Immigrants to the US and Social Security: Ripe for Ageism and Disabilty Bias

New America Media reveals a new version of Old Bias:

SAN FRANCISCO--As the debate over immigration reform tugs predictably back in Washington, an undercurrent of ageism and disability bias has been flowing beneath more obvious racial and class implications.

Take, for instance, the recent USA Today op-ed co-authored by former U.S. Sen. Jim DeMint, R-S.C., now president of the conservative Heritage Foundation, which warned, “The truly enormous costs come when unauthorized immigrants start collecting retirement benefits.”

DeMint and his colleague continued, “Social Security, Medicare, food stamps and other entitlement programs already impose huge, unfunded liabilities on taxpayers.” The op-ed goes on to declare that “an amnesty” proposed for 11 million unauthorized immigrants will add significant taxpayer costs because unauthorized immigrants average only a 10th-grade education.

Doing the Right Thing

Rather than being a burden, however, according to the Social Security Administration’s chief actuary, those presumed drains on the system have been a boon. They add $15 billion a year to Social Security in payroll taxes, only taking out $1billion annually in benefits. In the long term, immigration reform would modestly cut Social Security’s deficit, not worsen it.

According to Pew Research, that’s partly because of future rising income and home ownership levels for those immigrants’ children.

“Those opposed to immigration reform have attempted to use vital programs, like Social Security, as an economic excuse to avoid doing the right thing,” said Max Richtman, president and CEO of the National Committee to Preserve Social Security and Medicare (NCPSSM).

In a policy brief last week, NCPSSM cited Edward Alden of the Council on Foreign Relations, who has said that immigration reform would actually lead to higher wages and allow immigrants to pay more towards Social Security.

"They’re going to pay more into the Social Security system. The CBO has run these numbers in the past, in the short-run there’s a big boost for the Social Security system," Alden said

White House and Senate ‘Roadmaps’

According to a new policy analysis by the National Hispanic Council on Aging (NHCOA) and National Council on Aging (NCOA), today’s approximately 11 million unauthorized immigrants include 1.3 million individuals ages 45-54, and another half million who are 55 and older.

NHCOA’s Jason Coates and NCOA policy analyst Joe Caldwell examined “roadmaps” to citizenship outlined so far by the White House and the Senate’s bipartisan “Gang of Eight,” with legislation to come in a few months.

Both proposals signal long waits before eligible immigrants could even apply for lawful permanent resident status (green cards) and citizenship. And their access to health care and economic security benefits, especially important to elders and those with disabilities, is in doubt.

Under the current proposals, unauthorized immigrants could end up waiting a decade or more to qualify for health care and other safety-net programs.

While the Senate plan would link the waiting period for being able to apply for green cards to some assurance of border security, the White House has proposed allowing undocumented immigrants provisional status for six-to-eight years before they could become permanent residents. (Both the administration and Senate frameworks would expedite the process for “DREAMers,” agricultural workers, and highly skilled immigrants with advanced degrees in such areas as science and technology.)

Once an immigrant waited through those years on provisional, or temporary status and qualified for a permanent status (the green card), he or she would begin the five-year process toward naturalization. During that time, the White House and Senate proposals would deny them access to federal benefits, such as Medicaid, Supplemental Security Income and the Supplemental Nutrition Assistance Program (food stamps). President Obama’s proposal would deny access to subsidies under the Affordable Care Act. People could have to wait more than a decade for assistance.

Older adults would also have to wait that long to access Medicaid, which is the primary payer of long-term care in the U.S. States can waive the five-year waiting period normally required once someone becomes a permanent resident, but only for pregnant women and children, not for individuals with disabilities or seniors.

Statistics show that six-in-ten undocumented Hispanics is without health insurance.

They would also have to wait another five years -- that is about a decade after starting on the path to citizenship -- to qualify for federal Medicare.

Many of those 11 million undocumented people are overrepresented in low-paying and often physically demanding occupations, frequently incurring high rates of work-related injuries, and contributing to high rates of disability and chronic conditions over time.

Looming Shortage of Care Workers

The NHCOA-NCOA report also calls on the government to strengthen and stabilize the shrinking direct-care workforce, such as the nursing aides who assist patients with such crucial daily activities as getting dressed, taking medication, preparing meals and managing money.

