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Vocapedia > Health > Health Insurance > USA > Medicare


Federal health insurance program






What is the difference between Medicare and Medicaid?

Video        Caregiver Generation        23 November 2011















































































































Supporters of Medicare

at the Democratic National Convention

in Atlantic City, N.J., August 1964.


Tuesday was the 54th anniversary of the bill’s signing.


Photograph: Associated Press


Medicare for All? For More?

Here’s How Medicare Works

As Democrats embrace the idea of expanding the federal health insurance program,

we looked at what it covers and costs. It’s far from “free.”


July 31, 2019




























how-fraud-increases-medicare-spending-covid-19-testing - December 30, 2022
































































































































































Medicare's eligibility age










Medicare coverage












Hospice began more than 60 years ago

as a countercultural charity movement

to help patients die with comfort,

support and as little pain as possible.


After the 1980s,

when President Ronald Reagan authorized

Medicare to cover the service,

dying became a big business.


In 2000,

less than a third of all hospices

were for-profit.


Today, more than 70% are.


Between 2011 and 2019,

the number of hospices

owned by private equity firms



For profit-seeking providers,

hospice is lucrative:

Medicare pays a fixed rate per patient a day,

regardless of how much help is offered.


The aggregate Medicare margins

of for-profit providers

hover around 20%

compared with just 5% for nonprofits.


congress-industry-leaders-call-for-crackdown-on-hospice-fraud - December 19, 2022


hospice-healthcare-aseracare-medicare - November 28, 2022








Medicare > dental care










Medicare > dialysis care










Medicare beneficiaries










Rashi Fein        USA        1926-2014


influential economist

who strove to bring ethical

and humanitarian perspectives

to the nation’s health care system

and helped lay

the intellectual groundwork

for Medicare in the 1960s













Corpus of news articles


Health > Health Insurance > USA > Medicare


Federal health insurance program



Medicare for All? For More?

Here’s How Medicare Works


As Democrats embrace the idea

of expanding the federal health insurance program,

we looked at what it covers and costs.

It’s far from “free.”


July 31, 2019


By Abby Goodnough


Medicare, the federal health insurance program for people who are 65 or older, has become something of a panacea in the Democratic presidential race.

Some candidates, including Senators Bernie Sanders and Elizabeth Warren, want to give it to everyone and even expand its benefits. Others, like former Representative Beto O’Rourke, want to give it automatically to people who don’t have other health insurance. Many, including former Vice President Joseph R. Biden, want to give people the right to buy into a Medicare-like public health insurance program.

Whatever their positions, Medicare is what most of the candidates are holding up as a model for universal coverage, a goal they all embrace.

Medicare is popular among its 60 million beneficiaries, but the program also has limitations, and it is certainly not “free.” Co-payments can be high for some people, especially for long-term hospitalization and some medications. Some Democratic proposals, including those from Mr. Sanders and Ms. Warren, would change that by eliminating premiums and deductibles, and pay for the program instead with higher taxes.

As expansion of Medicare becomes a campaign season rallying cry, we took a look at what it’s like to be on Medicare now.

Here are some answers to basic questions.

What exactly does Medicare cover? Are the benefits good?
The benefits are comprehensive, though not exhaustive. Medicare divides benefits into categories. One, Part A, covers inpatient care at hospitals and — with some limits — skilled nursing facilities, where people often go to recover from an injury or illness. It also covers hospice care and, in some circumstances, home health care. Another category, Part B, covers doctor appointments, outpatient procedures and tests, some mental health services, as well as wheelchairs, walkers and other equipment. Prescription drugs are covered under Part D. Part C is a privately run managed care option called Medicare Advantage.

What doesn’t Medicare cover?

Medicare does not cover glasses, basic eye exams, hearing aids and most dental care — frustrating omissions for many beneficiaries, who are at an age when they are more likely to need these services. It also won’t pay for care received outside the United States.

