If you’re nearing age 65, here’s what you should know about Medicare. And no, it’s not free

  • High earners pay more for certain premiums, and there’s no out-of-pocket maximum.
  • If you don’t sign up when first eligible and don’t have qualifying coverage elsewhere, you’ll pay life-long penalties for enrolling late.
  • Medicare does not cover everything, which means you’ll need to plan for extra expenses.

After paying into Medicare through payroll withholdings at work for many years, some people approach their eligibility age of 65 with a misconception that their coverage will be free.

In reality, Medicare comes with a variety of expenses — including premiums, copays and deductibles. High earners pay more for certain premiums, and there’s no out-of-pocket maximum.

“I’d say a full third of people we talk to, who are just starting to do their research, are surprised — some are appalled and flabbergasted — that they have to pay anything for Medicare,” said Danielle Roberts, co-founder of insurance firm Boomer Benefits in Fort Worth, Texas.

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“The ‘Medicare for all’ conversation might contribute to that, because consumers hear ‘free, free, free’ and assume Medicare is already free,” she said.

While Congress begins wading through various bills that aim to overhaul the nation’s health-care system — including a “Medicare for All ” version in both the House and Senate that would come with no premiums, copays or deductibles — it’s important to know that the existing Medicare program begins costing you when you enroll. And if you fail to sign up on time, you could pay a life-lasting penalty.

Each day, about 10,000 baby boomers turn 65. Fidelity Investments estimates that the average male-female couple will spend a whopping $285,000 on health care from that age on.

And, that’s just a starting point. Things that are not covered by Medicare — dental, basic vision, over-the-counter medicines, long-term care — would be on top of that.

This makes figuring out your Medicare coverage a key part of managing your expenses. Here’s what you need to know.

The cost

As long as you have at least a 10-year work history, you pay no premiums for Medicare Part A, which covers hospital stays, skilled nursing, hospice and some home health services. However, it has a deductible of $1,364 per benefit period, along with some caps on benefits.

Part B — which covers outpatient care and medical supplies — has a standard monthly premium of $135.50 this year, although higher earners pay more (see chart below). It also comes with a $185 deductible (for 2019). After it’s met, you typically pay 20 percent of covered services.

Cost of Medicare Part B premiums


″$85,000 OR LESS” ″$170,000 or less” ″$85,000 or less” $135.50
“ABOVE $85,000 UP TO $107,000” “Above $170,000 up to $214,000” Not applicable $189.60
“ABOVE $107,000 UP TO $133,500” “Above $214,000 up to $267,000” Not applicable $270.90
“ABOVE $133,500 UP TO $160,000” “Above $267,000 up to $320,000” Not applicable $352.20
“ABOVE $160,000 AND LESS THAN $500,000” “Above $320,000 and less than $750,000” “Above $85,000 and less than $415,000” $433.40
″$500,000 OR ABOVE” ″$750,000 and above” ″$415,000 and above” $460.50

Source: Centers for Medicare and Medicaid Services. *Part B premiums are based on modified adjusted gross income from two years earlier. So for 2019 it’s based on your 2017 tax return.

Those parts of Medicare don’t cover prescriptions. That’s where a Part D drug plan comes in.

You can get a standalone plan to use alongside original Medicare. Or, you can sign up for an Advantage Plan (Part C), which typically includes prescription drug coverage. If you go this route, your Parts A and B benefits also will be delivered via the insurance company offering the Advantage Plan.

The average cost for Part D coverage in 2019 is $32.50 per month, according to the Centers for Medicare and Medicaid Services, although high earners pay extra for their premiums (see chart below). The deductible for 2019 is $415.

Medicare Part D premiums 2019

If you fail to sign up for Medicare when you first qualify for coverage and you change your mind later, you could face life-lasting penalties, which would make your monthly premiums higher.

Some people with low incomes qualify for programs that reduce their Medicare-related costs. There’s extra help for prescription drug coverage, and some state-run savings programs help with copays, coinsurance, deductibles and premiums.

Avoiding life-lasting penalties

If you tapped your Social Security benefits before age 65, you’ll automatically be signed up for original Medicare (unless you live in Puerto Rico).

“About a month or two before you turn 65, you’ll be automatically enrolled, and your card will just show up in the mail,” Roberts said.

In this situation, you’ll see your Social Security check reduced by the cost of the Part B premium.

If you haven’t yet tapped Social Security, the burden is on you to sign up. In that case, you get a seven-month enrollment period that starts three months before your birthday month and ends three months after that.

Penalties if you don’t enroll

If you fail to sign up for Part B when you’re supposed to, you’ll face a 10 percent penalty for each year that you should have been enrolled. The amount gets tacked on to your monthly premium.

While Part D prescription coverage is optional, the penalty for not enrolling when you were first eligible is 1 percent for every month that you could have been signed up — unless you have qualifying coverage through an employer’s plan.

“We advise people even if they don’t take medicine right now, at least sign up for the cheapest drug plan just so you don’t face a penalty,” Roberts said. “And if something bad happens, you’re making sure you aren’t caught with no coverage.”

