Fix what we’ve got and make Medicare right this year

Fix what we’ve got and make Medicare right this year
© Greg Nash

Every January, Medicare providers — including hospitals, physicians in private practice and community health centers — brace themselves for the problems that result from changes in how they will be reimbursed by the federal government.

Most often this means medications they have been prescribing with coverage may be dropped with new ones added. It can mean procedures that have been covered no longer are covered. Patients may have to switch specialists or have treatment pre-approved by insurance.

But providers learn to anticipate and work around these changes. As complicated as these annual changes to Medicare seem, simple fixes to how Medicare is managed can create savings without having to eliminate insurance coverage.  


This is critical as the largest source of health care coverage in the U.S. comes from government-funded programs. More than 74 million receive Medicaid, 55 million have Medicare and 9.4 million veterans are covered through the VA’s Tricare program. Another 14 million receive assistance in obtaining coverage either through cost-sharing or tax credits provided by the federal government.

Yet, this year much larger questions beyond convenience and efficacy arise as to how new legislation impacts patient’s coverage and the bottom line for providers.

As a nurse practitioner caring for low-income individuals and families, I am aware of what treatments cost. The last year has brought a heightened sense of anxiety with patients rightfully concerned that cuts to Medicare or Medicaid may impact their coverage. Imagine making decisions on how to treat your cancer through a series of guesses regarding how legislators may or may not change your coverage in the future.

Even after multiple unsuccessful attempts at Affordable Care Act repeal, legislators continue with the Tax Cuts and Jobs Act that threatens $400 billion in cuts to Medicare funding. This could include a $25 million cut in 2018.

Though cuts have been temporarily stalled by an exception included in the Jan. 19 extension of government funding, this does not guarantee an enduring source of funding for Medicare, which to date serves millions of Americans.

House leader Paul RyanPaul Davis RyanPaul Ryan researched narcissistic personality disorder after Trump win: book Paul Ryan says it's 'really clear' Biden won election: 'It was not rigged. It was not stolen' Democrats fret over Trump-district retirements ahead of midterms MORE (R-Wisc.) celebrated the law’s repeal of the individual mandate but touted this as the pathway to cuts in Medicare, Medicaid, and social security in 2018. These cuts would ultimately be devastating to the public who rely on these services. Still policymakers are justified in calling for reform efforts. 

What eager legislators, such as Rand PaulRandal (Rand) Howard PaulWhite House debates vaccines for air travel Senate lawmakers let frustration show with Blinken Rand Paul: 'Hatred for Trump' blocking research into ivermectin as COVID-19 treatment MORE (R-Ky.) and Lindsey GrahamLindsey Olin GrahamRep. Tim Ryan becomes latest COVID-19 breakthrough case in Congress Graham found Trump election fraud arguments suitable for 'third grade': Woodward book Senate parliamentarian nixes Democrats' immigration plan MORE (R-S.C.), perhaps don’t appreciate is that large funding cuts and block grants have no hope in creating a sustainable form of long-term funding that provides stable insurance coverage.

Policymakers have an obligation to the public to fix what we already have before moving forward or making further cuts. 

With approximately 47 percent of all Americans depending on the government in some way to maintain or gain coverage, creating a national system where users have dependable insurance coverage requires a stable source of funding.

Patients will benefit from using this funding to focus on primary care, have the ability to seek care that is not dependent on location and also allows access to affordable medications when necessary.

Likewise, health care providers need assurance they will be compensated for providing these services and that patients can afford to access recommended treatment. 

The Centers for Medicare and Medicaid Services provide a template in terms of how health care dollars are spent. Improvements made here will eventually impact everyone nationwide regardless of their insurance coverage. A sense of stability will help to build relationships between health care providers and the community they serve and is likely to reach the ultimate goal of most legislators in generating cost savings. 

Unlike many with private insurance, traditional Medicare does not restrict use of health care providers; the average patient will see multiple primary care providers annually. Such a system means billing the government for redundant care. It also creates an exponentially high potential for doubling up on office visits, laboratory tests and prescription drugs. This can translate into major medical complications due to confusion or conflicting information.

It is routine for providers in my internal medicine practice to discover patients taking prescriptions from five or more physicians. With duplications in insulin and blood pressure pills, severe side effects are common. This is consistent with studies finding up to 62 percent of the elderly experience interactions between medications, putting them at increased risk for hospitalization and death.

Choosing a single provider for primary care allows this provider to know a patient well and coordinate care with other providers, streamlining care in terms of cost and quality. With traditional Medicare not requiring a referral to see a specialist, patients often “self-refer” for common conditions that can be addressed in primary care, generating further costs.  

These loopholes need to be closed.     

As a financial investment by the federal government, Medicare and Medicaid coverage needs to be universally accepted. Without this, the patchwork of acceptance for available insurance programs reduces access to care. Yet, only 72 percent of primary care practices are accepting new Medicare patients. This compares to 80 percent of primary care practices accepting private insurance; that number drops to only 45 percent with Medicaid coverage.

Access to care by geography is also an issue. Consider that more than 80 percent of rural counties lack a single psychiatrist. In those counties fortunate enough to have access, only 43 percent accept Medicaid.

Even in large urban areas, such as Chicago and its suburbs, low-income individuals frequently lack transportation and also have a limited network of doctors or hospitals close to home. Due to limited provider networks, I have seen patients with terminal cancer forced to travel 120 miles round trip to see a licensed pain specialist.

States participating in Medicaid expansion have already demonstrated significant reductions mortality, despite a persistently lower acceptance rate than private insurance. With 20 percent of the U.S. covered by Medicaid, including nearly one in four of the 52 million Americans living in rural areas, insuring a 100 percent acceptance rate for Medicaid, as well as Medicare would inevitably increase access and improve health. 

Additionally, drug pricing must be negotiated. When President George W. Bush signed Medicare drug coverage into law in 2003, legislators instituted a non-interference clause, eliminating the ability of Medicare to negotiate drug prices with pharmaceutical companies or develop a government formulary of covered medications.

Prescription drug spending is expected to reach $92 billion in 2018. This accounts for 15 percent of Medicare’s net expenditures and makes negotiating prices an essential step in checking uncontrolled costs.

Congressional Budget Office pilot program estimates that allowing a system of negotiating drug prices based on the quality of outcomes they produce, even on a limited amount of these drugs has a potential cost savings of $395 million in the next decade.

Reduction of spending on drug costs through price negotiation, will impact the public by reducing out of pocket costs that prevent patients from taking medication regularly. It also can prevent complications that require more costly treatment such as hospitalization. 

This month and this year, the impending cuts to Medicare may not be immediately apparent to the consumer. But ultimately decreasing payments to physicians and hospitals will make it more difficult for these sites to continue providing care and increase the cost passed on to millions of American taxpayers.

The key to stabilizing cost and sustaining healthcare coverage for the most Americans is not in creating something new, but in making already established public programs work. 

Melissa D. Kalensky is a family nurse practitioner caring for older adults in an internal medicine clinic in Chicago. She is an assistant professor in the College of Nursing at Rush University and a Public Voices Fellow of The OpEd Project.