Tuesday, April 26, 2011


Congressman Ryan, I Don’t Want To Be A Lab Rat

Apr. 22 2011 - 3:38 pm

Posted by Mark Sunshine

An open and a sent letter to Rep. Paul Ryan (R-Wisc.)

Congressman Paul Ryan
1233 Longworth HOB
Washington, D.C. 20515

Dear Congressman Ryan,

Please explain your Medicare plan to me and my wife. We are in our early fifties and are concerned about how your changes to Medicare will affect us. We know that Washington can seem disconnected from the real world but, for people of our age, your plan to do away with Medicare is very real.

Getting rid of Medicare feels like a free markets experiment to us and neither of us wants to be a “lab rat” for a social and economic experiment gone awry. Lab rats are usually expendable and we don’t want to be part of a discarded generation.

By way of background, both of us believe in free markets, personal responsibility and individual choice. We agree that the nation’s future demands fiscal responsibility. We are educated (we have graduate degrees), are employed, are savers and have put aside money for retirement.

We were surprised by the fast track House acceptance of your plan to eliminate Medicare benefits and change Medicaid. Because of the lack of meaningful debate or hearings we don’t know anything about the details of your plan and want to understand how it will change our lives.

Please do not take offense by any of the questions. They are intended to be non-partisan but these are questions that need to be addressed. We believe that elder care benefits will determine when we die and whether or not we end with dignity. We just want to know what the future holds under your voucher program.

As we understand your plan, when we reach our golden years, we, like every other senior in our age group, will be given a voucher to purchase private health insurance. We will need to personally chose which health care plan to purchase from what is hoped to be an array of choices. To the extent that insurance or non-covered health care costs exceed the amount of our voucher, we will pay the extra amount out of our savings.

Since we will be elderly, after we get sick we won’t have a “second chance” to go back to work, earn new money or financially recover. If our savings run out before we die that’s it — there won’t be any more money coming our way — so we think that it’s really important for your plan to get it right, and the first time. There won’t be any second chances for us.

Since you are known as a “serious and responsible” thinker, before proposing the dismantling of Medicare as we have known it, we assume you figured out what will replace it and verified that the private insurance market can fairly and adequately service the needs of seniors. We just want to know what you were thinking before introducing legislation on the floor of the House that was passed in a matter of hours from introduction.

We assume that you looked at the current Medicare Advantage program as a starting point for your plan. Medicare Advantage is also known as Medicare Part C and gives seniors the option to enter an HMO or PPO rather than receive traditional Medicare benefits.

We hope insurance experts told you that Medicare Part C is a bad reference point for what you want to do because it is a reversible option. Seniors that don’t like or aren’t adequately covered by Medicare Part C can opt back out into a traditional Medicare program. So the insured pool of seniors in the Medicare Advantage program isn’t random or representative of what will happen if your program is adopted. The Medicare Advantage program provides false comfort that private insurance can be expanded to all seniors without serious bad effect.

Below are some of our questions about your program. We will probably have other questions after we understand some of the basics of your plan.

1. How is your plan going to deal with pre-existing conditions and pricing?

If we need to change insurance companies will we be rejected by replacement companies because of pre-existing conditions?

Since your plan calls for a repeal of the President’s health care bill it seems that protections for pre-existing conditions will be repealed . Is that correct or do you expect to keep some parts of the President’s healthcare reform law?

Also, what insurance company in their right mind is going to voluntarily insure me and a group of old people? We will be a bad risk because every one of us will either be sick and dying or about to be sick and dying. For the insurance company to make a profit on a group of old people they will have to charge a really high premium. Will there be a cap on premiums and if so how is this a “free market solution”?

2. How does your program protect us if we have diminished mental capacity?

It is a fact that as some people age they have diminished mental capacity and I am expecting that neither my wife nor I will be an exception. I am worried that we won’t be able to make an informed decision as to which insurance plan to purchase. The contracts are complicated and full of small print. They are drafted by Wall Street lawyers and designed to protect the insurance company. If we can’t understand our insurance options and make an intelligent choice how will we purchase the right plan?

3. What happens when we have less than diminished capacity and can’t effectively make any decisions on our own?

I know from firsthand experience that in some states elderly are still deemed to have “legal capacity” even though they are dramatically diminished and can’t make their own decisions or take care of themselves. Are you proposing some new form of Federal definition of “capacity” that supersedes state law so that very impaired elderly people have someone that helps them purchase insurance?

As an example, my wife’s grandfather is 90+ years old and has had several strokes. He can’t read, talk, write, drive, feed or otherwise take care of himself without full time assistance. He lives in Maryland and despite his mental and physical disabilities, in the state of Maryland he is legally competent and was only recently denied his driver’s license renewal (we took away his car keys more than 8 years before Maryland took away his legal right to drive).

Even before my wife’s grandfather had his major stroke, when he was in his early 80s, he didn’t have the mental capacity to understand and purchase MediGap insurance. When he got sick we discovered that he had messed up the application and thought that he was covered even though he hadn’t paid premiums for years.