Coverage gaps in Medicare

Be sure to think about how you’ll pay for the things Medicare doesn’t cover. For instance, it generally doesn’t cover dental work and routine vision or hearing care. Same goes for long-term care, cosmetic procedures and — for the jet-setters — medical care overseas.

Many people decide to pair original Medicare with a supplemental policy — called Medigap — to help cover out-of-pocket costs such as deductibles and coinsurance. You cannot, however, pair a Medigap policy with an Advantage Plan.

If you end up choosing an Advantage Plan, there’s a good chance limited coverage for dental and vision will be included.

For long-term care coverage, some people consider purchasing insurance specifically designed to cover those expenses.


As Bernie Threatens, Insurers Respond With More Medicare Benefits

Democratic Presidential Candidates  Attend

HOUSTON, TX – APRIL 24: Democratic presidential candidate Sen. Bernie Sanders (I-VT) speaks to a crowd at the She The People Presidential Forum at Texas Southern University on April 24, 2019 in Houston, Texas. Many of the Democrat presidential

Undaunted by threats to implement a single payer form of “Medicare for All” that would put them out of business, health insurance companies are taking advantage of new federal rules to add new Medicare benefits.

Take Anthem, which last week said new supplemental benefits including those addressing social determinants of health have helped boost enrollment in its Medicare Advantage plans by nearly 14% to more than 1.1 million in the first quarter compared to the year-ago period. The operator of Blue Cross and Blue Shield plans in 14 states launched a “social determinants of health benefits package” earlier this year that allows seniors enrolled in its Medicare Advantage plans to get coverage for “healthy meals, transportation, adult day care and in-home personal care,” Anthem CEO Gail Boudreaux said.

But U.S. Sen. Bernie Sanders and some Democrats running for the presidency in 2020 are advocating a single payer version of Medicare for All that would replace the private healthcare system.

Sanders and others argue the single payer version of Medicare for All would eliminate co-payments, deductibles and allow Americans to pick the doctors they want free of insurance company restrictions and provider network rules. Sanders plan would cover a “robust set of benefits” including long-term care as Vox pointed out earlier this month and there would be a transition period for Americans to move to government-run Medicare as envisioned by the Vermont Senator.

The arguments of Sanders and supporters of single-payer Medicare are up against a tide of seniors picking private plans and new rules from the Trump administration that have gradually changed regulations to allow private insurers to expand Medicare Advantage and offer more benefits.

Anthem is the latest health insurer to show record growth in the number of seniors who are signing up for Medicare Advantage plans, which contract with the federal government to provide extra benefits and services to seniors, such as disease management and nurse help hotlines with some also offering vision, dental care and wellness programs. This year, Medicare Advantage enrollment across the country rose to more than 22 million.

Industry analysts see the additional supplemental benefits helping to attract even more seniors to Medicare Advantage with some reports projecting nearly 40 million seniors – or half of the nation’s Medicare population – to be enrolled in such plans within the next five years. Such projections are based on Medicare Advantage being continued by Congress and the next White House.

Meanwhile, insurers say the new rules from the Centers for Medicare & Medicaid Services (CMS) offer those eligible for Medicare more choices.

“With new flexibility introduced for 2019, Medicare Advantage plans were given even more runway to introduce innovative solutions that improve seniors’ health while reducing costs,” said Keith Fontenot, executive vice president, policy & strategy, America’s Health Insurance Plans, which represents the health insurance industry and companies including Anthem, Cigna, Centene and several Blue Cross and Blue Shield companies. “Addressing the social barriers that hinder people from getting and staying healthy is an important way health insurance providers increasingly care for the whole person.”

Health plans and providers, too, say the new rules will make it difficult for a future Congress or White House to upend private Medicare Advantage.

“The ability for Medicare Advantage plans to provide more holistic benefits in community settings will continue to drive Medicare Advantage market share as these new benefits, such as medically-tailored meals, transportation to a grocery store, and home improvements, address consumer needs beyond the traditional benefits offered through traditional Medicare,” said Brenda Schmidt, CEO of Solera Health, a company that connects patients and insurers to chronic disease prevention providers. “This increases the value that plans bring to their enrollees, making it difficult to make a case for uprooting them.”


Should You Sign Up for Medicare if You’re Covered by a Health Plan at Work?

Medicare eligibility begins at age 65, and you get a seven-month window to enroll that begins three months before the month of your 65th birthday and ends three months after the month of your 65th birthday. If you don’t sign up on time, you’ll face a lifelong surcharge on your Medicare Part B premiums, which is why seniors are generally advised to enroll during that initial window.

The rules are different, however, if you’re still working at age 65 and have coverage under a group health plan through work. As long as you have access to health insurance and work for a company with 20 or more employees, you get a special Medicare enrollment period that begins once your health coverage ends or once you separate from your employer — whichever happens first. As such, you don’t have to worry about facing a Part B premium surcharge if you don’t sign up at or around 65.

Doctor sitting next to senior man on exam table, talking

But just because you have a group health plan through work doesn’t mean you shouldn’t sign up for Medicare anyway. In some cases, enrolling right away still makes sense, even if you’re already covered.

