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Happy Birthday, Medicare! Teh Dartmouth Atlas, some peeps shredz it 4 U!

On July 30, 2013, Medicare will turn 48 years old. To celebrate, I'm outsourcing this post.

From an op-ed in last year's Houston Chronicle, written by a Texas physician, because never forget that Medicare was brought to you by a president from Texas:

It's a birthday that deserves to be celebrated, including here in the Lone Star State. Medicare provides 48 million Americans -- about 3 million of them in Texas -- with reasonably good access to health care, thereby easing their suffering, prolonging their lives, and reducing financial pressures on them and their families. Before Medicare was enacted in 1965, most retired older people were at risk of financial ruin when they got sick. Medicare changed that picture, and our state and nation are much better for it.

But LBJ didn't just recite a spell and wave a magic wand and conjure up Medicare out of mice and pumpkins, he had help. Robert Ball, one of the architects of both Social Security and Medicare, wrote an article giving us a behind-the-scenes look at how Medicare came to be:

How It All Began

What were we hoping to accomplish when we proposed a national hospital insurance plan for the elderly? No other country, as far as I know, had ever considered such an approach. Certainly the elderly were the most expensive and difficult group to cover, and, for the money spent, they clearly would yield the least return of any age group. Why not cover children and pregnant women, as has been discussed from time to time since? That would seem to have made more sense.

A first step toward universal coverage. For persons who are trying to understand what we were up to, the first broad point to keep in mind is that all of us who developed Medicare and fought for it-including Nelson Cruikshank and Lisbeth Schorr of the AFL-CIO and Wilbur Cohen, Alvin
David, Bill’ Fullerton, Art Hess, Ida Merriam, Irv Wolkstein, myself, and others at the Social Security Administration-had been advocates of universal national health insurance.1 We all saw insurance for the elderly as a fallback position, which we advocated solely because it seemed to have the best chance politically. Although the public record contains some explicit denials, we expected Medicare to be a first step toward universal national health insurance, perhaps with “Kiddicare” as another step.

What's all this got to do with the Dartmouth Atlas? you ask. Not much, except that just in time for Medicare's birthday, the Institute of Medicine released their report
Variation in Health Care Spending: Target Decision Making, Not Geography in which they kinda sorta begin to distance themselves a little bit from the Dartmouth Atlas "research." Because I am a fair and balanced person and an ethical blogger (ha!) I present you with two reviewers' opinions of the report.

Austin Frakt has been a long-time fan of the Dartmouth Atlas researchers and their work, so much so that his first post on the IOM report starts off with a disclaimer that he hasn't yet read it, followed by excerpts from the Dartmouth researchers' rebuttal of the report. You can read what he has to say so far here and here.

Buz Cooper, not-fan of the Dartmouth Atlas, was too polite to title his review "It's the Poverty, Stupid!" so here's a link to IOM says “Target Decision Making.” No. Target Poverty:

So what the report really found, but did not say, was that poverty and its associated poor health status is the major cause of geographic variation in health care and its effect is far greater than apparent from studies of HRRs which, because of aggregation, obfuscate its true magnitude.

If, like me, you like to geek out over some geodata analysis, Cooper provides a link to his (open access!) article Poverty, Wealth, and Health Care Utilization: A Geographic Assessment. Even if you have no intention whatsoever of reading the article, click through just to support the fact that it's open access; your tax dollars paid for that article after all.

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a little night musing's picture
Submitted by a little night ... on

from Healthcare-NOW!:

Healthcare-NOW! is pleased to join with Progressive Democrats of America to support a nationwide call-in day today to increase awareness and co-sponsors in Congress for HR 676--the Expanded and Improved Medicare for All Act.

Call the U.S. Capitol Switchboard toll-free at (866) 220-0044, ask for your representative's office, and then ask them to sign as a co-sponsor of HR 676. Don't know your Rep? Put your ZIP in here.

Or you can quickly email them here.

The current cosponsors (42) are listed here.

Once you call and email, please ask your friends and contacts to do so as well.

HR 676 would create a publicly financed, privately delivered healthcare system that uses the already existing Medicare program by expanding and improving it to all U.S. residents, and all residents living in U.S. territories.

Healthcare-NOW! is committed to building the movement for national, single-payer healthcare and we sincerely hope that you will call and email your Representative to ask them to become a cosponsor of the bill.

