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Commentary: You're Old, You're Sick, Get Over It
Marilyn M. Singleton, MD, JD


Senior citizens, don't be fooled. The federal government asserts that Medicare sets a high bar for medical care and we are lucky to have it. Not so. It does, however, claim a virtual monopoly on health insurance coverage for all eligible persons.

All citizens who receive Social Security or Railroad Retirement Board benefits automatically receive a Medicare Part A card in the mail around their 65th birthday. Part A covers hospital, hospice, and limited skilled nursing services. This entitlement has very long strings attached. If retirees disenroll from Medicare Part A they lose future Social Security benefits and must return all past benefits. Even working seniors enrolled in Medicare or collecting Social Security cannot participate in Health Savings Accounts (HSA)/high deductible health plans.

Most new Medicare eligibles also automatically receive a Part B card (coverage for physician services and outpatient injectables, particularly cancer medications). Part B is voluntary and recipients are advised they can send the card back if they want to opt out. Medicare warns that a late enrollment penalty awaits the tardy: the monthly premium for Part B may go up 10% for each full 12-month period that they could have had Part B, but didn't sign up for it—in perpetuity.

Bullying aside, it sounds pretty good. But Medicare, whose expenditures are 15 per cent of the federal budget, faces financial challenges, mainly due to our aging population. When Medicare started life expectancy was 70 years. Now it is 78.8 years. In 2012, per person personal health-related spending for the 65 and older population was more than 5 times higher than spending per child and 3 times the spending per working-age person. The Medicare Board of Trustees 2015 report estimates that under current law the Medicare trust fund will become insolvent in 2030.

Enter the Medicare hospice benefit in 1982. Policymakers believed this program would lower costs by reducing "aggressive" end-of-life treatments. With hospice care, Medicare pays a daily rate for services to persons with life expectancies of 6 months or less who choose to forgo life-saving or potentially curative treatment for the presumed terminal illness and related conditions.

But Medicare hospice expenditures are rising. Realistically, it isn't easy to predict who will live and who will die and when. Not only has the number of Medicare hospice patients with not immediately terminal conditions such as heart failure and dementia dramatically increased, 19 percent of such patients receive services for much longer than 6 months.

The renewed focus on Medicare cost containment has produced various suggestions, including vouchers, tax credits, extending income-based premiums, increasing the eligibility age, and allowing contributions to HSAs in retirement.

Expanding HSAs presents the best opportunity to regain real choice and control over our medical care consistent with one's personal values.

Instead, a culture of hastening death has gradually evolved, disguised as "death with dignity." First, California, Colorado, Oregon, Washington, Montana, and Vermont have legal physician-assisted suicide, with 20 other states considering legalization. Second, when older folks fall ill, despite the uncertainty of medical prognosis, some families feel they are not merely offered hospice as a choice but are steered toward it. Third, disturbing news articles report hospice treatment plans for those who aren't dying fast enough: "pain management" in terminal doses.

Finally, money talks. In the hospice program, if the patient goes to the hospital and the hospice "provider" (not one's own physician) did not make the arrangements, the patient might be responsible for the entire cost of the hospital care. Additionally, the Affordable Care Act created a Patient-Centered Outcomes Research Institute. The Institute investigates the effectiveness of various medical interventions, but is prohibited from treating "the life of an elderly, disabled, or terminally ill individual as of lower value than extending the life of an individual who is younger, nondisabled, or not terminally ill." However, the data may be used to determine coverage and payment rates. The patient can choose a federally determined "low-value" service, but the cost would be prohibitive. And the low physician payment rates will ensure that physicians' practices will not be actively seeking such patients. It is an empty choice.

One day in the hospital costs Medicare about $708. One day in hospice costs $183. One hundred twenty morphine tablets cost $20.88 retail. Health Savings Account money in the bank creates real options. But if you leave the choice up to the government, with a roll of the dice you could figuratively be in Jail rather than passing GO and getting another turn at life, just like in the game of Monopoly.

Dr. Singleton is a board-certified anesthesiologist and Association of American Physicians and Surgeons (AAPS) Board member. She graduated from Stanford and earned her MD at UCSF Medical School. Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard's Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law. She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers

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