But by far the most expensive thing Medicare doesn’t pay for is long-term care in nursing homes, assisted living facilities or at home. Some people buy long-term care insurance, or spend down their assets to qualify for Medicaid, which does cover nursing home care. A private room in a nursing home cost an average of $100,375 last year, according to Genworth, a financial company.

How much does it cost?

Part A typically has no monthly premiums (like Social Security, it’s financed by payroll taxes all workers pay), but it has a deductible of $1,364 per “episode of illness,” plus a fixed amount — as high as $682 a day — if you spend more than 60 days in the hospital.

For Part B — doctor’s visits and outpatient care — premiums are based on income. The standard premium this year is $135.50 a month, but financial help is available for people with low incomes who don’t qualify for Medicaid, the government health program for the poor, which covers just about everything.

Richer Medicare beneficiaries — individuals with annual incomes over $500,000 — pay $460.50 a month. Premiums are typically deducted from people’s Social Security checks. Part B also has a deductible of $185 a year, and co-payments of 20 percent after you reach your deductible.

Many people buy supplemental “Medigap” insurance to cover Medicare’s out-of-pocket costs.

Unlike Affordable Care Act plans, Medicare has no cap on out-of-pocket spending, so the cost can climb quite high for sick people. An analysis by the nonpartisan Kaiser Family Foundation found that Medicare enrollees in fair or poor health spent an average of $6,128 in 2013, or 47 percent of average Social Security income.

Prescription drug costs can also be high in Medicare, and they represent one of the most complex, confusing parts of the program. Medicare Part D plans are run by private insurers, and the premiums cost $40 a month on average this year, according to Kaiser. There are also annual deductibles before coverage kicks in — they are capped at $415 this year — plus co-payments and coinsurance. But if your income is low enough, you may qualify for extra help paying for drugs, and in some cases, owe no premiums or out-of-pocket costs.

Then, there is the dreaded “doughnut hole” — a gap in which the Medicare drug plans don’t pay for patients’ medications after they have spent a certain amount — this year, $3,820. At that point, enrollees have to pay 25 percent of the cost of brand-name drugs, and 37 percent of the cost of generic drugs, until their total out-of-pocket spending has reached $5,100. Once they hit that, they qualify for “catastrophic coverage,” and only pay a small co-payment for covered drugs for the rest of the year.

Kaiser recently found that one million Medicare beneficiaries had out-of-pocket spending above the catastrophic threshold in 2017, averaging $3,214.

What is Medicare Advantage?

Medicare Advantage is an increasingly popular alternative to traditional Medicare. Advantage plans are offered by private insurers that have contracts with Medicare. These plans have all the same benefits as traditional Medicare, and often more, such as dental care or health club memberships. Co-pays and deductibles vary depending on the plan. Unlike traditional Medicare, all Medicare Advantage plans have limits — $6,700 this year in most cases — on out-of-pocket spending.

Medicare pays Advantage plans a fixed monthly sum for each beneficiary, while in traditional Medicare, providers are paid for each service based on an annual fee schedule. As a result, Advantage plans tend to use tools like pre-authorization requirements and strict provider networks to control costs.

Those restrictions can be a turnoff to people with a lot of medical needs. Some data suggests people with Medicare Advantage tend to be healthier but less wealthy than those with traditional Medicare. One thing is certain: the private plans are growing in popularity. About one-third of Medicare recipients, or 22 million people, now have them, up from six million in 2005.

Can people choose any doctor they want?

This depends largely on whether they have traditional Medicare or a Medicare Advantage plan. Traditional Medicare allows beneficiaries to seek care from any doctor or hospital in the United States that accepts it, and does not require referrals to specialists or prior authorization for services.

But Medicare Advantage plans typically have strict networks of medical providers that beneficiaries have to use unless they are willing to pay more. Some Advantage plans may cover care outside the network, according to the Center for Medicare Advocacy, but the out-of-pocket costs are generally higher than for in-network care. Advantage plans do cover emergency care outside their network — if you are traveling domestically, for example — but nothing else.

Does every doctor and hospital accept Medicare?