Ben, Zoriada, and Jeff
Healthcare-NOW! National Staff

a little night musing's picture
Submitted by a little night ... on

I'm having a difference of opinion with my computer today or I'd being making a repost as usual of this, but instead I'll just link:

LBJ's Ruby Slippers

Three years ago I wrote in this post, and it's still true:

As we prepare to fight those who want to "reform" entitlement programs like Social Security and Medicare, we can be inspired by LBJ's statement: "We do know that it affects the economy. . . . it helps us in that respect. But that's not the basis to go to the Hill, or the justification. We've just got to say that by God you can't treat grandma this way. She's entitled to it and we promised it to her."

The promise is to every generation, that this society will protect you whenever you need it, that we all help one another.

Submitted by hipparchia on

I'm having a difference of opinion with my computer today

mine is being obstreperous too. thanks for the reminder - i love by God you can't treat grandma this way and i've used it to good effect before.

Bryan's picture
Submitted by Bryan on

They ran over it with a Lawnboy with new blades and a mulching kit, and then they composted it. That was a serious academic body slam.

We knew that the Dartmouth Atlas didn't correspond to reality, but couldn't be sure why. Well, that report shows why, and makes sense when you look at the areas where the costs are the highest.. Poor people can't afford to get care when it would be cheaper, they have to wait until they have no choice.

Submitted by hipparchia on

there's a lolcat for everything

Poor people can't afford to get care when it would be cheaper, they have to wait until they have no choice.

and they can't afford healthy food, and they live in the lead-painted houses in the polluted neighborhoods, and they have the crappy stress-filled jobs, and... not to mention that getting sick in this country can sure become a one-way ticket to the poorhouse too.

Submitted by lambert on

... by geography (county and region, at least) I imagine we'll see armies of consultants over the next decade or so descending on counties with higher rates, since they make "bad decisions," with lots of (not shown to work empirically) "wellness" palliatives for the patients who demand too much care, with plenty of paperwork for doctors who give it.

Submitted by hipparchia on


and since insurance companies actually get higher profits with more spending (they get to rake off 15-20% of the premiums), the fact that "wellness" programs don't reduce costs is a bonus!

a little night musing's picture
Submitted by a little night ... on

I've recently been undergoing physical therapy for a disabling condition that prevented me from being able to walk some of the time*. The insurance company cut off payments before I regained full range of motion and strength, leaving me with the possibility that my condition would continue to worsen, leading eventually to permanent disability or joint replacement.

So I was discussing this with my economist friend yesterday, and asked why the insurance company would not want me 100% so that they would not have to pay for more expensive things later on. She pointed out that by the time those particular chickens come home to roost, I will (probably? hopefully?) be Medicare's problem, so they have no incentive to care.

All the more reason not to have this mad ongepotchket system.

* (Leading also to the scary possibility of not being able to work any more, losing my employer-provided insurance (even such as it is), ... )

Submitted by hipparchia on

yikes! i'll be keeping my fingers crossed for you....

She pointed out that by the time those particular chickens come home to roost, I will (probably? hopefully?) be Medicare's problem, so they have no incentive to care.

yep! and if by some chance you don't make it to medicare age, they're hoping you'll lose your job, spend all your money, and then qualify for Medicaid.

... this mad ongepotchket system.

i'm going to have to find a way to use this in a post title. also, I had to look it up first. my liberal, multicultural, uu-leaning parents sent us kids off to jewish summer camp, where I learned much Zionism and almost no Yiddish. for some time there when people asked me what I wanted to be when I grew up, my answer was "a sabra!" yeah I know... also too, we hung out with arabs and Buddhists and when I discovered arabian horses, my answer to that question quickly morphed into "a Bedouin!" :)

Rainbow Girl's picture
Submitted by Rainbow Girl on

"By the time those particular chickens come home to roost, I will (probably? hopefully?) be Medicare's problem ..."

And in this country it is legal. Because in this country insurance companies, which profit from denying care, are a government-created cartel that controls the money flows of our "health care" system. Denying, stalling, delaying, engaging in bureaucratic confusionary tactics (again, resulting in delay) are the main currency of an insurance company's "healthy balance sheet" and "share price."

See similar time arbitrage frame in comments reported here at CW by the likes of Young Ezra, et al., regarding how the "kinks in ObamaCare will eventually be ironed out in a few years" and why don't the "whining" customers just shut up and grow up.

As if we're talking about something as un-momentous as the availability of blue toothbrushes to replace red ones.