Medicare as we know it has evolved substantially since its inception to cover more people in an increasingly comprehensive manner. This has of course led to increases in program cost. Private alternatives to medicare tend to be more efficient relative to cost secondary to their ability to make arbitrary coverage decisions. Medicare however, has always sought to pool risks; that is no enrollee can ever lose their coverage due to ill health.

Concerns with medicare include improving benefits, legitimate prescription drug coverage and cost-sharing issues. One of the primary goals of medicare has been to achieve some equality in service delivery without regard to economic status.

Medigap plans have evolved to assist patients in managing so-called gaps in medicare coverage. These plans have changed from community rated premium model, to a system whereby premiums rise with age, thus becoming increasingly unaffordable for those with average incomes.

Meanwhile, as with private health care coverage, provider reimbursement levels have not kept pace with cost, increasingly leading to providers declining to accept medicare patients. Access to a full range of providers is therefore limited in some cases by a patient's coverage and inability to pay for medical services.

John Russell, MS/ARNP (Acute Care), MBA, Health Systems Management