The advocacy groups say reforms should afford these workers the same streamlined and expedited visa process as those proposed for scientists, engineers and workers in other high-need areas, because the nation is facing a looming shortage of care workers.

The paper explains that as the U.S. population ages, U.S. demand for long-term care will leap from today’s 12 million to 27 million by 2050. The country will need 1.6 million additional direct-care workers by 2020 and 3 million by 2030.

Immigration reform is vital for meeting that projected need, say NHCOA and NCOA, because almost one in four current direct-care workers is foreign born. About half today are naturalized citizens and others have legal status, “but a significant portion is estimated to be unauthorized.”

Policy changes offering these workers authorized immigration status would improve the quality of care, says the paper, by allowing for improved background checks, providing workers opportunities for training and career advancement, building registries to assist individuals and find workers, and enabling workers to legally drive.

“Comprehensive immigration reform will help millions come out of the shadows. Many of the half million older adult immigrants [among them] have worked for decades and contributed millions to Social Security,” said NHCOA’s Jason Coates. Rather than begrudging them income and health security protections they have earned, he added, “We should reward their contributions to the to the United States.”

How Does Depression Wreck Your Life?

All too often stereotypes cast older persons as “grumpy.” Many people think that being down and depressed is normal in old age. Attention!

It is NOT a natural part of aging. 

Depression can happen to anyone at any age and is common among older adults and seniors. Some 15 out of 100 adults over the age of 65 suffer from depression in the US. Who are these older adults and why do so many of them suffering from depression? Studies show that the disorder affects people in nursing homes and hospitals in even greater numbers. Recognizing depression among old persons is not always easy. Depressed elders may find it difficult to describe their feelings. Many fear revealing their sadness since they may associate it with being “crazy” or lacking self-control. In the youth of today’s elders, they learned that depression often was associated with being “crazy” or weak-minded. Today, we know hat depression is a fully treatable medical or biological illness.

The Movie Grumpy Old Men

Aging, HIV and Depression

Experts have discovered a link between HIV-positive older adults and depression. To find out more about this development, I met up with Stephen Karpiak to talk about HIV positive older adults and seniors. A PhD, Karpiak joined ACRIA (AIDS Community Research of America) in 2002, as Assistant Director of Research. He served as primary investigator at the agency's new behavioral research effort, including conducting groundbreaking Research on Older Adults with HIV(ROAH) study. Earlier, he had worked for over 20 years at Columbia University's Medical School as a research scientist in neurobiology and immunology. Karpiak also started a Phoenix, Arizona, project to provide housing for homeless people living with HIV/AIDS. Dr. Karpiak has documented over 250 articles in scientific journals and books, and has been holding lectures all over the world.

 Dr. Karpiak

Karpiak told me that the ROAH goal focused on understanding the situation of those over the age of 50 who are living with HIV. ROAH sought answers to identify their psycho-social needs and determine how to support them most effectively to live longer, healthier and happier lives. ROAH assessed a 1,000-person cohort in New York City, examining a comprehensive array of issues, including health status, stigma, depression, social networks, spirituality, sexual behavior, and substance abuse.

ROAH showed that stigma, isolation and depression are the major problems for this group. The stigma against HIV/AIDS and is usually associated with homophobia, racism, ageism, etc.

ROAH demonstrated that by repressing the immune system, depression may render people more vulnerable to infectious diseases. Stress and depression have a harmful effect on cellular immunity, including those aspects of the immune system affected by HIV. Body cell mass depletion is associated with significant increase in fatigue, global distress and depressive symptoms, and reduced life satisfaction. Elevated symptoms of depression associated with a faster progression to AIDS and a higher risk of mortality.

Stigma often leads to isolation, depression and loneliness. Older HIV positive adults who are depressed are more likely to have financial problems, have fewer people to turn to for support, lack critical HIV-related information, live alone, have thoughts of suicide, and experience greater levels of stigma related to HIV and aging as compared to older adults who are not depressed. Depression may also stop persons from getting treated, avoiding doctor visits, social activities and other relationships. ROAH found that aging HIV-positive adults experience significant levels of depression, at a rate at least five times higher than the general New York City population.

Dr. Karpiak and Sanna Klemetti

Solutions?