No, but most do. According to the federal Centers for Medicare and Medicaid, 2,752 doctors and other providers opted out of Medicare in 2018 — a minute number considering there are more than one million practicing doctors alone. Psychiatrists are the biggest category of doctors who opt out, according to Kaiser.

A small share of doctors who accept Medicare are called “nonparticipating providers,” meaning they can choose to charge Medicare patients higher fees, up to a certain limit. The patients are responsible for paying the full amount beyond what Medicare pays — a practice called balance billing.

It is even more rare for a hospital not to accept Medicare, although some private psychiatric or other specialty hospitals that cater to the wealthy may not.

Can you appeal a decision if Medicare refuses to cover a service?

Yes, although few people take this step, at least according to a report last year by the inspector general at the Department of Health and Human Services. The report found that beneficiaries and providers appealed more than 863,000 denials from 2014 through 2016 — only about 1 percent of the total number of denials during that period. But their success rate was high: About 70 percent of the appeals were fully successful at the first level (there are five possible levels to keep appealing to), according to the report. Most were from providers regarding payments that had been denied, not patients regarding services that had been denied.

Reed Abelson contributed reporting.

Medicare for All? For More? Here’s How Medicare Works,
July 31, 2019,






Medicare and Medicaid at 50


JULY 3, 2015

The New York Times

The Opinion Pages




Medicare and Medicaid, the two mainstays of government health insurance, turn 50 this month, having made it possible for most Americans in poverty and old age to get medical care. While the Affordable Care Act fills the gap for people who don’t qualify for help from those two programs, there are important improvements still needed in both Medicare and Medicaid.

At the time the two programs were enacted in July 1965, advocates of Medicare, which today covers 46 million Americans over the age of 65 and nine million younger disabled people, expected that it would expand to cover virtually all Americans. Although polls between 1999 and 2009 showed consistent majorities in favor of expanding Medicare to people between the ages of 55 and 64 to cover more of the uninsured, it never happened.

Still, its achievement in improving life expectancy and reducing poverty among the elderly has been enormous. Before Medicare, almost half of all Americans 65 and older had no health insurance. Today that number is 2 percent. Analysts say that between 1970 and 2010, Medicare contributed to a five-year increase in life expectancy at age 65, by providing early access to needed medical care. Even compared with people under age 65 who have insurance, those on Medicare are less likely to miss needed care or have unmanageable medical bills.

While Medicare, which covers hospital care, doctors’ services and prescription drugs, is comprehensive, many people are still left struggling to pay premiums, cost-sharing for various services and the full cost of items not covered by Medicare, like dental care and extended stays in nursing homes. Roughly half of all Medicare recipients live on incomes of less than $24,000 per person, and while the poorest of them get additional help from Medicaid, many do not. Medicare still lacks a cap on the amount a beneficiary has to pay out of pocket, the most basic function of insurance. By contrast, the Affordable Care Act puts limits on beneficiary spending per year and over a lifetime.

The Affordable Care Act has helped Medicare beneficiaries by eliminating co-payments and deductibles for preventive care like mammograms and colonoscopies, and by providing discounts for very heavy users of prescription drugs. It will strengthen Medicare as a system through demonstration projects to find new ways to deliver care that will improve its quality and lower its cost. The challenge will be to identify and spread the most promising innovations so that they benefit not just Medicare, but the entire health care system.

Medicaid, the other part of the medical safety net, is a joint state-federal program for the poor. For the past five decades, it has been critical in reducing childhood deaths and infant mortality. It has saved the lives of patients with chronic conditions like heart disease, diabetes and asthma. Last year it covered some 64 million people in a typical month and 80 million people at some point during the year. If Medicaid did not exist, life expectancy in America would be much lower.

The problem with Medicaid is that federal rules give states great leeway in deciding whom the program helps. Many states are so cheap that only extremely poor parents qualify for Medicaid coverage and childless adults are excluded entirely. Texas, for example, only covers parents who earn up to 15 percent of the federal poverty level, or less than $4,000 a year for a family of four, and does not cover other non-disabled adults at all, while other states, including New York and California, offer far better coverage. The result is huge differences across the country for assistance to poor, sick people.

