This post takes as its point of departure a remark in comments:
If it boils down to a simple question, then that can be recast as having to convince the elderly of a simple proposition: Their quantum of suffering will have to increase.
I think this observation relies on an over-simplified view of the aged. As you can see in the chart above, according to the Social Security Administration more than 25% of those aged 65 and older have incomes above the median income. When you consider native-born Americans alone, the percentage is even higher but that’s a subject for another post.
Is it unreasonable to reform our system away from first dollar coverage under Medicare for all of those over 65? I don’t think so. I would rephrase the proposition above that the elderly be convinced that they must be willing to pay more of their own costs to the extent that they are able.
Would a few hundred or a few thousand dollars for those in the top income deciles mark the difference between a comfortable old age and living in squalor and eating cat food, as implied by the Left Blogosphere where the Deficit Reduction Committee has been disdainfully dubbed the “Cat Food Commission”? To the extent that there is excess utilization of medical care by the elderly, it might reduce it and by doing so moderate the rise in healthcare costs (if high costs are caused by excess utilization).
“I think this observation relies on an over-simplified view of the aged. ”
My view of the aged is colored by the fact that, in view of their numbers in the general population, they have the highest suicide rate. The world the elderly inhabit is one the young cannot begin to understand, I think. It’s all around a world of loss: loss of health, loss of independence, loss of friends and loved ones. Fear, loss, and isolation are, I’m afraid, the condition of most elderly.
Perhaps as you say, those who can afford it can be convinced to contribute more to their healthcare and so on. Maybe this will have to be done. But we shouldn’t think it won’t come at price for all the elderly that a mere dollar figure can hope to capture.
sam, are you suggesting that making life worthwhile is something that’s within the power of government to ensure? I sincerely doubt it.
That the elderly have a higher suicide rate is not surprising. Living longer means you have more time to accumulate problems and isolation is frequently a problem of the elderly. I’m not certain what the government might do that would prevent an elderly person from being isolated, from having become an alcoholic, or from losing all of his or her money at the track.
H0wever, I’m pretty convinced that if paying an extra $100 or even $1,000 in healthcare expenses drives a 65 year old who’s making more than $100,000 a year to suicide, there are other problems involved.
Alongisde income levels we should also be considering net worth levels as well as expenditure details. The income & expense & net worth profiles of a young family with children are going to be different from a retired couple even if the income levels are the same.
There’s a certain amount of insanity that tends to accompany this topic. Some very isolated people aside, the vast majority of elders have kids, grandkids, or other family members that they presumably intend to bequeath their wealth to someday. Every dollar they save now on Medicare comes straight out of those future beneficiaries’ pockets. And for the very wealthy elderly, it may even come at the cost of an estate tax.
I think it would be interesting to determine why the distribution of income in not “normal” in a statistical sense. That peak in the 50k-79k bin is not something I would have expected. I’m sure the deviations from “normal” are due to who chooses to retire versus who chooses (or even HAS the choice) to continue working, but I think any discussion needs to address the underlying reasons.
That’s not the way I read Sam’s comment. He’s saying that among the losses suffered by the elderly are some withing traditional government purview.
BTW, as we look at current retirees’ incomes should we worry that they are the last great Defined Benefits generation?
Let’s look at the specific diction.
What does that mean? If it’s not just a rhetorical flourish, I take it to mean things that aren’t within the realm of government. Perhaps I’m misunderstanding what he’s saying but I take it to mean that regardless of income or wealth reducing the benefit being given to the aged will result in some, presumably psychic, damage.
Preserve one’s independence and autonomy might be something like that. I support Medicare and Social Security for just those reasons but I think the benefits are quantifiable, at least to some degree. As I said either in the post or comments the indigent elderly may not be the responsibility of the federal government but that doesn’t mean that taking care of them doesn’t come from the public purse.
sam –
My friend, are you currently in a dispirited mode? When was this ever different?:
“My view of the aged is colored by the fact that, in view of their numbers in the general population, they have the highest suicide rate. The world the elderly inhabit is one the young cannot begin to understand, I think. It’s all around a world of loss: loss of health, loss of independence, loss of friends and loved ones. Fear, loss, and isolation are, I’m afraid, the condition of most elderly.”