I asked Dr. Karpiak what has or can be done about this situation. As a matter of fact, successful projects exist. One example is the MacArthur Foundation Model that expects participants to make one phone call every week to ask the HIV affected person how he/she is doing. The effect of this simple and effective program has been great. Another ACRIA project is The Go 4 Part Program, funded by Mac AIDS fund. It's a two day HIV – aging training program. Around 25 educators visit about two cities per year, to bring AIDS, health and aging organizations together to educate them about these issues. They also introduce ideas on how to reduce the problems. They usually invite one person from the meetings to New York to see the work carried out at ACRIA.

More about ROAH

Sanna Klemetti

s.klemetti@globalaging.org

Will President Obama sell Out US Seniors and our children for a Deal with the Republicans?

Salivating Over Social Security Cuts

Dear Global Action on Aging Friends,

Wherever you live, please note the very real possibility that President Obama will seriously weaken or even destroy the Social Security Program for a "deal" with Republicans over the US Budget.  Not only will such action undercut the modest living standard of US elders but it also threatens young workers who have contributed to the program since they entered the workforce. 

Mind you, US citizens have already seen the Federal Government "borrow" from Social Security to support other programs--and failed to re-pay the debt.  Read excerpts from Robert Reich's Blog (April 10, 2013) for the full story:

ohn Boehner, Speaker of the House, revealed why it's politically naive for the President to offer up cuts in Social Security in the hope of getting Republicans to close some tax loopholes for the rich. "If the President believes these modest entitlement savings are needed to help shore up these programs, there's no reason they should be held hostage for more tax hikes,” Boehner said in a statement released Friday.

House Majority Leader Eric Cantor agreed. He said on CNBC he didn't understand "why we just don't see the White House come forward and do the things that we agree on” such as cutting Social Security, without additional tax increases.

Get it? The Republican leadership is already salivating over the President's proposed Social Security cut. They've been wanting to cut Social Security for years.

But they won't agree to close tax loopholes for the rich.

They're already characterizing the President's plan as a way to "save” Social Security - even though the cuts would undermine it - and they're embracing it as an act of "bi-partisanship.”

"I'm encouraged by any steps that President Obama is taking to save and preserve Social Security,” cooed Texas Republican firebrand Ted Cruz. "I think it should be a bipartisan priority to strengthen Social Security and Medicare to preserve the benefits for existing seniors.”

Oh, please.

And the day Ted Cruz agrees to raise taxes on the wealthy or even close a tax loophole will be when Texas freezes over.

The President is scheduled to dine with a dozen Senate Republicans Wednesday night. Among those attending will be John Boozman of Arkansas, who has already praised Obama for "starting to throw things on the table,” like the Social Security cuts.

That's exactly the problem. The President throws things on the table before the Republicans have even sat down for dinner.

The President's predilection for negotiating with himself is not new. But his willingness to do it with Social Security, the government's most popular program - which Democrats have protected from Republican assaults for almost eighty years - doesn't bode well.

The President desperately wants a "grand bargain” on the deficit. Republicans know he does. Watch your wallets.

GAA Readers:  Write the President and your Congressional Representatives to protest!  Organize a Demonstration (with your family and friends in your Community) demanding a stop to this disastrous plan to ruin US Social Security! Take action to alert citizens, young and old! 

Susanne Paul for Global Action on Aging

How to Prevent Amputation among Diabetic Elders

Global Action on Aging

Chiquita Smith is the most beloved volunteer in our GAA family. Blind due to diabetes, she is a strong advocate for impoverished older persons living in public nursing homes in the New York City area.  She led GAA interns on investigative visits to such homes and asked interns to describe what they saw.  For example, "Are older persons parked in hallways one behind another in wheehchairs?  Is anyone speaking to them?  Are they asleep?"   She wanted interns to describe the clothing that the older residents were wearing-- "Did it match, top and bottom?  Was their bed clean?  Did they have any visitors?"  And she instructed the young people to inquire of residents if they had had the opportunity to vote in the last public election.  GAA interns benefted from her advocacy and helped prepare her "talking points" with the institutions' administrators. If Chiquita did not get satisfactory answers and action from administrators, she wrote to City and State Health officials informing them of the situation.  What a role model for the young. . . and a very strong advocate for poor old people.