Comparing your costs

Though Medicare Part B, which covers doctor visits and diagnostics, charges enrollees a premium, Part A, which covers hospital care, is free for most folks who sign up. As such, it pays to enroll in Medicare Part A at the very least, even if you have a health plan through work. This way, Medicare will serve as your secondary insurance and perhaps cover services your primary insurance plan won’t pay for. The only exception is if you’re contributing to a health savings account; you can’t be enrolled in Medicare and continue funding one, so take that under consideration.

Now Medicare Part B does charge a premium for coverage. The standard Part B premium is $135.50 a month, though higher earners can pay more. There are additional costs associated with Medicare coverage as well. For example, under Part B, you’ll be liable for a $185 annual deductible, and you’ll usually pay 20% of the Medicare-approved amount of the care you receive. This means that if a test or treatment costs $100, you’ll be on the hook for $20.

There are costs associated with Part A, too, even though there usually isn’t a premium involved. Specifically, you’ll pay a $1,364 deductible for each benefit period you’re receiving hospital care, plus coinsurance per day once you’ve been in the hospital for a certain point.

And don’t forget about Part D. If you give up your group health plan through work and get Medicare instead, you’ll need it for prescription coverage, which means you’ll pay a premium for your plan itself, plus copays on your medications.

That said, if you’re paying a small fortune for your group health plan through work, and you’re subject to hefty deductibles and copayments, then it makes sense to run the numbers and see if coverage under Medicare will end up saving you money. This could end up being the case if your premiums aren’t generously subsidized by your employer, or if you happen to have an unusually expensive plan.

If your group health plan offers a relatively narrow scope of coverage, it might also make sense to look at Medicare and see if it’ll better serve your needs. Keep in mind, though, that there are a number of essential health services that Medicare won’t pay for, like dental care, vision, and hearing aids, so be sure to review not only your costs, but also, the coverage you’re entitled to under each plan option.

What’s the best choice for you?

Much of the time, sticking with a group health plan through work will make more financial sense than getting on Medicare (aside from Part A). But if you happen to have a lousy or extremely expensive plan through work, then Medicare could be a better solution. Run the numbers and see where you’re most likely to come out ahead before landing on a final decision.


Want to Expand Medicare? Then Answer the $5 Trillion Questions.

If you think the fight with insurance companies is tough, just wait until single-payer advocates have to go head-to-head with doctors.


The debate over expanding Medicare is at the center of the fight for the Democratic presidential nomination. Yet for such a crucial topic, there are still two questions that advocates—especially those championing Medicare for All—have yet to properly answer.

The first is how to take on the medical establishment and pay doctors less. Medicare for All would eliminate greedy and needless insurance companies, which will fight to the bitter end to keep making their fat profits. But even that battle pales in comparison with taking on the doctors, hospitals, and providers who charge private insurance higher prices for medical services. To understand this, consider where Medicare for All would get its savings. Proponents argue that Medicare for All would increase government spending but reduce overall spending on health care. That’s true; over the course of 10 years, Medicare for All could save $2 trillion. But only about 20 percent of those savings would come from eliminating insurance companies, while another 10 percent would come from cost controls on prescription drugs. The remaining 70 percent would come from cutting rates for medical providers. Without those cuts, health-care spending could increase more than $3 trillion under Medicare for All. That’s a $5 trillion swing, all determined by the question of how to tackle the medical establishment.

During a campaign, there’s good reason to focus on the insurance industry first; it’s the thing that most people absolutely hate about our broken health-care system. But if the campaign fails to make the case that the prices charged by medical providers are too high, then the politics could shift against Medicare for All once the doctors start complaining. The medical establishment will insist that hospitals will close, especially in poorer areas, and without a set of responses in place, that argument could imperil the push for health-care reform

The political instinct will be to buy off the medical establishment, even as that increases the cost of the proposal. When Aneurin Bevan, the architect of Britain’s National Health Service, was asked how he overcame the initial resistance of doctors, he replied that he “stuffed their mouths with gold.” Today, that would involve maintaining the current high rates seen in private-insurance payments. And even then, when President Harry Truman tried to emphasize how much better off American doctors would be under his universal plan in 1945, they waged what was then the most expensive lobbying campaign in history to defeat it.

If the answer to the first question is to keep paying doctors inflated rates, then the answer to the second question—who will bear the new taxes?—becomes even more important. While overall spending on health care would go down if we spent less on doctors, government spending would still go up. If poorly designed, Medicare for All could place the tax burden on Medicaid recipients (by imposing payroll taxes when they already have low-cost government insurance), professional and unionized workers (who would see their high-end health care disappear), and blue states (if what they currently spend on expanded Medicaid is swept into the baseline for Medicare for All). Meanwhile, the plan could most benefit the elderly, who would get even better Medicare while paying nothing extra, and red states that have kept their public health-care spending low. The first group is the base for the left, the second for Trump. That means if we don’t think through this tax question, it could be difficult to hold a political coalition together.

