Entitlements and estate taxes: the Medicare connection

I really liked Dr. David J. Gross's letter to the Wall St. Journal advocating that estates reimburse Medicare in cases where the program has paid out more than the recipient paid in.A couple of people  --one in the comments section of my blog post, and another in a WSJ letter reply-- make what they must think is the killer counter-argument:

• If estates have to pay for overuse, then they should also be reimbursed for underuse. Today's WSJ letter writer included Social Security in this argument, then ends the letter with "Nice try, but not too logical."

Maybe I'm missing something, but I'm having trouble understanding where these commenters are coming from. Based on the context of their comments, I think perhaps their main issue is ideological opposition to estate taxes. But in my view, their arguments to provide refunds for underuse are improvements on the original concept, not arguments against it.

• Providing refunds could enhance cost consciousness among recipients, thus helping control the cost of the overall program
• It would increase alignment between patients and Accountable Care Organizations

Why not start by implementing a 25 percent levy when Medicare pays out more than it takes in, with a 100 percent refund when Medicare has paid less?