Today Chiquita is in Beth Israel Hosptial in New York having had two legs amputated due to diabetes. Will you hold her in your thoughts during these difficult days for her?   We are posting an article by Laurie Umeh (National Health Service Corps, July 2006) in her honor.

"Preventing Amputation in Older Adults with Diabetes, Proper Foot Care Is No. 1 Strategy
By Laurie Umeh, NP Lower extremity limb loss is a dreaded complication of diabetes at any age. For the older adult, limb amputation often has particularly far-reaching consequences: loss of mobility and independence. Amputation may be the one event that ultimately and prematurely forces someone into nursing home placement. Diabetes mellitus (DM) increases the risk of lower extremity amputation 15-fold.¹ Older adults in general are particularly vulnerable; approximately 96% of amputations occur in people older than 45.² Survival statistics about amputation are bleak. The 5-year survival rate after amputation is only 27%.³For the older adult who has had an amputation, rehabilitation may be limited by cardiovascular disease or other medical conditions. Many older amputees find a prosthetic limb heavy and uncomfortable and lack the stamina to ambulate with it.⁴ In one study, only 53% of patients older than 65 could be fitted with a prosthetic limb.⁵The direct and indirect costs of amputations represent a major burden for the health care system. Yet 85% of lower extremity amputations can be prevented through programs for preventing and treating foot ulcers, preventing ulcer recurrence and educating patients about proper foot care.⁷The cascade of events that ultimately culminates in limb amputation often begins with an innocuous-appearing ulcer on the foot. The mechanism of injury may seem trivial — a wrinkled sock, an improperly trimmed toenail or a foot that swelled in its shoe and led to skin breakdown. A tiny blister or shallow ulceration becomes a draining, infected wound. After months of immobility and heroic efforts to save the ailing limb, osteomyelitis sets in, and amputation often results.As providers of primary health care in clinic and nursing home settings, nurse practitioners are perfectly positioned to champion primary and secondary prevention of diabetic ulcers and lower extremity amputation. The ability to perform foot care has limits in the older person with DM. Understanding the disease process, acquiring a repertoire of effective wound treatments, and knowing when to refer may prevent the progression of injury to ulceration and ulceration to amputation.

Please share this information with your friends, particularly those who suffer from Diabetes. 

Susanne Paul for Global Action on Aging

Older Persons Fighting HIV/AIDS in South Africa

The World Health Organization (WHO) recently analyzed HIV/AIDS issues among older people in  South Africa. What did the researchers find?

Increasingly older people are contracting HIV/AIDS. However, existing data does not specify how many have been infected. Also, WHO says that  older people continue to be excluded from HIV prevention and treatment programmes.  UNAIDS estimates that 2.8 million people 50 years and older were living with HIV in 2006 and the prevalence of HIV in South Africa among people age 50-54 was 10.8%, 4.5% among those aged 55-59, and 3.9% among those aged 60 and over.  But we don't have current data.

Older people in nearly every culture depend on family support.  Usually younger persons care for the most old or infirm.  However, HIV/AIDS changes such family relationships.  When adult children die, older persons once again step in to head the household and care for orphaned children. The number of grandparents caring for AIDS orphans in developing countries has doubled over the last ten years.  At least half of the world’s 15 million AIDS orphans are being cared by a grandparent. As GAA has pointed out many times, older caregivers are often women who face serious financial, physical and emotional stress due to their caregiving responsibilities in their later years.

Here are some WHO recommendations to citizens and governments to reduce the heavy impact of HIV/AIDS on older people:

• provide concrete support to older people, such as social pensions;
• train HIV/AIDS service and health providers on gerontological issues;
• insure psychological and medical support for older people living with ill family members;
• include older people in HIV/AIDS education/training programmes

Susanne Paul
Global Action on Aging

Why don't More Older Persons organize for Our Rights?

Dear GAA Blog Reader,

Over the last week, I've posted several articles describing how the Governments of South Korea, China and the US are threatening to reduce their existing social security programs.   None of these programs appear to be adequate to meet the needs of their older citizens.  But why don't older people rise up against these threats that can shorten and reduce our last days to miserable conditions?

A visiting friend at dinner last night suggested an explanation that I want to test with you.   He suggested that governments appear to be threatening elders in this way:  "They tell older citizens that their needs will take national resources away from the young--their childen and their grandchildren."  The message:  "Stop complaining about social support programs; if we governments spend on you, we won't have enough resources to provide for the young."