The Bernie Sanders campaign has released a list of potential financing options to start the debate over the tax burden—but this is only a start. The sticker shock of the initial taxes is the thing that will most likely kill public enthusiasm for a single-payer system. If it’s left unanswered, the question of who would bear the brunt of those new taxes will be determined by the proposal’s enemies.

These two questions need to be resolved before we start seeing the path to sweeping reform. Building arguments and analyses along these lines will help us figure out what kind of coalition we can form to expand health care to everyone. The momentum is growing, but with that progress comes the need to answer the $5 trillion questions.


Medicare supplement plans are changing: What you need to know

CHICAGO (Reuters) – If you are buying a Medicare supplemental policy in the United States, make sure you choose your insurance carefully over the next few months.

At the end of 2019, the doors will close on Plan F, which is considered the Cadillac plan of supplemental insurance policies known as Medigap. Designed for people who do not like healthcare cost surprises, it is the most popular of supplemental plans used to pay for services that Medicare does not cover.

But unless prices increase significantly, the existing Plan G may be a better deal.

The government is cutting off access to Plan F for new Medicare enrollees to control costs. Eight other supplements (here) will remain open.

Insurance experts expect Plan G to become the new draw for people wanting the most coverage without surprises.

Although Plan F is the most expensive option, retirees pay top dollar because they can go to any doctor or hospital that accepts Medicare patients. There is no surprise bill afterward – no deductible, co-payments or coinsurance.

Participants already in Plan F when the doors close at the end of next year will be able to stick with the plan (here). But if you turn 65 any time after the beginning of 2020, you will not be able to buy Plan F.

In addition, if you are in Medicare now and buy a Medicare Advantage plan or another Medigap insurance plan, switching after Jan. 1, 2020 could be difficult. Most states allow insurance companies to screen for conditions ranging from diabetes to heart attacks and cancer. On that basis, you could be turned away from Plan F or face high premiums.

Plan G is currently identical to Plan F except for the $183 deductible participants must pay at the beginning of the year.

Rates differ by state and insurance company, but the national average for Plan F premiums is $185.96 a month, compared with $155.70 for Plan G, said Kris Schneider, vice president of consumer and carrier engagement for AON Retiree Health Solutions.

“Buying G is a no -brainer,” said Jeff Goldman, an insurance agent at G.M. Goldman & Associates in Skokie, Illinois. “You save about $350 a year on premiums, so it makes no sense to buy F to cover the $183 deductible.”

Lower costs have been drawing an increasing number of Medigap customers into Plan G in the last three years – about 37 percent of new enrollees versus 53 percent in Plan F, according to CSG Actuarial.

Experts are not sure what will happen to costs once insurance companies see the effects of the 2020 changes. Some expect Plan G rates to jump because under Medicare rules, the plan must accept new enrollees regardless of health conditions.

Others estimate Plan F premiums to soar because new healthy 65-year-olds will no longer come into the plan, resulting in an older, sicker pool of people to cover.

“I see no way around Plan F rates continually increasing, perhaps exponentially after 2026,” said Adam Wasmund, chief marketing officer of Jack Schoeder & Associates, which advises health insurance brokers.

There will be more clarity as state regulators approve rates and insurance companies examine the claims of participants in both Plan F and Plan G. But Wasmund is concerned that the federal government could raise Plan G deductibles in an attempt to curb more Medicare usage in the future.

“Could the deductible be $200, $1,000 or $2,000?” said Wasmund. “Who’s to say what the government will do?”


Medicare for All should guarantee coverage for oral health

With multiple “Medicare for All” proposals now circulating in Congress, opportunities arise to fix past mistakes that have segregated care for our mouths and teeth from the rest of our bodies. Polling shows that today’s universal coverage efforts are driven largely by public outcry that people can’t afford the health care they need to be happy, healthy, and successful. As this robust discussion continues, it’s time to include comprehensive dental care as a standard part of health coverage. No plan can fully address consumers’ concerns without it.

Regardless of income or insurer, people report more significant financial barriers to accessing dental care than any other aspect of health care — even though oral health is a crucial part of overall well-being. Untreated dental disease is linked to a variety of health issues. It can raise the risk for heart disease, make diabetes more difficult to manage, and may be linked to pregnancy complications such as premature birth. In childhood, tooth decay can harm healthy development and lead to lower grades, limiting students’ potential.

In adulthood, poor oral health can impede job prospects and earnings, particularly for women. Parents’ oral health and ability to access care affects their child’s health in other ways, too. If a mother has untreated dental disease, her child is three times more likely to suffer tooth decay. And when parents lose health coverage, it jeopardizes their child’s access to care. Ensuring that all Americans have the opportunity to achieve good oral health can help families stay healthy and boost prosperity for all.

Seizing the opportunity to break the silo between dental and medical coverage is not only good for kids and families, but it’s essential to reining in health care costs. The U.S. spends about $2 billion a year in dental-related visits to emergency rooms. Children in families without support to help them avoid tooth decay can end up on hospital operating tables, which can cost upwards of $15,000. Many of these expenses could be avoided by securing access to oral health coverage and preventive care for everyone in the family.