I’m with Dave, government will not fix these issues.
And I should come clean. My views on what the well-off must do to get us out of this pickle re: SS and Medicare probably exceed what any of you think based upon my past commenting record. That’s just a pragmatist’s view. As a point of equity and adherence to contract, its the mother of all travesties and the prime justification for limited government, but as a pragmatic matter, inevitable.
Our federal budget is becoming a transfer mechanism to send money from the young to the elderly. It is not sustainable and needs to change. Since Social Security is a minor problem, we need to solve Medicare. You could make the elderly pay for more of their care, but I see no evidence that will do much to control costs (except at extremes), which is the real problem.
Steve
Despite knowing in advance that it will have no resonance with the numbers people here . . .
We have a problem of philosophy. In particular our attitudes toward death.
Right now we believe that all life is precious and that we must do all we can to prolong it, without regard for cost to society or to family (both financial and emotional.) We believe that individuals should not be able to decide to die but must avail themselves of every means to prolong their lives. In some sense we define death as failure. Not as a natural and inevitable thing, but as a failure of will or technology.
We end up vowing to go all-in, cost be damned, to keep 90 year-olds alive until their 91st birthday. Even if they don’t want to be kept alive.
A more rational approach might have the terminally ill, or the incurable and suffering, able to decide for themselves how many resources to commit and how long to prolong life. And make those decisions in a philosophical environment that suggests they look long and hard at the cost to society and their families.
Until we change how we think about death we are trapped by our own presuppositions into the kind of “whatever it costs!” trap we’re in now.
Oh, and before anyone says we can’t alter philosophies, sure we can. Look how much our attitudes toward the environment have changed in just a few decades, or our attitudes toward animals, or people of different races. These are all at base philosophical beliefs that have changed radically in a very short space of time.
A more rational approach might have the terminally ill, or the incurable and suffering, able to decide for themselves how many resources to commit and how long to prolong life.
There is plenty to merit to the general theme of your position, but it can’t be grafted onto existing social programs. P.J. O’Rourke channeling Milton Friedman:
Valid points Michael. I actually do see some patients who decline treatment, saw one today, so as to leave more money for their family, and they dont think the treatment will do much. However, most people dont really think about death and plan for it ahead of time. The decisions are then made under duress. Usually when tired. Part of the reason I dont see markets working well. People are not rational at these times.
Steve
OT, but for you Michael.
http://andrewsullivan.theatlantic.com/the_daily_dish/2010/11/quote-for-the-day-ctd.html
Steve
3. You spend other people’s money on yourself. You get what you want but price no longer matters. The second wives who ride around with the middle-aged men in the Porsches do this kind of spending at Neiman Marcus.
Cute. So why have we all stopped throwing trash out of our cars onto the street? Why do we drive around with the soda cans in our cars, waiting until we find a proper trash can, rather than simply spend the public’s money in he form of road clean-up crews? We changed the way we thought about the commons. A philosophical shift not connected to money.
Steve:
It was a rare moment of wit for the Simpsons. I really wish they had ended the series 4 or 5 years ago. I know it still makes money, and yes, I’ve dragged series on longer than maybe I should, but The Simpsons was brilliant in its day.
Let me go way, way out on a limb here and try to explain what I was getting at.
In Aeschylus’s Agamemnon, Agamemnon is ordered by God to sacrifice his daughter Iphigenia that the Greek fleet will get fair winds to Troy. He does so under necessity, under the command of God. The Chorus, the moral voice in the play, holds him blameless for the act. What they do not hold him blameless for is his attitude towards the act. Clytemnestra voices the attitude of the Chorus in her own speech:
“Holding her in no special honor, as if it were the death of a beast where sheep abound in well-fleeced flocks, he sacrificed his own child.”
Even though he acted under necessity, his attitude toward the act condemned him: he conformed his feelings toward the killing with the necessity that impelled it: He killed her without remorse, with no more feeling than if she were a mere animal.
I’ve acknowledged that we, under necessity, may have to curtail to health care given the elderly — and this necessity may well impel us to curtail it down the line, not just for those financially able to bear the cutbacks. I’m just asking that we not delude ourselves, conform our feelings to the necessity, and devalue the suffering that this may cause. But if talk about the elderly and their “ill-gotten gains” –as if they were nothing more than parasites–becomes the norm, I fear we’re well on our way to that.
