Same Future for Medicare, Great for Few and Worse for Most Americans

Medicare designs and dollar distributions are important to understand. Not only does Medicare design distribute dollars poorly, its design influences private insurers to do much the same. These plans act together to defeat Basic Health Access where most Americans most need care.

The problems arising from Medicare design are best seen in 2621 counties lowest in health care workforce

• because Medicare, Medicaid, and other worst public and private health insurance plans are concentrated in the populations found in these counties with 40% of the US population.
• because the designers are far away from the people and providers in these counties and fail to understand the consequences of their designs

Older, oldest, poor, disabled, and Veteran populations are all concentrated in these counties along with the populations with the lowest social determinants and worst outcomes.

The Short Era of Building Up Health Access

The 1965 to 1978 designs for Medicare and Medicaid consistently increased health care funding going to these counties. There were regular adjustments in payments to cover the increased costs of delivering health care. More could invest in health care and more could locate practices in these counties. These 2621 counties had 36% of the population at that time but still had half enough workforce and local services. The Medicare and Medicaid dollars helped them to build up. The dollars helped to recruit and retain more local workforce.

The initial designs to support elderly and poor acted to build up health care, jobs, social determinants, practices, and facilities in these counties where concentrations of poor and elderly were found.

Since the 1980s the designs based on cost cutting and micromanagement have shaped the opposite. 

Revenue increases have been minimal and have not covered the increasing costs of delivering care, not to mention the added costs from innovation, digitalization, and regulation in the last 12 years. Low payments for basic services and costly forced regulatory changes are most disabling for practices in these counties, as 90% of locally available health services are basic services.

• Generalists and general specialists and related health care delivery team members are half enough as compared to the population numbers in these counties. They essentially have always been half enough. There is no sudden crisis in shortages. This has been long term, persistent, and shaped entirely by the financial design.
• If you see someone promoting a crisis in primary care or in workforce - they are selling something that benefits themselves such as more GME billions or more training of their kind of graduates (that fail to be able to distribute because of the financial design) Myths of Physician Ages and Shortages The Dean's Lie about existing or new MD schools as a fix for primary care, The Overproduction of NP and other Workforce, Why Expanding FM Residencies will not work, Lobbying for more billions for GME and the list goes on

For Whom the Micromanagement Bell Tolls

These primary care practices in the 2621 counties had about 60,000 physicians. This 25% of the primary care workforce with only 20% of primary care spending has been tasked with serving 40% of the most complex American populations.

• They are paid 15% less as documented by Medicare’s own 2011 data.
• They are paid less by other plans
• They tend to be smaller size practices that are more disabled and financially damaged due to changes in policy designs – and the constant changes have hurt them most in the past decade.

The Toxic Impact of Micromanagement Can Be Seen in Billions Less to Invest in Primary Care Delivery

Medicare innovation and regulation focus has resulted in a decline from 38 billion in 2008 down to less than 30 billion to invest in primary care. This is the toxic impact of HITECH, ACA, MACRA, and value based changes upon practices in 2621 counties lowest in health care workforce across MD DO NP and PA. These estimates are based on only 30% penetration and do not include losses from discriminatory penalties, lower productivity, and higher turnover as shaped by Medicare design. The dollars to invest are also lower due to the usual cost of delivery increases. Revenue has not been adjusted for the higher costs and consequences of usual disruptions from losses of key personnel or changes in EHR, billing, ownership, or location that impact the small and medium size practices most.

Feeding Troughs Shape More Feeding Their Way - and Stealing Dollars Away from Most Americans

Medicare as with other plans have been exploited by those larger and more powerful, resulting in cost cutting that has not helped to save costs – and that has hurt places with the fewest dollars most vulnerable to regulation and designs by those who understand them poorly – if at all. Micromanagement for quality has also not helped to improve outcomes – especially where workforce, social support resources, and social determinants are worse.

More Americans Moving to Counties Lowest in Concentrations - Rapidly

These 2621 counties lowest in health care workforce and social support resources and outcomes are growing fastest and should reach a majority of the US population some time in the 2050s. Half of the Medicare population will be found in these counties a decade earlier because of the concentrations of elderly and disabled.

Review the following Key Facts about Medicare and my comments as to the relevance or irrelevance with regard to the care of most Americans most behind.

