And what is the most significant way the Federales control their medical care costs ?

Milliman has calculated the cost-shift from Medicare and Medicaid into the private sector as roughly $90 billion a year, or 15% of private insurance costs.

In brief, this happens because:

(1) the government plans pay less than what the medical service providers think their services are worth (2) How does the government get away with this? Just as Hank says, "because they're the government". (3) service providers then increase the fees they bill their privately-insured patients, to make up as much of the difference as they can, meaning that (4) there is a significant shift of costs actually incurred under Medicare and Medicaid, but which emerge as private insurance costs and are then paid for by private insurance plan sponsors and privately-insured people.

This so-called "cost-shift" makes Medicare and Medicaid appear less expensive and makes private insurance appear about 15% more expensive. Private plans would have 15% lower premiums in the absence of the cost-shift and Medicare and Medicaid would have higher premiums. The Milliman work reveals this difference is a serious amount of money.

This cost-shift from the public sector into the private has been going on for as long as I've been in the business. In fact, I first learned of it in this iconic 1970 Atlantic Monthly article.

You’ll find the cost-shift mentioned toward the end of this article, just click to page 4 and read the author’s 4th and 5th conclusions. He calls the cost shift "welfare reimbursements". The amount in his analysis is $10.00 added to the daily hospital cost of $60.00, resulting in a total billed charge of $70 per day (remember this was 40 years ago) - - in other words, the need to recover federal cost underpayments in 1970 resulted in a daily hospital charge 16% higher than it would otherwise have been. Remarkably, just about the same as Milliman finds today.

The author of the article was a 27-year-old physician. You will recognize his name - and you'll do yourself a big favor if you take the time to read his entire article.

So there is no doubt that this cost shift has existed for decades, and that it makes private insurance premiums roughly 15% higher than they need to be. Its existence raises important questions that need to be answered. Here are some of the questions:

1. What will Medicare do, if or when there is no longer a private sector into which it can shift a meaningful share of its costs? How would the Federales explain the noticeable increase in required funding that will emerge? Who would the Federales then blame? Who would the Federales then tax?

2. What will medical service providers do, if they can no longer recover from private insurance plans some or all of the revenues they cannot collect from Medicare or Medicaid? How might threats of reduced incomes affect medical professionals' fee negotiations and their willingness to participate in Medicare and Medicaid? How would community hospitals survive? How many physicians might simply retire early? How many talented young students might decide not to pursue careers in medicine?

Where have you seen these questions addressed? Where have you even seen them asked?