“I’ve acknowledged that we, under necessity, may have to curtail to health care given the elderly — and this necessity may well impel us to curtail it down the line, not just for those financially able to bear the cutbacks. I’m just asking that we not delude ourselves, conform our feelings to the necessity, and devalue the suffering that this may cause. But if talk about the elderly and their “ill-gotten gains†–as if they were nothing more than parasites–becomes the norm, I fear we’re well on our way to that.”
Spare me the crying towel, sam. The “ill gotten gains” relate to SS. And its just a matter of arithmetic.
I also always make an inquiry of people at this point of debate. If you want to take the position that it is just the correct humanitarian position to take to care of everyone who is downtrodden, no matter the cost, then why does that end at our border? After all, there are downtrodden people world wide. Taking care of the downtrodden in the US is bringing us to the point of bankruptcy. Imagine if we attempted to take care of the world? We would all be basically broke and destitue as well. (But its humanitarian, you know.) These humanitarian invokations are just designed to pull at heartstrings, and are meaningless.
Can we get that chart with wealth? When you retire income naturally drops, no big shock really. However, many people aren’t going to retire and live a mean and nasty life–that is they may have a sizable amount of assets that they can draw down during their remaining years. Or failing that consumption. Measuring welfare by income is at best a questionable proxy.
So to help the young understand we impose on them a loss of income? And given the way our current systems are structured in the future that will likely become a sizable loss of income too.
Really? Which ones? Lets see can government stop the ravages of aging on human health no. Can they slow it down? No. At best they can deal with some effects, but here the incentives are hugely important. Right now the incentives are messed up? That is why we are looking at the kind of problems we ware looking at. Health care consumption for the elderly needs to be reworked. That will almost surely result in a reduction in said consumption.
Michael,
Don’t be so sure….because I agree with you. Do families always make the right decision when a loved one is terminally ill. Is the phrase, “Do everything you can,” that a loved one utters the same phrase that the terminally ill person might utter? Might they say, “I’m ready, I’ve had a good long life and I’m tired and pain, and I want to go.” I can see how people might say the latter and how family and loved ones might have an issue with it and prefer the former. But are we “doing everything we can” for the person who is sick….or the family and loved ones?
See Michael, some of us number people might surprise you.
The $1,000 fine probably didn’t hurt either. 🙂
But you are right we can change our philosophy.
steve,
Especially when price is not a factor.
sam (again),
Down the line health care for the elderly will be curtailed one way or the other. We can agree to try and do it rationally now, or just let things continue and let the chips fall where they may.
Unfortunately you have people like those you can find at Fire Dog Lake that have decided that just about any change has to be labeled the “cat food” policy.
My guess is that we wont be able to decide rationally. Democracy is not about being rational. Its about power.
I’m not the least surprised that Drew utterly and completely missed my point.
Damn, there’s a fine? Does it apply to cigar butts that might “accidentally” fall from my fingers as I’m driving down the freeway?
Hey, they’re biodegradable. Plus the hobos love a good cigar butt.
Why do we drive around with the soda cans in our cars, waiting until we find a proper trash can, rather than simply spend the public’s money in he form of road clean-up crews?
Yes, there’s a fine Reynolds.
However there were other considerations. Most people noticed the amount of trash building up besides the road and decided they didn’t like it. The government didn’t really do a good job of cleaning up all the refuse. I don’t blame them in that as there was so much of it scattered over too much territory. Only widespread behavioral changes would fix the problem.
And keeping some extra trash in one’s car until getting to a trash can really isn’t that big a sacrifice.
On the other hand, letting Mom and Dad die because they can’t get medical treatment would be a big deal for most people. So the situations aren’t exactly analogous.
I will rely on your greater expertise in this area. 😉
On the other hand, letting Mom and Dad die because they can’t get medical treatment would be a big deal for most people. So the situations aren’t exactly analogous.
That said I think a great many people are changing their attitudes about death. When my brother found out he had advanced lung cancer about 2 1/2 years ago he decided to forgo treatment. He actually lasted almost a year longer than the doctors had expected.
