Well, the answer is nothing. It does what it is designed to do, protect the elderly from being uninsured. And everything.

In 1966, when Medicare was young, it covered the elderly for the first time. At the time it was passed, only one in eight elderly persons had health insurance. Commercial insurers disdained this group as unprofitable due to their high medical costs. Medicare gave Social Security recipients some protection from the high cost of medical care. Without this protection, much of the elderly person’s income could be eaten up in medical costs.

Of course, mistakes were made. I came on the scene in 1970 as a nurse, and vividly remember old people who definitely misused their coverage. Such as one old gent who would get his bowels bound up, report in for an enema, and be admitted for a couple of days to get him straightened out. Whereupon he would order from the kitchen a grilled cheese sandwich, apparently the only thing he ate. Which is why he had the problem in the first place. Eventually these things made the cost of the program go up, and things like co-pays and deductibles were added to the program to keep costs down.

Medicare has four parts nowadays, labeled A, B, C, and D. At first Medicare only had Part A and B. Part A is hospital insurance, and it doesn’t have a premium. You get it when you get your Social Security. Part B is coverage for doctors and some other things liked durable medical equipment. It is not mandatory, and has a premium. The original premium was $3 in 1965. In 2000, it was $45.50. Today in 2008, it is $96.80, having increased 96% in the last eight years. Thank you President Bush. Need I mention that our Social Security COLAs (cost of living allowances) haven’t gone up anywhere near 96% in the same time period?

Part C is the Medicare Advantage plans, which are also voluntary. Many of them are administered by HMO’s, and will give you more coverage than Original Medicare. For instance, the plan I am in will cover minimal dental and vision care, something not covered by Original Medicare. These plans were an attempt to sneak in some privatization of Medicare. Unfortunately, they are heavily subsidized and will probably be cut as inefficient and costly in the near future. Many insurance companies are dropping them. It is relatively expensive, and the cost is on top of the Medicare Part B premium, and you must maintain your Part B coverage to be eligible for them. Did I mention the 96% rise in Part B premiums over the last eight years? I did?

Medicare Part D is prescription drug coverage. It is more or less mandatory, in that if you don’t sign up for it when you are eligible, it costs you more when you do sign up. It has been a boon, I am sure, to some people who didn’t have drug coverage previously, but for many others, it is known as Medicare D(isaster) for good reasons. The people hardest hit were the so-called “dual eligibles”, those people eligible for both Medicare and Medicaid. They went from paying nothing for their prescriptions on Medicaid, to at least having a $1-3 copay for their prescriptions. These people live on SSI, which now is about $650/month. Suddenly having this cost affected their already meager income adversely. At that income, their food stamps are also meager, less than $50/month, and so now they are faced with buying food or buying their medications that used to be free.

The other “wonderful” part of Medicare D(isaster) is the “donut hole”. This is a level of coverage where you must pay full costs of your prescriptions after you and the insurance company combined have paid a certain amount. After you have accumulated another amount, coverage kicks back in at 100%, so called catastrophic coverage. The intent was to encourage people to use generic drugs whenever possible to lower costs. Only two of my seven prescriptions are non-generic, and I will still hit the donut hole sometime towards the end of the year. Which combined with the deductible that will be due in January, makes for a fun and exciting Christmas season.

So, how would I, in my infinite wisdom, change Medicare?

A) Reverse priorities. Make doctor’s care primary and hospital care secondary. Make keeping people out of hospitals a priority. Hospitals are the most expensive component of medical care. To do this, increase what primary physicians are paid to see Medicare patients in their offices to a decent level, and increase preventitive screening programs.

B) Pay for folks drugs. Really, if most people took their meds as ordered, it would keep a lot of them out of the hospital and ER. Especially if they didn’t have to choose between eating, heating and their medications. I really hate January because of the deductibles and the high heating costs. Did I mention how much fun Christmas is with the doughnut hole?

C) Have the fiscal year start in July instead of January, when heating costs are high. Then the deductibles wouldn’t be such a pain. Of course, you could leave them in January in areas of the country where cooling costs are higher than heating costs.

D) Eliminate the donut hole. I imagine that the administrative costs of this thing outweigh any savings it produces for the government. And while we are at it, allow the government to bargain with the pharmaceutical companies for the lowest cost of drugs.

E) With the proliferation of $4 generic drug programs, allow elders to get their generics from one of those programs, and just cover the non-generic prescriptions. It would save me money, because my generic co-pay is $5, and maybe then my non-generic co-pay could be less than the present $35 for Tier Two meds. God help me if I ever need Tier Three or Four meds.

Right now I am paying approximately 25% of my income just in insurance premiums and co-pays. I don’t know if I can continue to afford this. But since I don’t have any savings, if I don’t continue with the Medicare Advantage plan, the deductibles for Original Medicare will kill me. This way I never see the money, so I don’t miss it as much. If I had it, I would probably spend it on something foolish, like food or heat. Go figure.