A Christian Scientist’s guide for opting out of Medicare
You will find it here (pdf), and the broader set of links is here, some of the key material starts at p.10. There is some general background here. You can’t get your “money back,” but you can have the payments transferred to a qualified Christian Science care facility. In other words, Medicare will pay for prayer. A few points:
1. It would be easy to generalize this idea, and also easy to give people — whether or not they are Christian Scientists — some of their money back in return for forgoing higher levels of care.
2. American society recognizes the right of Christian Scientists not to pursue traditional forms of Medicare. Can not that principle be extended, and in a way which saves money?
3. There is no public outcry about the horrible life outcomes, and endings, suffered by older Christian Scientists (there is a justified outcry about foregone treatments for the children). It is not obvious that they have worse or less dignified deaths. Here is a JAMA paper showing higher death rates for Christian Scientists, although presumably some of that effect is due to withholding care from younger people. There is more information on the young here. A Washington State study, cited in the JAMA piece, suggests the overall life expectancy effect of being a Christian Scientist is negative but small.
4. In any case I see no obvious moral repugnance, or public unacceptability, to giving people more money, in return for the equivalent of Christian Scientist health outcomes at later ages.
5. That said, taking the money instead of the Medicare does not (at all) require you to consume zero subsequent health care.
6. Large numbers of American retirees in Mexico and Costa Rica receive a lot or all of their health care without Medicare intervention. Again, this is not considered scandalous nor are these horrible lives with horrible ends. I am simply proposing that we pay people to be willing to do this.
7. The Medicare Advisory Board will be able to find only so much “pure fat” in its spending cuts. And fiscal considerations will require a relatively modest federal mandate, in terms of the number of conditions it covers. One way or another, letting some people do without massively subsidized care will become a reality (in fact it already is a reality), we are simply debating its scope and the fairness and efficiency principles for its implementation.
8. In the German system, if you don’t sign up at the right time you can be left uninsured. A German may face this issue when living in the United States, but perhaps returning to Germany, namely when to let coverage lapse. Again, this does not make for major scandals or unacceptable outcomes. Some Germans choose to take that chance and of course they save some on the premium, with some risk at the back end.
9. If some individuals take the cash and secede from full Medicare, that frees up medical services, and lowers prices, for others. The net decline in medical services isn’t as large as it appears at first.
10. In the comments I read so much about choice biases and hyperbolic discounting, but no one mentions that most people significantly overrate the effectiveness of medical care, relative to the results in the RCT and refereed literature. The comments themselves are evidence for this proposition.
11. There is nothing sacrosanct about the current division of benefits between Social Security and Medicare. And no matter how you chop that one up, some important marginal needs are left unsatisfied.
12. Here are comments from Ezra Klein and Kevin Drum and Karl Smith. Here is my last post on the topic.