The Affordable Care Act was intended to reduce this disparity by offering additional federal funding for states to expand their Medicaid programs to cover all adults up to 138 percent of the federal poverty level, or $32,913 for a family of four. Yet 21 states, the vast majority run by Republican governors, have chosen not to expand.

Medicaid could be improved by raising its payments to doctors, who often refuse to take Medicaid patients because the rates are so low compared to private insurance and Medicare. Medicaid should also cover legal immigrants, who currently have to wait five years to be eligible, and illegal immigrants, who are currently denied coverage entirely.

Despite the perennial fear that the costs of these two programs will grow uncontrolled, spending in both has been growing at a relatively modest rate in recent years. Medicare and Medicaid have changed and grown over the decades, through Republican and Democratic administrations, to meet new challenges. Their performance and popular support has allowed them to withstand ideologically-driven attacks on their continuance as government entitlements. These programs succeed, in fact, because they entitle all eligible Americans to receive the health care they need.

A version of this editorial appears in print on July 3, 2015,
on page A20 of the New York edition with the headline: Medicare and Medicaid at 50.

Medicare and Medicaid at 50,
JULY 3, 2015,






Obama Proposes $320 Billion

in Medicare and Medicaid Cuts

Over 10 Years


September 19, 2011
The New York Times


WASHINGTON — President Obama’s budget director said Monday that the president’s new deficit-reduction plan would impose “a lot of pain,” and that is clearly true of White House proposals to cut $320 billion from projected spending on Medicare and Medicaid in the coming decade.

Mr. Obama proposed higher premiums and deductibles for many Medicare beneficiaries and lower Medicare payments to teaching hospitals and rural hospitals. He would start charging co-payments to frail homebound older people who receive home health services. And he would reduce the growth of federal payments to states for treating low-income people under Medicaid.

The White House said Mr. Obama’s proposals would cut $248 billion from the projected growth of Medicare in the next 10 years, while shaving $72 billion from Medicaid and other health programs. A large share of the Medicare savings would, in effect, be used to pay doctors, who would otherwise face deep cuts in the fees they receive for treating Medicare patients.

The proposals are part of a package to reduce deficits by more than $3 trillion over 10 years, beyond the $1 trillion in savings already assumed under the debt limit law that Mr. Obama signed in early August. The package includes tax changes intended to raise $1.5 trillion in revenue over 10 years.

Mr. Obama would also allow the Postal Service to cut its losses by ending Saturday mail delivery. He would reduce farm subsidies by $31 billion over 10 years, require federal employees to contribute more to their pension plans, force military retirees to pay more for prescription drugs and charge higher fees to air travelers for “aviation security.”

Jacob J. Lew, director of the White House Office of Management and Budget, rejected suggestions that the White House was going after rich people.

“If you look at the details of what’s in the plan that the president is sending to the Congress,” Mr. Lew said, “there is a lot of pain, and it’s spread — it’s spread broadly and we think fairly.”

Medicare and Medicaid insure more than 100 million people and account for nearly one-fourth of all federal spending. The proposed savings, which provoked predictable protests from health care providers, represent less than 3 percent of what the government expects to spend on the programs in the next 10 years.

Speaking in the Rose Garden on Monday, Mr. Obama said his plan — in the form of recommendations to a bipartisan Congressional committee on deficit reduction — “includes structural reforms to reduce the cost of health care in programs like Medicare and Medicaid.”

The proposal would require new beneficiaries to pay higher deductibles before Medicare coverage of doctors’ services and other outpatient care kicks in. The deductible, now $162 a year, is already adjusted for inflation. Mr. Obama would increase it further by $25 in 2017, 2019 and 2021.

In addition, the White House would increase Medicare premiums by about 30 percent for new beneficiaries who buy generous private insurance to help fill gaps in Medicare.

Many beneficiaries choose these private Medigap policies because they want the financial security they get from the extra insurance. But the White House said this protection “gives individuals less incentive to consider the costs of health care and thus raises Medicare costs.”