Despite this evidence, dental coverage for adults is not guaranteed by any federal health program. In Medicare, the basis for many universal coverage bills, seniors’ oral health care is conspicuously absent. There are efforts underway to remedy this barrier to care by adding comprehensive dental coverage to Medicare Part B. But several proposals to let younger adults buy into Medicare are based on its current set of as-yet-incomplete benefits.

In Medicaid, whether low-wage adults and pregnant women have oral health benefits varies by state: Tennessee’s Medicaid program does not offer any dental coverage for adults; in Arizona, it’s limited to emergency care; Ohio and North Carolina, in contrast, offer relatively robust care. Individuals’ health should not depend on where they live.

Some Medicare buy-in measures look to coverage standards set by the Affordable Care Act (ACA), but they also have limitations. Oral health for kids through age 18 is baked into the benefit structure of plans adhering to ACA rules as an essential health benefit. But that coverage is often sold separately from medical plans. There’s no requirement for marketplace plans to offer any dental benefits to adults. A public coverage option based on the ACA will likely fall short for families unless new policies compel major changes, such as integrating oral health into private health insurance and expanding the ACA’s 10 essential health benefits to include dental coverage for adults.

Policymakers have, over time, strengthened children’s oral health coverage in Medicaid, the Children’s Health Insurance Program, and private insurance. For the past two decades, kids’ coverage has steadily increased and rates of untreated tooth decay have declined. As of 2015, 9 in 10 children had comprehensive dental coverage. This is incredible progress.

At the same time, we have much to do to protect these gains and help all children stay cavity free: 2017 was the first time in 10 years that children’s access to health coverage lost ground. And harmful disparities in oral health exist based on race, income, geography, and other factors. Improving national policies around oral health coverage and care for the whole family could help address these challenges to support every child’s health and success.

Although it may be too early for one coverage expansion proposal to take root, every effort can steer the U.S. health system toward a plan that better meets the needs of all people. Especially with proposals that rely on a program as influential as Medicare, it’s essential to ensure that any universal coverage strategy doesn’t further entrench a flawed model — one that walls off one part of the body from another, or dices up coverage between children, parents, and other adults on whom kids count to help them learn and grow.

Rather than replicate today’s painful, costly, and piecemeal approaches to dental and medical coverage, we should build a better future by ensuring that oral health is an integral part of future health insurance plans.


Dentists have had to prove their worth in the US since the 1800s. They started out as an off-shoot of barbers.

When you had a toothache in the 1800s, you didn’t have to go far. Most barbers would take a gander and even pull a tooth — for a fee.

Back then, being a barber was a catch-all profession. And when it comes to dental insurance, we still live with the relics of barbers’ professional versatility today. Mary Otto, author of the book “Teeth,” told The Atlantic: “In the barber-surgeon days, dentist skills were among one of the many personal services that barber surgeons provided, like leeching and cupping and tooth extractions. They approached it as a mechanical challenge, to repair and extract teeth.”


A dentist, William T. G. Morton, was the first to use anesthesia in the U.S. in 1846 to remove a tumor during a public surgery. Extended surgeries were soon absorbed into a regular medical practice.

At the time, dentists struggled to gain public trust, like medical doctors who carried the air of intellectuals.

Dentists, for all their usefulness, were barbers, usually self-taught and not terribly consistent across the board.

In 1850, the first school for dentistry was founded in Baltimore through a charter from the state of Maryland. Dentists couldn’t secure funding from the University of Maryland in Baltimore to join its medical school.

Today, a professional and insurance schism persists when it comes to medicine and dentistry.

Medical insurance in America sprang from a need to make factories more productive. The Blue Cross Association in Texas promised blue-collar workers a total of 21 paid hospital days a year if they were injured. By the 1950s, insured rates grew from 10% nationally to 60%.

All the while, dentists were restricted to private practices. Patients had to pay out of pocket for dental procedures. In the 1940s, clothing stores were offering dental procedures at a discount to customers.

That changed in 1954, when the International Longshoreman’s and Warehouseman’s union established the first dental insurance. But it was an ongoing fight for unions to keep dental plans covered at work.

The new plans were clearly needed. According to the CDC, in 1960, the average American over 65 only had seven of their original teeth.


But when Medicare was created in 1965, it also codified the divide, covering medical issues and leaving out dental.  Most insurance companies followed suit.

Now, 77% of Americans have dental insurance but 90% get the coverage from their job, compared to the 91% of Americans with medical insurance and 49% who get medical insurance from their employer.

The Affordable Care Act provided some change. It mandated that a child’s health insurance include dental. But as we live longer, we’re finding dental health is critical to overall wellness, especially as a Surgeon General report has found substantial links between oral health and everything from heart attacks to stroke and premature births.


Retiring seniors may face dilemmas in dental care

Organizations on mission to lower access barriers


-LeAnn Bjerken
Dr. Timothy Naomi and Siobhan Whitney advocate for dental care in the Inland Northwest’s senior population.

While it’s no secret that medical care is one of the biggest expenses for retirees, dental care is another health cost seniors might not be aware they should be saving for, some providers here say.

