I’m just five months away from eligibility for Medicare.  Aging isn’t the most pleasant of prospects but, as the television ad says, one of the good things about turning 65 is Medicare.  Yes, indeed.

I’m comparatively lucky that, a year after I returned to the States from Europe, where I had lived for 27 years, I managed to purchase health insurance.  This was a new experience for me, after enjoying the benefits of Britain’s National Health, and it came with all the usual issues.  Like almost any one in their sixties, I had “pre-existing conditions.”  One of them was hypertension, which is so prevalent --twenty-four percent of the adult, civilian, non-institutionalized population of the United States suffers from hypertension—that to use it as a condition that disqualifies people from securing health insurance is a major threat to public health and the economy.  (We’ll discuss that at length in another essay.)  In the end, I got my insurance, but it initially wouldn’t cover blood pressure or my glaucoma.   But, at $450 a month it was, from everything I heard, comparatively cheap, although there were co-pays and deductibles.    Still, when I went into hospital for a week at the end of last year, the insurance company, to my relief, paid for almost everything without hesitation.  It might not have.

Anticipating my switch to Medicare in November, I have begun to read all about the way it works and what its limitations are—and they are certainly real.  But, whatever else may be said, gaining access to Medicare produces a small revolution in many people’s lives.  That is because, as a 2010 report on health in the United States, produced by U.S. Department of Health and Human Services (with the Centers for Disease Control and Prevention and the National Center for Health Statistics), tells us, in 1993-94, 18.9% of U.S. adults between the ages of 18 and 64 had “no usual source of health care.”  By 2008-9, this had risen to 19.5—one in five!  This is one of the reasons that, among the 34 OECD (Organization for Economic Co-operation and Development) countries, the most developed nations in the world, the five with the highest poverty rates are, in order, (5) Turkey, (4) the United States, (3) Chile, (2) Israel and (1) Mexico.

The particular paradox (or crime, if you will) that confronts and challenges the United States is that, unlike Mexico or Turkey, it is widely regarded as the most prosperous country in the world.  Yet, its immense aggregate wealth is apportioned in such an inequitable way that it condemns vast numbers of its citizens to real or near poverty for most of their lives.  Such victims, not of their own inadequacy but of the nature of our profit-driven economic system, cannot afford basic health care.  Over the years, the U.S. has only managed, by various means, grudgingly, to devise an awkward, costly and largely ineffectual system for dealing with this urgent social problem, one of the most critical of our time.  But, it is far from ensuring universal quality care commensurate with our potential as a nation.

As Wendell Potter, the former head of corporate communications for health-insurance giant Cigna and now a leading industry critic, notes, Obama’s Patient Protection and Affordable Care Act undoubtedly remedies some of the worst abuses of the current system (or will, after all its provisions kick in over the next few years).  But, it singularly fails to rise above the conventional assumption that the market can should remain the principal mechanism through which people acquire adequate and secure health care—not surprisingly, since it was modeled on the Massachusetts health reform of Republican governor Mitt Romney.   As a 2009 report by doctors at the Harvard Medical School concluded, while that state reform “improved access to care for some residents, many low-income patients who previously received completely free care under the state’s old free care program now face co-payments, premiums and deductibles that stop them from getting needed care.”

According to a study in the American Journal of Medicine (March 2011), the Massachusetts reforms did little to effectively protect people against bankruptcy in the face of medical expenditures.  As one of its co-authors, Dr. David Himmelstein, now a professor of public health at City University of New York, has said, “Massachusetts’ health reform, like the national law modeled after it, takes many of the uninsured and makes them underinsured, typically giving them a skimpy, defective private policy that’s like an umbrella that melts in the rain: the protection’s not there when you need it.”  As a result, bankruptcies have not significantly declined.  As the AJM study observes: “Health costs in the state have risen sharply since reform was enacted. Even before the changes in health care laws, most medical bankruptcies in Massachusetts – as in other states – afflicted middle-class families with health insurance. High premium costs and gaps in coverage – co-payments, deductibles and uncovered services – often left insured families liable for substantial out-of-pocket costs. None of that changed. For example, under Massachusetts’ reform, the least expensive individual coverage available to a 56-year-old Bostonian carries a premium of $5,616, a deductible of $2,000, and covers only 80 percent of the next $15,000 in costs for covered services.”