But there was something of a downside. He also refused to let them biopsy his tumor as it would had required some non-minor surgery, due to the placement of the tumor. If he HAD let them do the biopsy, they would have been able to determine much sooner that he had a somewhat rair form of the cancer – one that was alot more treatable than he thought. In other words, my brother essentially killed himself because he didn’t want to go under the knife. If he had he may have lived long enough (and painlessly enough) to die from a stroke/runaway bus/crazed emu attack/aneurysm instead, which would have been much less agonising. But it’s hard to know the future….
“Especially when price is not a factor.”
How many people would you expect to be comfortable enough with death to immediately start negotiating prices? Besides, price is almost always a factor. Not many people have insurance that covers everything.
Steve
Well, sam. You took my reference to “ill gotten gains,” a perfectly valid observation, and twisted it into calling the elderly parasites. I simply responded.
If I could beg of you, how did I “utterly and completely miss” your point?
And you, Mr. Reynolds, could I beg of you that you limit the cigar intake? (I’ve made a similar request of Mr. Knapp, who combines the pleasure with Scotch, a wicked combo.) I was at a wine tasting dinner this past Saturday and one of the participants was an oral surgeon. The things he had to say about tobacco and oral cancers was sobering.
I may not agree with your politics, but I’d like to have you around for the quality of the books.
Drew:
Goddammit my wife got to you didn’t she?
I am actually considering it. It has occurred to me that a diet of cigars and whiskey may not be healthy. I’ve had the misfortune of seeing myself on TV and in videotapes a lot lately. I’m 56 and don’t look a day over 70.
Now Michael, and I mean this in only the best way, I had you at low 60’s. Sorry.
Seriously, this surgeon told us that he actually smokes cigars. The natural question was WTF?!
Are you sitting down? He smokes them with cold Kaluha. Why? To provide a basic ( as in acid and basic) chemical opposition to the tobacco juices. And reduce the temperature effect.
So see, MR, I’m your best friend. You can tell your wife to stick it, because Drew says cold Kaluha and cigars are just fine.
Yeah, you try that with her. ;->
steve,
I don’t doubt that there are cases where price crops up, but it is not nearly enough of a factor. That is why we are in the situation we are in. We have really no way of rationing health care right now. That is why we have unsustainable growth rates. Any other explanation just doesn’t work.
The real reason why people don’t like the idea of markets in health care is for one simple reason:
People with treatable problems wont get treatment and will suffer and/or die.
That is it. All other considerations are minor. We don’t worry if someone can’t get a car…so markets are fine. We don’t mind if people can’t get a book, dvd, computer, television, or the latest cell phone….so markets work fine. But when grandma has a treatable condition, but can’t get treatment its a wonderful issue for politicians to run on. Everybody worries about being in that situation so its a comforting policy to put in place. Not only that, but now you don’t have to save for health care when you are elderly either (or at least not as much) and consumption today sure as Hell beats consumption 35 years down the road!
I think that the cartel pricing explanation I’ve related here a number of times works, too, at least as a contributing factor.
Cartel pricing can explain a one time price increase, a growth rate over and above the economic growth rate? No, something else is needed.
We do have a growing cohort of elderly who are living longer and longer…and shocking are also using more and more health care. And thanks to Medicare the issue of price, for the patient, is not much of a factor at all.
Now maybe using the market to allocate health care is not something people want, but having the current set of constraints is clearly a failed proposition. But any, and I mean any, attempt to address the cost problem is one that is automatically vilified in our system by whatever side is not putting forward a potential solution.
A reasonable solution is not politically feasible. This is why I think the moderates are being extraordinarily foolish. You think that that there is a solution when the simple answer is there is not. The best you can hope for is postponing the day of reckoning, but you’ll never solve the problem entirely.
Look at recent history.
Was propping up zombie banks a good idea?
Has finance reform brought added transparency to the market and reduced the likelihood of future crises?
Will health care “reform” reduce the growth rate of costs?
The answer is no, no and no.
But I’m sure there is a pony in there somewhere if we just keep looking.
“But any, and I mean any, attempt to address the cost problem is one that is automatically vilified in our system by whatever side is not putting forward a potential solution.”
Which is our real problem. There are ways to solve the cost issue. It is our politics which prevent it.
Steve