Although Medicare covers health expenses like hospital stays, doctor visits, and prescription drugs, it doesn’t cover dental care, which forces many seniors to either rethink how to pay for dental care costs, or simply go without.

Unfortunately, opting out of oral health care is a bad idea, in particular for seniors, says Dr. Timothy Naomi, a dentist with Providence Medical Group and director of Providence Health Care’s new dental residency program, which is set to start in July 2020.

“I suspect that oral health isn’t as big of a concern for people who are planning retirement as it should be,” says Naomi. “It’s a common fallacy that losing teeth is a normal part of aging, but if you see a dentist regularly there’s no reason you can’t reach age 103 and still have all your teeth.”

“For those over 65, coming in on a regular six- to eight-month basis is still very important, because as we reach those later decades of life, we become more prone to certain oral health issues,” he says. “And it’s always more expensive and time consuming to fix problems later, rather than working to prevent them.”

While there are many barriers preventing seniors from seeking dental care, Naomi says cost is a big factor.

“A fair number of elderly patients we see are eligible for Medicaid due to medical issues and financial constraints,” he says. “Unfortunately, there are others who don’t qualify for Medicaid and Medicare doesn’t cover dental care. It’s a real issue for these patients, many of whom are already on fixed incomes, and it’s not one that’s easy to solve.”

Medicare is a federal program that provides health coverage for people over 65, and some younger people with disabilities regardless of income. Medicaid, meanwhile, is a state and federal program that provides health coverage to those with low income.

Because of the costs involved, Naomi says it’s not unusual to see patients making decisions based on the level of care they can afford.

“We do see patients who’ll choose an extraction rather than a root canal, or a denture rather than an implant,” he says. “When treatment is costly, you do end up seeing more cases of what we call compromise or palliative type care.”

Naomi says many of the scenarios he sees in which the cost of dental care is unexpected are those where the patient is living in a skilled nursing facility.

“Most of those patients are people who aren’t capable of performing their own oral hygiene routine,” he says. “Unfortunately, in many nursing facilities oral health care is less than optimal, so when the patient’s family is able to bring them to us for an appointment, issues stemming from a lack of care come up all at once, and they can be unexpectedly costly.”

Naomi says elderly patients also might have medical conditions that require medications that produce oral side effects like dry mouth, another factor contributing to oral disease.

“The trouble is that saliva doesn’t just lubricate, it also has immune complexes in it to help fight oral diseases, so, a dry mouth increases the risk of that for patients taking those medications,” he says.

Naomi says certain existing health conditions like diabetes can be compounded by oral health issues like gum disease, an infection and inflammation of the gums.

“For diabetic patients the big thing is getting their blood sugar under control, which is made more difficult with the presence of chronic infection like gum disease,” he says. “It’s not infrequent to see patients admitted for high blood sugar who have oral health issues they need to consult with us on.”

While some nursing facilities are able to bring in a visiting dentist for exams, and possibly even a dental hygienist for cleanings, Naomi says most of these visits aren’t able to comprehensively address a patient’s needs.

“They can identify issues, but there’s nowhere for the patient to go for follow-up work or more involved procedures,” he says.

Naomi says issues with transportation and needs for more complex procedures are also barriers to for seniors seeking dental care.

“Many seniors struggle with access to transportation to get to and from an appointment,” he says. “It can also be hard to find a dentist who is able to treat older patients.”

Naomi says many dental offices, particularly rural facilities, either aren’t equipped to accommodate more specialized procedures, or their staffs aren’t trained in working with elderly patients who have dementia or other complicating health conditions.

“It’s very much a comfort-zone issue,” he says. “If that facility’s staff doesn’t feel it has the resources to accommodate a patient, that patient has to look elsewhere for care. The trouble is there’s nowhere else to go.”

Pearl Bouchard is the manager for Community Living Connections, a program within Aging & Long Term Care of Eastern Washington, a social service agency that helps older adults and people living with disabilities access needed services.

Community Living Connections works with adults who are on Medicaid, and seniors who are on Medicare, as well as those who qualify for both Medicaid and Medicare, she says.

Because Medicare doesn’t cover most dental care, Bouchard says Community Living Connections often assists seniors in researching alternative dental plans that may cover specific care needs. The organization also can help seniors plan and start a separate savings account to cover dental care costs.

“In some cases, the premiums you pay are equal to or greater than initial coverage, so it may be a better option to instead start a separate savings account for dental care,” she says. “Sometimes when a patient needs a more advanced procedure done, we’re able to refer them to a local clinic like CHAS health, which can offer services on a sliding fee scale.”

Monica Kundrna, a state health insurance benefits adviser with Community Living Connections, says that while Medicare doesn’t cover most dental care, some Medicare Advantage plans will offer dental care seniors can purchase separately to cover preventive services.

“Some low-income seniors who are eligible for both Medicare and Medicaid can also take advantage of special-needs plans that offer dental services,” she adds.

When it comes to senior dental care, Bouchard says the program also works closely with the Arcora Foundation, a nonprofit organization formed by Delta Dental of Washington, in its efforts to help Washington seniors access dental care more readily.