As far as the U.S. in general is concerned, given our reliance on private insurers, too many people get inadequate value for money.  While the CEOs of the major insurance companies do very nicely (in 2010, for example, the CEO of Cigna received total compensation –salary, bonuses and stock— of over 15 million dollars), many of their customers get insufficient and unreliable care.  Too many others, priced out of the market, get none at all.  As a result, if you compare the U.S. to other OECD countries, we are an utter shameful case.  In 2009, for example, U.S. Infant  mortality was the fourth worst in the OECD, after Mexico, Turkey and the Slovak Republic.  (This is closely related to the percentage of U.S. children living in poverty; we are fourth, after Mexico, Turkey and Poland.)   In its 2010 report, Deadly Delivery: the Maternal Healthcare Crisis in the United States, Amnesty International reported that “women in the USA have a greater lifetime risk of dying of pregnancy-related complications than women in 40 other countries….the likelihood of a woman dying in childbirth in the USA is five times greater than in Greece, four times greater than in Germany, and three times greater than in Spain.

There is little doubt that these disparities largely reflect our failure to universalize health care and to depend, instead, on for-profit health insurance which not everyone can afford.  Thus, in 2008-09, for the 44-64 age group --a group that is particularly prone to a wide range of preventable or treatable diseases, including diabetes, cardiovascular disease, cancer, etc.-- 11.6% had no health insurance.  About fifteen percent did not get or delayed seeking medical care due to its cost, meaning that conditions become progressively more complicated and costly to treat.  The impact, for the individuals concerned and for society collectively, is immeasurably destructive.

But, here’s the crucial point: the percentage of people without health insurance drops dramatically to 5.1%, for those 65 and over.  The reason is very simple: Medicare.  If you are poor and can just hang on until the last decades of your life, you can finally manage to obtain access to the medical care that you always needed.

Of course, as I’ve learned, Medicare is hardly perfect.  It was never made to provide complete coverage, so it is essential to top it up with a Medicare Supplement Insurance (Medigap) plan, to cover co-payments, coinsurance and deductibles.  What this means is that Medicare, as presently constituted, not surprisingly provides business for the health insurance industry.  But, what of the elderly poor-–and 16 percent of people 65-74 years of age and 23 percent of people 75 years or older are poor or near poor-- who lack the financial resources to purchase supplemental insurance?  For many, as Diane Rowland and Barbara Lyons, of the Henry J. Kaiser Family Foundation, wrote in 1996 in the Health Care Financing Review, “gaps in the scope of Medicare's benefits and financial obligations for coverage can result in onerous financial burdens.”  For several million elderly poor, Medicaid (a federal and state funded means-tested program for people and families on low income) provides their Medigap coverage.  But, it does not reach everyone.

Medicare, for all its manifest virtues, is far from being an effective means of providing access to quality health care for all people above 65.  As Rowland and Lyons go on to note, “Although Medicare coverage is universal, ability to pay for Medicare's cost-sharing requirements varies for elderly people at different income levels and with different levels of insurance supplementation.  Lack of supplementary coverage, through private insurance or Medicaid, to fill gaps in Medicare coverage influences access to health services by elderly people.  One-half of the population that relies solely on Medicare is poor or near-poor and likely to experience financial burdens that jeopardize access to care.”

The answer, however, is not, as most Republicans advocate, to alter Medicare in such a way that even more people are unable to meet the costs of necessary health care.  Medicare is the closest thing that we have in this country to a model for how we could act like a truly civilized country.  So, what we really need to do now is make it work as effectively as possible--not just for me, but for everyone.