have been relaxed, but the big headlines have focused on the sky-high infection and death rates in nursing homes.
This is not a new problem. The U.S. Government Accountability Office (GAO) reported recently (https://bit.ly/2yD2i3y) that 82% of nursing facilities nationwide were cited with infection control deficiencies in one or more years between 2013 and 2017, with 48% cited in multiple years.
The Centers for Medicare & Medicaid Services (CMS), which runs Medicare, reoriented its inspection practices around infection control in March, but state surveys still are finding compliance problems with hand hygiene, proper use of personal protective equipment and isolating infected patients (https://bit.ly/3gD0Org).
“This crisis has underscored the incredible need for quality healthcare and good coverage for all citizens, but particularly for people who are older, have disabilities and need longer-term or chronic care,” said Judith Stein, founder and executive director of the Center for Medicare Advocacy (CMA).
Medicare is quietly being privatized. Medicare Advantage – the privately offered alternative to traditional Medicare – is on track to cover 47% of all enrollees in 2029, up from 34% this year, according to a Kaiser Family Foundation (KFF) analysis of Congressional Budget Office projections (https://bit.ly/2TGaXcW). And all prescription drug coverage is offered by private insurers through Medicare-sponsored marketplaces.
Critics question the effectiveness of outsourcing so much of Medicare coverage to commercial insurers (https://nyti.ms/2zxoU5W). Enrollees must navigate hundreds of plan choices that need to be re-evaluated regularly, yet many have significant, complex healthcare needs, and some have cognitive impairments that make shopping difficult.
In some cases, the playing field for private plans and original Medicare is uneven. For example, Advantage plans must cap an enrollee’s annual out-of-pocket expenses at $6,700, and most have lower caps, averaging $5,059 last year for in-network services, according to KFF. But in original Medicare, you can get out-of-pocket protections only by adding supplemental coverage, often a commercial Medigap plan. And here, there is a major catch. The best time to buy a Medigap plan – and often the only time – is when you first sign up for Medicare.
Medigap plans cannot reject you, or charge a higher premium, because of pre-existing conditions during the six months after you first sign up for Part B (outpatient services). In most states, you can be rejected or charged more after that time.
This limited “guaranteed issue” protection effectively makes an initial decision to pick a Medicare Advantage plan a permanent selection for many enrollees.
Medicare Advantage is a managed care offering, which means your in-network healthcare provider choices are limited – and that can be a problem when serious healthcare issues arise. Medicare tacitly acknowledged that problem recently when it relaxed network rules for COVID-19 care.
Meanwhile, 6 million original Medicare enrollees have no supplemental insurance, according to KFF. During the COVID-19 crisis, that means a hospitalization would leave them vulnerable to the standard Part A deductible of $1,408 for each stay, and daily co-payments for stays exceeding 60 days.
EYES, EARS AND MOUTH
Many seniors are surprised to learn that Medicare does not cover routine dental, vision or hearing care – a gap that dates to the initial definition of healthcare coverage that did not include these services. “Since then, we’ve learned otherwise,” said Stein. “Certainly oral health is extremely important systemically, and we’re even learning that untreated hearing loss can increase things like falls and dementia.”
Many Advantage plans offer some level of dental, vision and hearing coverage – although it is important to look carefully at the details of what is included (https://reut.rs/2XClarF). But leaving “eyes, ears and mouth” uncovered in original Medicare – which still accounts for two-thirds of enrollment – makes no sense.
PRESCRIPTION DRUG CAP
When Medicare prescription drug insurance was created in 2003, the idea that beneficiaries with very high drug costs should pick up 5% of the tab seemed reasonable – but that was well before specialty drugs were invented that carry price tags in the tens of thousands of dollars. And some specialty-tier drugs are not covered by Part D plans.
It is well past time for an out-of-pocket cap on prescription drug costs.
Before the COVID-19 emergency, Medicare coverage of telehealth services – where providers provide care via a video or phone link-up – was very limited. Coverage has been expanded during the crisis, and the use of telehealth services can play a useful role in Medicare going forward. But we will need to spell out thoughtful policies that ensure equitable use of telehealth. “I’m concerned that the telehealth reforms could be good but a slippery slope if it leads to less care being available for some, and in-person care being available for others,” said Stein.
For more on Medicare reform, check out my podcast interview this week with Judith Stein of the Center for Medicare Advocacy (https://bit.ly/2X94kla).
(The opinions expressed here are those of the author, a columnist for Reuters.)
(Reporting by Mark Miller in Chicago; Editing by Matthew Lewis)