Mr. Obama would raise $20 billion over 10 years by charging higher premiums to higher-income beneficiaries and by freezing the income thresholds so more people would have to pay the surcharges.

About 5 percent of the 48 million Medicare beneficiaries now pay the higher premiums. The proportion would eventually rise to 25 percent under the proposal.

Starting in 2017, Mr. Obama would require certain new beneficiaries to pay co-payments for home health care, which is now exempt from such charges. The co-payment would be $100 per episode, defined as a series of five or more home health visits not preceded by a stay in a hospital or a skilled nursing home.

Howard J. Bedlin, vice president of the National Council on Aging, a service and advocacy group, said such co-payments would “significantly increase out-of-pocket costs for many low-income widows with multiple chronic conditions.” Likewise, Mr. Bedlin said, “The Medigap proposal would shift costs onto Medicare beneficiaries.”

Mr. Obama also proposed these changes:

¶ Require drug companies to provide additional discounts, or rebates, to Medicare for prescription drugs bought by low-income beneficiaries. This proposal, opposed by drug makers, would save the government $135 billion over 10 years.

¶ Squeeze $42 billion over 10 years from Medicare payments to nursing homes, home health agencies and rehabilitation hospitals. Cut Medicare payments to nursing homes with large numbers of patients hospitalized because they did not receive appropriate care in the nursing home.

¶ Require doctors to get approval from Medicare for the most expensive imaging services.

¶ Revise the formula for calculating Medicaid payments to states, saving $15 billion over 10 years. Restrict states’ ability to finance their share of costs by imposing taxes on care providers.

¶ Cut $3.5 billion over 10 years from a prevention and public health fund created by the new health care law.

Another White House proposal would save $20 billion over 10 years by reducing Medicare payments to hospitals and other providers for bad debts that result when beneficiaries fail to pay deductibles and co-payments.

Obama Proposes $320 Billion
in Medicare and Medicaid Cuts Over 10 Years,






Senate Passes

Health Care Overhaul

on Party-Line Vote


December 25, 2009

The New York Times



WASHINGTON — The Senate voted Thursday to reinvent the nation’s health care system, passing a bill to guarantee access to health insurance for tens of millions of Americans and to rein in health costs.

The 60-to-39 party-line vote, starting at 7:05 a.m. on the 25th straight day of debate on the legislation, brings Democrats closer to a goal they have pursued for decades and brings President Obama a step closer to success in his signature domestic initiative. When the roll was called, with Vice President Joseph R. Biden Jr. presiding, it was the first time the Senate had gathered for a vote on Christmas Eve since 1895.

If the bill becomes law, it would be a milestone in social policy, comparable to the creation of Social Security in 1935 and Medicare in 1965. But unlike those programs, the initiative lacks bipartisan support. Only one Republican supported a broadly similar bill that the House approved last month 220 to 215, and no Republicans backed the Senate version.

After the vote, lawmakers and Mr. Obama wasted no time leaving for their holiday break, well aware that their return to Washington would mean plunging into negotiations to reconcile the measures passed by the two chambers.

If a deal can be struck, as seems likely, the resulting law would vastly expand the role and responsibilities of the federal government. It would, as lawmakers said repeatedly in the debate, touch the lives of nearly all Americans.

The bill would require most Americans to have health insurance, would add 15 million people to the Medicaid rolls and would subsidize private coverage for low- and middle-income people, at a cost to the government of $871 billion over 10 years, according to the Congressional Budget Office.

The budget office estimates that the bill would provide coverage to 31 million uninsured people, but still leave 23 million uninsured in 2019. One-third of those remaining uninsured would be illegal immigrants.

Mr. Obama hailed the Senate action. “We are now incredibly close to making health insurance reform a reality,” he said, before leaving the White House to celebrate Christmas in Hawaii.

The president, who endorsed the Senate and House bills, said he would be deeply involved in trying to help the two chambers work out their differences. But it is unclear how specific he will be — if, for example, he will push for one type of tax over another or try to concoct a compromise on insurance coverage for abortion.