If that happens to me or my wife, who will help us when we are still deemed competent by the state, but clearly unable to live independently or make adult decisions?

And, what happens if we are deemed incompetent?

Who will take care of us and purchase insurance if we are truly incapacitated?

Also, what happens to us if our guardian makes a bad insurance purchasing decision and we neither have money, insurance nor capacity to help ourselves?

4. If an insurance company decides to incorrectly deny benefits who will protect and defend us?

When we are old and sick who will protect us from an insurance company refusing payment on legitimate claims?

Even worse, how will anyone even know if an insurance company refuses payment on necessary care and I (or my wife) am harmed as a result?

Will the insurance company have any liability for refusing to pay for care or for dictating what care we receive? Can we sue? If we are old and permanently harmed, will it even matter if we can sue?

Who at the insurance company will be making coverage and payment decisions? What standard of care will they need to use? Do they have a fiduciary responsibility to me as the insured or will their shareholders obligations be more important?

Will the insurance company be allowed to earn more money if they deny care to seniors?

It’s my impression that seniors and their doctors know the Medicare rules and as long as they stay within the rules, reimbursement is predictable and timely. No one from the government has a financial incentive to deny payment or mess around with patient care.

Private insurance is different. There is a big incentive to go cheap on care and not pay out benefits. I am worried that panels of insurance executives will end up effectively deciding who lives and who dies in an effort to maximize profits while fulfilling fiduciary responsibilities to their shareholders. These will be real Death Panels and the prospect terrifies me. It’s bad enough when insurance companies take advantage of young people. How will old people who killed off by insurance companies defend themselves?

5. What will protect us from bait and switch advertising and tactics?

For seniors, it’s too late to figure out that an insurance company has pulled a bait and switch after care is denied.

I think that the recent national experience of having banks bait and switch virtually every individual and institutional customer should be enough to be concerned about conflicts of interest between customer needs and shareholder profits. Regulators couldn’t control the banks, why do you think they will be able to control insurance companies any better?

Seniors need more protection than bank customers. The elderly can’t risk regulators being late to the game. There aren’t any do overs when it comes to seniors. Small mistakes are fatal.

How do you propose to protect me and my wife from bait and switch tactics?

6. Medicare is a national program but insurance is regulated on a state by state basis. Are you proposing an expansion of Federal authority over insurance companies or will the options, protections and risks be different depending upon what state I live in?

When I am a senior, will I have to decide where to live based upon insurance regulation of my state? My parents didn’t have to make those choices or decisions, nor did their parents, nor did anyone before me since Medicare was enacted.

Will my wife and I have to move from our home if our state has crummy insurance and consumer protection laws?

Or, are you proposing new Federal regulation over insurers that provides consistent national coverage for seniors that isn’t dependent upon state residence status?

And, if you are proposing new Federal insurance regulations how do governors, state insurance officials and state’s rights advocates feel about the Federal government expanding onto their turf? Also, where in your budget is the funding for this new agency?

7. What happens if I outlive my financial resources? Will Medicaid cover me so that I can die with dignity? Or will I just die?

With the cost of nursing home care in some places exceeding $75,000 per year per person, it isn’t hard to imagine that my wife and I may outlive our financial resources. You are proposing large scale cuts to Medicaid. What happens if we run out of money before we die because we are placed in a nursing home?

Will someone take care of us and help us when we literally can’t go to the bathroom by ourselves but also have no money to pay for help?

Or will we have to choose between food, clothing or housing and medical care (and that assumes we have the mental or physical capacity to make choices)? Will your plan make us homeless and indigent like many of the elderly of the 1920’s and 1930’s?

8. What other large industrialized countries have adopted a plan for senior care similar to what you propose and how has it worked?

I am hoping that sometime since the beginning of the industrial revolution another country has tried your plan and it worked.

Can you point to any country, anywhere in the world, where your plan has been tested and it worked? I would feel a lot better if that were the case.

Congressman Ryan, please feel free to provide as much detail as possible on how, as a practical matter, your plan will be implemented. I understand that your objective is to save money — I just wonder if there isn’t a less radical approach that would work.

For example what’s wrong with modifying the current Medicare system to include means testing on co-payments and deductibles, increasing the eligibility age by a few years, restricting payment of certain elective procedures and working to reduce hospital and provider administrative costs. Tort reform relating to end of life care couldn’t hurt either. These changes would be easy to implement, fair to all and still provide protection for the elderly.

When I was a child I read stories about how animals that that get old walk into the forest to die. They are never heard from again and as a result aren’t a burden on their herd. The remaining animals have better survival odds because they are not forced to waste precious resources on old animals that are going to die anyway.

For better or worse, a long time ago we decided that we were different than animals and that old people shouldn’t be asked to “take one” for the team.

Congressman Ryan, I am worried that your plan basically is telling me and my wife to get ready for that long walk into the forest. Please tell me it isn’t true and that I am over reacting.


Mark Sunshine

PS. Even though I don’t live in your district it would be nice if you answer this letter.

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