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You Want Me to be Blind and Toothless?

Issue 265

Expanding Medicare coverage to hearing, vision and dental would alleviate the suffering of millions including this writer.

Steven Wishnia Jul 31

Senator Bernie Sanders has introduced legislation to have Medicare cover dental, vision, and hearing care, along with other additions such as lowering the age of eligibility from 65 to 60. They would be included in a budget reconciliation bill to preclude a filibuster by Senate Republicans, which would be painfully inevitable if it were a standalone measure.

The legislation is “still a work in progress,” cautions Physicians for a National Health Program President Dr. Susan Rogers. But for me, it can’t come a moment too soon. What are three body parts and functions that almost universally deteriorate in older people? Their eyesight, their teeth, and their hearing. What kind of perversity would withhold care for that?

It’s personal. Medicare does not cover the dental work I need after decades of wear and tear on my adult teeth. That has run well into four figures over the last six months, a serious sum on a freelance writer’s income. I’ve been wearing glasses since I was seven years old but haven’t been to an eye doctor in almost three years. The last time I went, they tried to charge me almost $700 for a checkup and refused to negotiate. (My hearing is not too bad, especially considering that I’ve been playing amplified music for 50 years.)

What shocked me most when I turned 65 was how much Medicare cost. Basic coverage for doctors and a minimal private prescription-drug policy comes to about $170 a month. Medicare also covers only 80% of doctor and hospital expenses, and private insurance that would cover most — but not all — of the other 20% would bring the bill up to around $500.

The reason Medicare does not cover vision, dental or health is primarily because it was modeled on benefits provided by private insurance when it was enacted in 1965, says Dr. David Himmelstein, a professor of public health at Hunter College and longtime advocate of single-payer health care. Those benefits, largely provided by employers, were aimed at working-age people, he adds. Vision, dental and hearing care were omitted even though the elderly are more likely to need it, notes Rogers.

The 80/20 split was partially a compromise to defuse opposition from insurance companies, says Rogers, and partially, says Himmelstein, because there was a consensus in the health-policy community that “you needed to have some kind of barrier to keep people from seeking care they didn’t need.” But that 20% copayment, they say, was minimal in the 1960s. Since then, health care costs have inflated so much that it’s unaffordable.

Coverage for prescription drugs, also a relatively small expense in 1965, was not added until 2003.

Private Medicare Advantage plans, which began in 1997, often cover vision, dental, and hearing — but the catch is that they also often have a limited network of providers who accept them and people going outside that network will get billed for the full list price.

The fundamental choice the market demands is either you pay up or you go without important or essential care. 

The free market simply doesn’t work for health care. The opportunity-cost principle that holds down the price of luxuries and limits most people’s overindulgence in them just doesn’t exist. For example, if I wanted to buy a Fender electric guitar, I’d have choices all along the range from a $220 Indonesian-made budget model to a $3,900 custom-made instrument, and I could save up for it or find a deal on a used one.

But if I break my leg, I can’t wait until Bellevue has a sale on orthopedics. If I get an infection, I’d be unlikely to find legitimate antibiotics on Craigslist.

The current U.S. system has two perverse pricing practices. It forces people to pay the most when they are least able to work to recoup those costs. And list prices are insanely inflated; Medicare and insurance companies negotiate them down dramatically but the person who’s uninsured or under-insured gets stuck owing the full rate.

The market also doesn’t work for selecting health insurance policies. “There’s no transparency in cost because the costs vary so much and you don’t know what you’ll need,” says Rogers. It is far too common that someone schedules a surgery with a hospital and a surgeon that accept their insurance, only to get whacked with a $7,000 bill because the anesthesiologist was out of network.

Insurance companies often argue that high copayments and “narrow networks” are necessary to save costs and discourage unnecessary use. The implication is that people must have “skin in the game” or else they would go to

a podiatrist to get their toenails clipped. That hasn’t happened in any country with universal health care, says Rogers, and elderly Americans didn’t “flock to the doctor and overwhelm the system” when Medicare went into effect.

The fundamental choice the market demands is either you pay up or you go without important or essential care. This is both bad for public health and more costly in the long run, because people who go without such care will eventually need it for much more advanced ailments.

The proper metaphor isn’t “skin in the game,” but from The Merchant of Venice: “a pound of flesh.”

“The whole idea that the market can control costs is really erroneous. It hasn’t worked,” says Rogers. Instead, the money is “going to a system that offers profits for not providing health care.”

Medicare for All, in contrast, would have no premiums, no deductibles, and no copayments, says Nancy J. Altman, president of Social Security Works.

Having the Medicare program cover people 65 and older, she explains, was President Lyndon Johnson’s “fallback” to provide health care for the elderly after the national universal health care plan envisioned as the next step after Social Security proved politically impossible. President Harry Truman’s plan was blocked in the late 1940s, when the medical industry denounced it as “socialized medicine” and powerful Southern members of Congress feared it would force the desegregation of hospitals.

Adding vision, dental and hearing coverage, Altman says, “would be an excellent next step toward ensuring that health care is a right and not a privilege.”

It would also be an excellent political move, says Himmelstein: Obviously, the concept of expanding Medicare benefits for people who already have them “has a huge constituency” behind it.

Rogers, however, worries that coverage could be sanded down to inadequacy, such as paying only for routine dental care like cleaning, and not the more complex care older people need, such as partial bridges and crowns.

Medicare, “even though it was a legislative act, it required social movements to make it work. I think we have to remember that,” she says. If Medicare is expanded or Medicare for All enacted, she adds, “we’ll still need to continue social activism to make sure it works.”

And the alternative — as I’d ask anyone opposing adding vision and dental coverage: “You want me to be blind and toothless?”

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