Our friend thinks that older persons must see this propaganda for what it is: a way to ignore the social needs of elders and claim that it's unfair to want social programs and other programs in old age.

Of course, the issue of greater taxes for the upper 1% goes unnoticed. 

What do you think?  Do you hear this argument in your country?  Please comment to Global Action on Aging.

Have a good week! 

Susanne Paul for Global Action on Aging 

How Does Big Pharma Make its Profits Grow?

The blog, diggredditstumble, has analyzed how major pharmaceutical companies have developed cozy relations with US legislators and  profited enormously.  And You and I?   We US citizens pay enormously.  Read this summary of the blog’s analysis:

US corporations spend billions of dollars each year on lobbying, trying to gain favorable treatment from legislators.

It's actually the pharmaceutical industry that spends the most each year to influence US lawmakers, forking over a total of $2.6 billion on lobbying activities from 1998 through 2012, according to OpenSecrets.org. To get some perspective on just how big that number is, consider that the oil and gas companies and their trade associations spent $1.4 billion lobbying Congress over the same time frame while the defense and aerospace industry spent $662 million, a fourth of Big Pharma's total.

US legislators permit pharmaceutical companies to engage in predatory pricing practices while they enjoy exclusive rights to manufacture drugs for 20 years or more. All at the same time that drug costs and drug price inflation are among of the main drivers of health care costs for individuals and families and threaten the fiscal health of our public health care programs.

Other governments set a limit on drug price increases. However, US citizens pay more for the same drugs as US-based drug companies dig ever deeper into the pockets of sick Americans to bolster their profits and meet earnings expectations of Wall Street analysts.

Each year, the Canadian government's Patented Medicine Prices Review Board releases a study analyzing drug prices around the world. According to that study, prices in the US have gone up an average of 8 percent a year from 2006 through 2011, while drug prices in Canada have remained flat.  Back in 2006 for example, US consumers paid about 70 percent more than our Canadian neighbors for prescription drugs still on patent. Five years later, in 2011, that difference had surged to 100 percent. And with drug price inflation in the United States hitting 11 percent in 2011, that gap will undoubtedly grow ever wider in the future.  

Big Pharma’s successful lobbying of US legislators touches virtually every US citizen. It affects health insurance premiums, impacts the solvency of our Medicare system, which began to include a prescription drug benefit in 2006.  While helpful to Medicare beneficiaries, it rained money on the pharmaceutical industry.  Why?  The industry's friends in Congress (and the White House at the time) went along with Big Pharma's demand that Medicare not be allowed to negotiate pricing with drug makers to make medicines more affordable to beneficiaries.

Drug makers got a huge new revenue stream from taxpayers, but ordinary citizens got cheated. The Department of Veterans Affairs can bargain with drug makers to get better deals on prices. But, incredibly, not the Medicare program.

The Congressional Budget Office estimates that the government could save $112 billion over the coming decade if Congress reconsidered its 2006 gift to drug makers and gave Medicare the ability to negotiate prices.  And you and I should believe politicians when they say that Medicare costs too much?   Remember that the next time you hear a politician say that the only way to keep the program from going broke is to cut benefits and raise the eligibility age for Medicare from 65 to 67 years.

In the weeks ahead, keep an eye on how health insurers will push for ways to weaken the consumer protections in ObamaCare so they can keep meeting Wall Street's profit expectations. 

Older people, who frequently need medications, are often blamed for costing "too much."  We must expose and end this gold heist for Big Pharma at the expense of seniors' health.

Susanne Paul, Global Action on Aging

Amour by Michael Hanake

A review on Michael Hanake's "Amour" at Old Age

Michael Hanake’s Amour has been nominated for the Best Picture, Best Actress in a Leading Role (at age 85, Emmanuelle Riva is the oldest actress to be nominated for an Academy Award), Best Original Screenplay and Best Director at the 85th Academy Awards. Known for his disturbing yet realistic style, Hanake’s Amour has already won the Palme d’Or at the 2012 Cannes Film Festival. The movie received mixed reviews. Some said there was nothing relating to Amour (love) and it was rather a cold, cruel and brutal movie, whereas others interpreted it as a mere act of love. Here is a comprehensive review by Manohla Dargis from the New York Times, if you haven’t seen the movie and would like to know more about the plot. I would like to group my remarks in two categories: cinematographic and content-related.

