An Overview of Medicare for Clinicians
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BACKGROUND: Medicare is estimated to cover 14% of the population of the USA (Henry J Kais Fam Found 2017), over fifty million people. Despite covering a smaller percentage of the population than employer-sponsored insurance and Medicaid, Medicare is the most common payer for inpatient encounters. The Healthcare Cost and Utilization Project estimated that in 2015, Medicare was the primary payer for 39.4% of hospitalizations (HCUP 2019). While in daily practice it may be practical to assume that patients eligible for Medicare are financially insulated from the costs of care, the reality is that no care exists in a vacuum. Medicare is a complex program that mitigates but does not completely eliminate costs to patients. OBJECTIVE: This review aims to shed light for providers on the basics of Medicare, and how beneficiaries are impacted financially by their care to better understand some of the social barriers our patients face in seeking care. KEY WORDS: Medicare; health insurance; health policy. J Gen Intern Med DOI: 10.1007/s11606-019-05327-6 © Society of General Internal Medicine 2019
HISTORY OF PASSAGE OF MEDICARE
Medicine was evolving rapidly in the second half of the nineteenth century. With the introduction of various discoveries such as anesthesia and antiseptic surgery, hospital care was changing. Rather than long-term care of the chronically unwell, hospitals came to utilize ever advancing therapies to treat patients.1,2 With this increasing complexity of care came a parallel increase in costs. This rise in costs was reflected in the work of a group formed in 1927 called the Committee on the Cost of Medical Care (CCMC).3 In its final report in 1933, the committee made several recommendations to address the evolving landscape of healthcare costs. One of the most controversial of these recommendations was summarized in a reflection written by the CCMC’s Director of Study, I.S Falk, 25 years after the committee’s dissolution. His description of this majority recommendation was that “medical costs should be placed on a group payment basis through insurance, taxation, or both.”4 This notion of public health insurance had previously been advocated by Theodore Roosevelt in his run for a third term as Received June 10, 2018 Revised January 28, 2019 Accepted August 15, 2019
a progressive, but never came to fruition after his loss to Woodrow Wilson.2 Two decades later, around the time the CCMC completed its final report, the idea reemerged as a possible component of Social Security in Franklin Roosevelt’s New Deal.5 The resistance to national health insurance was fierce, however, with lobbying groups including the American Medical Association strongly opposed out of concern that group payment would compromise physician autonomy. The CCMC’s majority recommendations cited above were accompanied by a minority report written by dissenters within the committee. They broke with the majority by arguing against group payment methods, and opposition groups seized onto this minority recommendation. Roosevelt dropped comprehen
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