Key Facts about Medicare from Peter G Peterson Foundation https://www.pgpf.org/budget-basics/medicare

"The number of people enrolled in Medicare has tripled since 1970, climbing from 20 million in 1970 to 61 million in 2019, and it is projected to reach about 88 million in 30 years. A major driver of Medicare enrollment is the increase in the number of older Americans. There are currently 56 million people age 65 and older, and that number is projected to increase by more than 50 percent by 2049. In addition to that population, Medicare also covers certain younger people with disabilities or specific illnesses."

Comment: As Americans get older and sicker and health insurance does less, they will be poorer. This will force them to move to away from counties with higher concentrations of health care where housing and costs of living are increasing beyond their means. They are forced to move to counties with lower costs of housing and living – especially the 2621 counties lowest in health care workforce and social supports. They will bring with them their lowest outcomes, joining others with the same poor social determinants and outcomes.

"One of the biggest misconceptions about Medicare is that it is self-financed by current beneficiaries through premiums and by future beneficiaries through payroll taxes. In fact, payroll taxes and premiums together only cover about half of the program’s cost."

Comment: Our nation and its designers do not support the people or practices in these 2621 counties. Their value is placed lower. Their local services are basic services paid lowest, and they are paid 15% less. The policy changes, the cost cutting, and the lack of increased funding to improve basic services and access – will make the situations worse.

"Medicare is the second largest program in the federal budget. In 2019, it cost $644 billion — representing 14 percent of total federal spending.1 Medicare has a large impact on the overall healthcare market: it finances about one-fifth of all health spending and about 40 percent of all home health spending."

Comment: Medicare could be a major boost to health access, dollars, jobs, and economics to 2621 counties most behind - if Medicare paid more for basic services – but it does not. The design is specific to sending the fewest possible dollars to support health care services where most Americans have the least.

Comment: Social Security is the largest program in the federal budget and is one of few that distributes dollars through basic and disability benefits at about 42 to 44% of dollars going to these 2621 counties with 40% of the US population. But cuts in programs for the elderly, poor, Veterans, and disabled will hurt these counties worse.

"In 2019, Medicare provided benefits to 19 percent of the population.2 Medicare spending is a major driver of long-term federal spending and is projected to double from 3 percent of GDP in fiscal year 2019 to 6 percent in fiscal year 2049 due to the retirement of the baby-boom generation and the rapid growth of per capita healthcare costs."

Comment: Medicare spending increases are likely to be in any number of areas except spending in these 2621 counties that most lack health care workforce. Continued closures of practices and hospitals are specific to these counties and will also worsen dollars, cash flows, economics, jobs, social determinants, and basic health access.

How Is It Possible to Do More Where Most Americans Most Lack Care? It Is Not Possible as the Designs and Designers Are Making This Worse.

• Primary Care Spending is Flat Already
• Spending for Health Care in these Counties is Flat
• More Billions of Health Care Dollars, the Few that Go to these Counties, Are Being Diverted Away for Costly Micromanagements of Cost and Quality – Making the Situation Worse

And It Will Continue to Worsen

More Americans Are Forced to Move to These Counties As They Age and Get Poorer and as they Get Sicker and Get Poorer Because of Getting Sick

• Health services and social support resources will continue to shrink.

"To preserve Medicare and to put the nation on a sustainable fiscal path in the long term, more reforms are required and policymakers will need to address the program’s growing costs — one of the primary drivers of our rising federal debt. Balancing cost concerns with considerations about the health and welfare of our nation’s older citizens will be important for successful long-term solutions."

Comment: More cost cutting focus will clearly play out poorly for most Americans already most behind. Their access barriers and underutilization are not even recognized. Their basic needs have not been met. The cost cutting has not spared them. The micromanagement focus has made this worse. Their outcomes are lower - because of the populations that they serve. And these populations will continue to have lesser outcomes - and the outcomes will be made worse as the designs of health care and economics make them worse via maldistributions of dollars.

Comment: It is quite clear after four decades of policy design changes that the focus on cost cutting and micromanagement – has worsened the health and health care situations for the 130 million in 2621 counties lowest in health care workforce.

• Expansions of Medicaid, high deductible, and worst private plans expand plans that pay less than the cost of delivery, and pay less where shortages exist, and require more costly and burdensome changes. When these tens of millions pay for private insurance – only ten cents on the dollar returns to their county’s local health care providers.
• As long as the designers fail to understand dollar distributions and diversions and discriminations by design – the health care problems and poor outcomes of most Americans most behind will continue.