First of all the fact that the movie is directed by a 70 year old man and its two leading actors are 82 and 85 years old is worthy of appreciation. The beautiful and reserved Anne (Emmanuelle Riva) and courteous Georges (Jean-Louis Trintignant) draw the audience into the elegantly cultured, well-educated and decorated bourgeois world of two retired music teachers. One could assume that a movie filmed in a single set - except from the opening scene the whole movie is filmed in the old couple’s grand apartment in Paris - will be boring, but Hanake’s angles are so well placed that they only make the audience associate and empathize more with the aging couple’s way of living. Another detail that I loved was the little noises that the characters and the apartment radiated when for example Georges and Anne chewed the haricots verts, a typical side dish in France, or when the hardwood floor squeaked as Georges pushed Anne’s wheelchair. Hanake also gave a powerful message on how life at old age rotates around a small dining table in the kitchen of an colossal Parisian apartment. I think that is why the chewing, eating, gulping and moving cutlery sounds conveyed such reassurance because they were also the proof that the couple was still living a “normal” life despite of Anne’s stroke.

As someone who regularly thinks about old age since I’ve been academically and professionally involved in aging for the last four years, I think I was not as much shaken as others by the uncomfortable truth that Amour throws out to your face that we will all die one day and it probably will not be the most pleasant moment of our lives. But the disturbing realization does not stop here. It would, if we all died suddenly without making any inconvenience for ourselves as well as others who care for us. But there is usually a gradual transition from the first moment we realize that the end is coming for our beloveds to the moment when the end really comes. In between two moments a series of feelings pass through our minds: shock, denial, acceptance, struggle, hope, despair, frustration, struggle, despair and relief. Through Georges the audience observed every single of these feelings which in my opinion makes Amour a successful movie. I think Hanake’s education in psychology, drama and philosophy contributed significantly to his success in depicting such powerful but intangible moments of life. The most striking moment for me was when Georges gave up on taking care of his paralyzed wife after he saw that Anne refused to continue living by spitting out the extremely little amount of water that Georges physically forced her to drink.  

There are other powerful scenes about the relationship between Eva, the couple’s only daughter and Georges and Anne in the movie. Eva (Isabelle Huppert) lives in London, has a husband who cheats on her and two grown-up children who live their own life. The audience senses that Eva does not know much about her own children. Eva and her husband are also having financial difficulties. This part about the self-centered daughter was not that original for me because it’s been a common theme. However, the surprise visit that Eva makes to her father who she knows is already trying hard to take care of his paralyzed wife, made me ask myself the following question: who has the right in the family to decide about a loved one’s caregiving, the spouse or the children? Considering that Georges is the one who lives with Anne all the time and witnesses her indignity and hears her cries of pain, it seems logical that he should decide what to do. On the other hand, just because Eva is far and cannot be there with her mom, does she deserve to be left out from the decision-making of her mom’s constantly worsening condition? Doesn’t she want the best for her mom too? To sooth his daughter’s worry about Georges not being reasonable and responsible enough to put Anne in a nursing home where she’ll be better taken care of, Georges says to Eva something like “ I love your mother as much as you do and I promised that I won’t put her back in the hospital or in a nursing home. What they do in the hospital can be done here at home. I won’t break my promise.” Eva then accuses her father of being cold and indifferent. It is so true that people get accustomed even to worst conditions and normalize them. For Georges who lives with Anne 24/7, Anne’s condition is normal, a natural consequence of the stroke, whereas for Eva who comes to visit them once in a while, Anne’s condition is unbearable and something has to be done. The discussions that the father and daughter have makes the audience leave the apartment for a moment and see the situation from afar.

I went to see the movie at 11:05 am and the theatre was full of old people. I wanted to ask how they felt watching the movie but I did not feel comfortable doing it. I would love to hear remarks from older persons.  

By Duygu Basaran Sahin

duygubasaran@gmail.com

Dr. Oliver Fein's Interview on Medicare Costs

Becker's Hospital Review published Bob Herman's interview with Dr. Oliver Fein of Weill Cornell Medical College on February 6, 2013.  Read this article to understand how financial interests--operating at many levels--are raising the cost of health care in the US.   When you finish, send your comments, please.