Senator Olympia J. Snowe of Maine, a moderate Republican who has spent years working with Democrats on health care and other issues, said she was “extremely disappointed” with the bill’s evolution in recent weeks. After Senate Democrats locked up 60 votes within their caucus, she said, “there was zero opportunity to amend the bill or modify it, and Democrats had no incentive to reach across the aisle.”

Like many Republicans, Ms. Snowe was troubled by new taxes and fees in the bill, which she said could have “a dampening effect on job creation and job preservation.” The bill would increase the Medicare payroll tax on high-income people and levy a new excise tax on high-premium insurance policies, as one way to control costs.

When the roll was called Thursday morning, the mood was solemn as senators called out “aye” or “no.” Senator Robert C. Byrd, the 92-year-old Democrat from West Virginia, deviated slightly from the protocol.

“This is for my friend Ted Kennedy,” Mr. Byrd said. “Aye!”

Senator Kennedy of Massachusetts, a longtime champion of universal health care, died of brain cancer in August at age 77.

Senator Jim Bunning, Republican of Kentucky, did not vote.

The fight on Capitol Hill prefigures a larger political battle that is likely to play out in the elections of 2010 and 2012, as Democrats try to persuade a skeptical public of the bill’s merits, while Republicans warn that it will drive up costs for those who already have insurance.

“Our members are leaving happy and upbeat,” said the Senate Republican leader, Mitch McConnell of Kentucky. “The public is on our side. This fight is not over.”

After struggling for years to expand health insurance in modest, incremental ways, Democrats decided this year that they could not let another opportunity slip away. As usual, lawmakers were deluged with appeals from lobbyists for health care interests who have stymied similar ambitious efforts in the past. But this year was different.

Lawmakers listened to countless stories of hardship told by constituents who had been denied insurance, lost coverage when they got sick or seen their premiums soar. Hostility to the insurance industry was a theme throughout the Senate debate.

Senator Sherrod Brown, Democrat of Ohio, said insurance companies were often “just one step ahead of the sheriff.” Senator Dianne Feinstein, Democrat of California, said the industry “lacks a moral compass.” And Senator Sheldon Whitehouse, Democrat of Rhode Island, said the business model of the industry “deserves a stake through its cold and greedy heart.”

The bill would establish strict federal standards for an industry that, since its inception, has been regulated mainly by the states. Under it, insurers could not deny coverage because of a person’s medical condition; could not charge higher premiums because of a person’s sex or health status; and could not rescind coverage when a person became sick or disabled. The government would, in effect, limit insurers’ profits by requiring them to spend at least 80 to 85 cents of every premium dollar on health care.

The specificity of federal standards is illustrated by one section of the bill, which requires insurers to issue a benefits summary that “does not exceed four pages in length and does not include print smaller than 12-point font.”

Another force propelling health legislation through the Senate was the Democrats’ view that it was a moral imperative and an economic necessity.

“The health insurance policies of America, what we have right now is a moral disgrace,” said Senator Tom Harkin, Democrat of Iowa. “We are called upon to right a great injustice, a great wrong that has been put upon the American people.”

Costs of the bill would, according to the Congressional Budget Office, be more than offset by new taxes and fees and by savings in Medicare. The bill would squeeze nearly a half-trillion dollars from Medicare over the next 10 years, mainly by reducing the growth of payments to hospitals, nursing homes, Medicare Advantage plans and other providers.

Republicans asserted that the cuts would hurt Medicare beneficiaries. But AARP, the lobby for older Americans, and the American Medical Association ran an advertisement urging senators to pass the bill, under which Medicare would cover more of the cost for prescription drugs and preventive health services.

Karen M. Ignagni, president of America’s Health Insurance Plans, a trade group, said the bill appeared to be unstoppable. But she added: “We are not sure it will be workable. It could disrupt existing coverage for families, seniors and small businesses, particularly between now and when the legislation is fully implemented in 2014.”

Senate Passes Health Care Overhaul on Party-Line Vote,










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