Dear Joe:

It was good to see your column on Medicare in The New York Times the other day. I had heard from a mutual source that you were set to tackle the subject. That’s all to the good since Medicare is so important to just about everyone in the country, and there has been lots of misinformation and disinformation floating around. Medicare is a tough topic to write about. I have been at it for nearly a quarter of a century, and sometimes I am still bewildered by the program. Why, I just signed up for Medicare, and put myself in the shoes of someone trying to figure out the myriad choices for covering Medicare’s gaps. I found it dismayingly difficult. The learning curve is steep.

That’s why I’m pointing out an error that one of your readers has also noted. He correctly points out that other writers have made the same mistake. You say there are parts of Congressman Paul Ryan’s plan that “deserve serious consideration like means-testing,” which you define as “forcing the elderly wealthy to pay more for health care than everyone else,” and that, at the very least, “shouldn’t be dismissed out of hand.” Joe, they are already paying more to receive their Part B benefits, which cover hospital outpatient and physician care, and for Part D, which is the prescription drug benefit. As I have pointed out several times, these benefits are already means-tested, a fact that is just beginning to sink in to those on Medicare. What other kinds of means-testing do you have in mind?

To review: Seniors with higher incomes—$85,000 for individuals and $170,000 for couples—have been paying higher Part B premiums for a while. The monthly premium this year is $115.40, but those with higher incomes pay from about $46 to $254 a month on top of that. Higher premiums for Part D have just kicked in. The premiums vary depending on the kind of drug plan seniors choose from private insurers. In addition to those premiums, seniors are paying from $12 to $69 more. Those with higher incomes also get smaller government subsidies to help pay for their medicines. That’s means testing, and more and more seniors will be affected as the years go on.

You’re right to argue that we need a robust and honest discussion of Medicare’s underlying problem—the relentless rise in the cost of care that the program pays for. But so far, politicians and the press have been reluctant to talk about the real issue here—the inability of Medicare to say “no” to makers of medical technology and health care providers who don’t want their profits curbed. You know, the new tests and treatments that sometimes come into widespread use before the science says whether or not they are effective. Once a doctor or hospital buys this stuff, they have to jack up their prices to pay for it, and that in turns jacks up what Medicare must pay. This is a thorny problem.

Case in point. Last week, The Hill reported that a top Democrat and top Republican on the House Energy and Commerce Health Committee are challenging a recommendation made by the Medicare Payment Advisory Commission (MedPAC) that would require doctors who order large numbers of imaging tests to obtain prior authorization, in an attempt to cut down on their usage. The letter from the pols said: “MedPAC views medical imaging as a major driver of Medicare expenditure growth. Today, we must question the validity of that claim.” Lots of stuff here to explore for future columns!

In the meantime, CJR’s Campaign Desk has some posts that you might find helpful. You might also find useful a Q and A I did with Reporting on Health, a website that’s read by a lot of journos.

Best,
Trudy

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Trudy Lieberman is a fellow at the Center for Advancing Health and a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR’s healthcare desk, which is part of our United States Project on the coverage of politics and policy. Follow her on Twitter @Trudy_Lieberman.