"For Oliver Fein, MD, Medicare and other public healthcare policies have been a major part of his life since he left Case Western Reserve University School of Medicine in 1967. Currently, Dr. Fein is a general internist at NewYork-Presbyterian Hospital in New York City, a professor of clinical medicine and public health at Weill Cornell Medical College and chair of the New York Metro Chapter of Physicians for a National Health Program.

Dr. Fein says he has always been interested in the delivery of healthcare to vulnerable populations, especially the poor and elderly. He spent his residency in public hospitals, and his clinical practice was based in academic medical centers where he could continue to see Medicaid and Medicare patients. When it comes to Medicare, Dr. Fein explains it is "not a perfect program," but it will continue to be tremendously important for hospitals and physicians alike.

Here, he shares his thoughts on where Medicare stands today, if the program is really as insolvent, as some say it is, and what he would do if he helmed CMS.

Question: Medicare is, for all intents and purposes, one of the most important payors in the country. What are some of the fundamental problems with it, and what does it do well? Is it really as insolvent as some public policy leaders say it is?

Dr. Oliver Fein: Let's start with what Medicare does well. [Medicare] is a situation where when you turn 65 and have worked 40 quarters, or 10 years, in this country, you're eligible. The simple eligibility of Medicare is just wonderful, and I think people really appreciate that.

From a physician's point of view, the sense I have is, there are some that believe Medicare doesn't pay them enough. So, therefore, they don't take Medicare patients. I think that's been highly exaggerated. There was a study from the Archives of Internal Medicine in 2011 that argues, in fact, the number of physicians that accept Medicare is much larger than acknowledged in the anecdotal literature. That may change if this whole [sustainable growth rate] issue isn't solved.

The other thing to say is many [physicians] who are in private practice have told me they like Medicare because they can count on getting the check each month. There's no hassle of claims being denied that occurs with private health insurance. What has happened is most insurers are for-profit entities. Any way they can delay payment means they can make money on premiums they've collected. Well, since there is no for-profit motive in Medicare, claims denials are rare. I think overall, beneficiaries like Medicare, and it's a program that physicians overwhelmingly think is an important program for them.

For hospitals, Medicare is kind of their intermediate payor. It may not be as good as contracts they've been able to negotiate with private insurers, but it's better than contracts with Medicaid insurers. The result is even specialized places like Memorial Sloan-Kettering Cancer Center take Medicare whereas they may deny certain for-profit private insurers because they feel they don't get adequate reimbursement from them.

In terms of Medicare's solvency, Medicare's trustees and most economists will say the money that has been collected from people's payroll checks makes the program solvent through 2024. So what does that mean? The money is there to pay projected payouts that will be needed in those years for Part A. Some people are talking about Medicare going broke after that. It is perhaps that the monies collected won't equal what's paid out — but that assumes there's no change in the payroll tax. Currently, [payroll tax contributions to Medicare] are 1.45 percent from you and 1.45 percent from your employer. Let's increase that by a little bit to 1.5 or 1.55 percent of salary, and we could extend the life of this program on the Part A side to perhaps 2040 or 2050. I think that's one dimension.

The other thing to realize is that on the Part B side, Medicare is a 25-75 program. The beneficiary, on average, contributes 25 percent of cost of the program, and the government takes the rest out of current tax revenues. Does that mean program is broke? Well, if we continue to have wars in Afghanistan and Iraq and have military costs that are so substantial, we're not going to collect enough tax revenue to cover it. [However], if you just shrink [the military budget] a little bit, we'll have plenty of money to cover Part B contributions.

Part C, or Medicare Advantage, is also designed in such a way where beneficiaries are able to elect a private health insurance company to mange their benefits. And when that happens, the doctor and the hospital are dealing with a private insurance company, not Medicare. What has been shown is private [Medicare Advantage] companies are getting 11 to 14 percent more money than if the beneficiary stayed in the public program. The program is designed to reimburse the private insurance companies more generously. They also risk select, and one of the classic ways they do that is by offering a free gym club membership, for example. So if we really paid private insurers less [Medicare] money, there would be more money in program, and again one wouldn't be talking about us going broke.

Q: There's been a consistent refrain in the hospital sector that raising the eligibility age of Medicare from 65 to 67 or higher would help control costs as well. What do you think would result from that plan?