“The Arcora Foundation conducted recent surveys regarding oral health disparities and discovered about 45 percent of seniors have some kind of difficulty with their teeth,” she says. “The Arcora Foundation is working on several initiatives here and across Washington that are designed to help those populations.”

Arcora estimates more than 480,000 seniors 65 years and older in Washington state don’t have any dental coverage.

Naomi says Providence’s new dental residency program, which received some funding through the Arcora Foundation, was created in part to help eliminate the current gap in care for Medicaid adults and seniors.

“We’ll have faculty here that can care for patients with special needs, including seniors,” he says. “This program will focus on training dentists to be able to go out into the community with the ability and help care for those patients that have difficulty finding care elsewhere.”

As the Journal reported in February, Providence is partnering with nonprofit health services provider Community Health Association of Spokane on a $3.5 million remodel of a medical office building in north Spokane that will serve as one of two sites for the new dental residency program.

Naomi says Providence is already hiring staff for the other site, a newly created dental clinic space in the Sacred Heart Doctors building at 105 W. Eighth, which is expected to be ready to open by May 1.

Meanwhile, he says, the North Side CHAS clinic should be completed in late summer or early fall, and the new dental residency program is on schedule to begin in July of 2020, provided it receives the necessary accreditation.

“We submitted our accreditation application through the Commission on Dental Accreditation in November and have been assigned a site visit date to take place in August,” he says. “If all goes well, we should receive our provisional accreditation in January.”

Siobhan Whitney, strategy and business development consultant with Providence, says the health provider has also partnered with the Arcora Foundation to fund a new tele-dental program that will provide more location-specific services like exams, radiographs, and imaging, to seniors that struggle with transportation.

As part of Providence’s work with SmileSpokane on its Increasing Access initiative, the tele-dental program enables seniors to set up an appointment  at a location that’s convenient for them. The program is meant to eliminate transportation barriers and increase senior’s access to dental care.

SmileSpokane is a community organization that was formed in 2015, with the goal of improving oral health throughout the Spokane area.


Dems’ 2020 ‘Medicare for All’ Plan Compared to Failed Veterans Healthcare, Like ‘Soviet Grocery Stores’

Democrats have scheduled the first-ever hearing on a plan to eliminate private health insurance in favor of a government-run program next Tuesday in the House of Representatives.

One thing Republicans and Democrats do agree on is that the American health care system is broken. But Republicans, and even some Democrats, contend that replacing what’s broken with a government fix is a recipe for disaster.

Health care has become the central campaign issue of 2020 since Democratic presidential frontrunner Sen. Bernie Sanders unveiled his plan for a single payer system to replace private health insurance companies early this month.

“Healthcare is a human right, not a privilege,” said Sanders, echoing the motto that has become a mantra among Democrats.

“The best way to go forward in my view is through a ‘Medicare for all,’ single payer program,” Sanders said at a CNN town hall this week.

And he’s not the only presidential candidate taking “Medicare for All” to the trail.

“We need to have ‘Medicare for all’,” that’s just the bottom line, said California Sen. Kamala Harris.

Harris, speaking at the town hall, said, “Having a system that makes a difference in terms of who receives what based on your income is unconscionable, it is cruel, and in many situations that I have witnessed, inhumane.”

But the vision of more affordable coverage that lowers the number of uninsured is meeting a political reality.

The 19th Democrat to enter the 2020 race came out against a single-payer system.

“If I’m elected, I’m not going to force you off your private healthcare plan,” said Massachusetts Congressman Seth Moulton, announcing his candidacy on ABC.

Moulton is a former Marine Corps officer who receives health care through the Veterans Health Administration.

“I think every American should have access to good affordable healthcare, but I made a commitment to continue getting my own healthcare at the VA when I was elected to Congress, that’s single-payer, and I’ll tell you it’s not perfect,” he said.

Bob Moffit of the Heritage Foundation says that plan is the closest thing in the United States to “Medicare for all” and “that is a very bad way to run a health care program.”

The Veteran’s Health Administration, says Moffit, is “positively scandalous,” with “bureaucratic manipulation of waiting lists resulting in the delay and the denial of care.”

Moffit contends that cutting private insurance companies out of the equation is a bad solution.

“The result would be something like American medical clinics being turned into the equivalent of Soviet grocery stores,” he said.

President Trump insists a Republican plan will be ready for a vote after the 2020 election. Moffit says that’s too little, too late, and that the President should articulate a vision of health care reform now.

Some estimates put the cost of a “Medicare for all” plan at anywhere from $25- to $35-Trillion over just 10 years. Under the plan, 180 million Americans would see their private health insurance replaced with a public plan.


The health care industry is putting faith in Joe Biden in its war against Medicare-for-all

Tasos Katopodis/Getty Images

The health care industry is happy to see Joe Biden jumping into the Democratic presidential race, hoping he can be a bulwark against their true 2020 opponent: Medicare-for-all.