OF: It will deal with the government costs. If you don't cover a whole sector of the population, sure, Part A costs will be less, Part B costs will be less, Part C and D costs will be less. But it is enormously unfair, and the hospital sector will ultimately get very hurt by this. This works for people of upper incomes because many of them actually do work past age 67. It's the laboring class — the coal miners, steelworkers, garbage collectors, people who have to do real, physical labor who frankly ought to retire at age 65 who are the ones really adversely affected by this.

If those older, low-income folks are laid off by their employers, they lose their insurance — and that will come back to slap hospitals in the face. When contrasted with 30-year-olds with no insurance, hospitals will find themselves swimming in a new form of debt.

Q: What about the inverse? What if Medicare's age was lowered to add in younger, healthier people?

OF: That's where we should be going, it seems to me. Incorporate younger people in Medicare, who will cost the program much less on a per capita basis. One could decide to cover children. Children are a great example. They require relatively cheap care even though they do have immunizations in the first year of life. But on a per capita basis, they are much cheaper. Let's incorporate them in the Medicare program, and as they get older, keep them in the program.

Q: What about reducing the number of health insurers? Would that make financial planning at hospitals, for example, easier?

OF: The studies we've looked at show that since administrative costs of multiple health insurers are on average 20 percent to the insurance company and up to 40 percent to the physician because they have to hire extra staff to deal with multiple insurers and challenge unjustly denied claims. [Physicians for a National Health Program] decided to compare Toronto General in single-payor Canada with Massachusetts General Hospital in Boston, since they are similarly sized. At Toronto General, there were three billers in the billing office; Massachusetts General had over 300.

Frankly, every single-payor bill that exists in Congress includes jobs retraining, so if we went to single-payor, there wouldn't be this concern. We haven't actually seen a good economic study of how many fewer employees you would need in the insurance sector. Some people have looked at the issue in terms of the amount of time a primary care physician has to spend dealing with prior approval, denial of claims, so on and so forth. Larry Casalino, MD, PhD, [chief of the division of outcomes and effectiveness research at Weill Cornell Medical College] shows that in terms of income, practicing primary care physicians are probably spending an enormous amount of money having to deal with multiple insurers.

Q: If you were in charge of CMS, what would be some of your main initiatives?

OF: Initially, I would try to figure out a good strategy to reduce payments to the private health insurers who take Part C and see if we couldn't get that down to a more reasonable amount of money. CMS doesn't control the percentage of payroll tax, and CMS doesn't control how to get more money into the system. All that it could control is how to spend less and do it efficiently.

Medicare's deductable for Part A has become quite substantial. It's now over $1,100. Part B's deductible is $140. Part D's is $335. These are major barriers to low-income patients' access to care. I would like to see them reduced or eliminated. I also would like get rid of the doughnut hole, and the proposal in the ACA will eliminate it later in 2020.

I would propose a lot of things Don Berwick, MD, [former CMS administrator] was doing to boost quality and reduce cost, but they would not be adequate. For instance, penalties for readmissions — yeah sure. But hospitals are paid on a DRG basis, and physicians are paid on a fee-for-service basis. The physician has an incentive to keep patient in hospital longer, and the hospital has an incentive to get the patient out.

To the degree the physician has patients' interest in mind, it may be good for physicians to resist the hospitals' pressures to discharge early. I'm not sure I want to give physicians a financial incentive to do that, but it may make sense that the physician who is close to the patient feels this patient really can't go home, is not medically stable, the home situation isn't ideal to go to yet — I respect that. That's important."

Flu is Hitting US Older People at very High Rates

Influenza, known as "flu," is attacking seniors across the US. 

This strain, H3N2, is emerging as the most dangerous for older people.  USA Today reports that those over 65 years are dying at the rate of 116 per 100,000 persons.  This rate is the highest that the Center for Disease Control (CDC) has seen. Experts expect the death rate to go higher as more elders catch this version of the flu. 

It's not too late to get a vaccination against this virus. 

If you begin to feel sick, contact a doctor right away.  Anti-viral drugs, taken within 48 hours of the onset, are very helpful in preventing complications and keeping people out of the hospital.

Take care of yourself--whether you are 15, 50, 85 or 105 years old.

Susanne Paul
Global Action on Aging