Many of the top Democratic primary candidates have embraced Bernie Sanders’s Medicare-for-all plan, which would essentially eliminate private health insurance.

Biden hasn’t. He also hasn’t rolled out his health care platform, as Vox’s Sarah Kliff recently wrote, but he seems likely to present a center-left alternative to single-payer.

“I’ve definitely had clients ask, where is Biden?” said Kim Monk, the managing director at Capital Alpha, which advises Wall Street investors from Washington, DC. “He’s basically an establishment candidate and would be much more in tune to building on what’s there as opposed to coming in and destroying what’s there and starting over.”

One analyst told investors amid a mild market freakout over single-payer the other day, as Axios reported: “How could the news get better? Biden wins the Democratic nomination without changing his current view against single payer.”

Industry lobbyists aren’t certain Biden will win. One Democratic health care lobbyist grimly predicted to me Sanders would take the Democratic nomination. A trade association leader brought up Biden’s two previous failed presidential bids. But they finally have a candidate in their corner with the profile to battle Sanders and single-payer.

The health care industry versus Medicare-for-all

The health care industry — doctors, hospitals, insurers, pharmaceuticals — has united in the Partnership for America’s Health Care Future, a lobbying coalition, to stop Medicare-for-all. That organization aggressively denounces single-payer at every opportunity, and has condemned proposals like a public option or letting people 55 and older buy into Medicare.

“Let’s do Alexander-Murray,” a top trade association president told me, referring to the bipartisan Obamacare stabilization plan from Sens. Lamar Alexander (R-TN) and Patty Murray (D-WA) that fizzled out after Obamacare repeal failed. “Make the individual market better, which we clearly could do; it wouldn’t cost that much money.”

Industry insiders expect Biden to, at most, support a public option that allows some or all people under 65 to buy into Medicare. The Biden campaign did not respond to requests for comment on the candidate’s health care plans.

“The industry would just like to see a candidate who would be responsible and be pragmatic,” this person said. “From the industry standpoint, it’s like, what was all the energy about 2010? Biden would be more sympathetic toward that.”

Sanders has made Medicare-for-all something of a primary litmus test, and several of his opponents — Sens. Elizabeth Warren, Kamala Harris, Cory Booker, and Kirsten Gillibrand — have signed on to his bill. Not every 2020 Democrat is backing single-payer, of course. Pete Buttigieg, Beto O’Rourke, and Amy Klobuchar talk about alternative plans that don’t go as far as the single-payer system envisioned by the Vermont senator.

But it’s Biden who’s leading the polls, edging out Sanders for the most part, while the other lesser-known candidates still trail behind. He’ll position himself as the most viable center-left alternative to Sanders, the best bet to beat Trump in the general election. The primary will be Biden versus Sanders until proven otherwise, and the industry obviously views the vice president as the guy on their side.

“This encapsulates a liberal versus a moderate in people’s minds. People want to beat Trump. They know a socialist can’t. The government isn’t going to fix everything,” a Democratic health care lobbyist said. “To that extent, people are waiting for” a candidate like Biden who wants more incremental improvements.

Democratic voters do like Medicare-for-all, but the politics is complicated

We shouldn’t understate the success single-payer supporters have had in bringing the idea into the mainstream political debate. Sanders has gone from being the lone sponsor of a single-payer bill in the Senate to having a bill with 17 co-sponsors, including Warren, Harris, Booker, and Gillibrand. A full 80 percent of Democratic voters said they supported the plan in the most recent poll from the Kaiser Family Foundation.

But that survey also found that more Democratic voters said they wanted to focus on improving the ACA than said they wanted Congress to pass a national Medicare-for-all plan.

Kaiser Family Foundation

Kaiser has previously found that Democratic voters support a Medicare buy-in at a higher rate than Medicare-for-all, though more than half of them support the latter. It’s just not clear that single-payer health care is a red line for many Democratic voters yet, even if the Sanders wing is fervently behind the idea.

Other surveys have shown that Democratic voters are, for the moment, prioritizing electability above other considerations when thinking about the 2020 field. Based on the reporting that led up to Biden’s entry into the fray, these concerns about electability are a big reason he’s getting into the race.

That’s good news from the health care industry’s perspective. “If Biden can do it, take off and be a liberal pragmatist, that’s a good thing from most of our standpoints,” said the trade association leader.

But that person also made note of Biden’s failed presidential runs in 1988 and 2008. Uncle Joe isn’t being treated as a white knight to save the industry from the nationalizing hands of Bernie Sanders — their great fear is either their complete elimination or cuts to payments, both treated as existential threats — so they see themselves as at war with Medicare-for-all itself. It’s bigger than a specific candidate.

“The insurers would much rather have Biden than Warren, Sanders, or a couple of others. However, right now, they’re focusing their attention on the policy and politics of Medicare-for-all and not spending much time thinking publicly about which candidate they prefer or pushing one candidate over another,” another lobbyist told me.

The health care industry does generally seem to see Biden as their best chance to stop Sanders, or Warren or any of the other Medicare-for-all supporters. At least one high-profile guest at the vice president’s first big fundraiser is reported to be a health care executive.


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