What’s the matter with Medicare?

Medicare has been treated as a whipping boy in the discussions around reforming our current healthcare financing system. I maintain that most of the criticisms are flawed, and don’t stand up to critical scrutiny. Medicare is a fundamentally sound program, which has been compromised both by unaddressed demographic changes, and by intentionally unfunded program expansions.

Among the unavoidable challenges Medicare faces, most have nothing to do with program efficiency, and everything to do with the demographics of the beneficiaries: 
 High-cost population. Older people are simply more expensive to cover. Medicare disproportionally covers these populations. These people were not covered before, which is why Medicare was developed, and why it’s so popular.
 Increased expectation of heroic life-extension measures. Dying people seeking to extend their lives are very expensive.
 Fewer workers support more beneficiaries. Longevity increases, shifts in the demographic age profile of our population, further magnify the first two imbalances.

Despite this, by most key metrics, Medicare operates far more efficiently than do private insurance companies. Critics state that because of the client base, its 75% administrative cost advantage may be somewhat overstated. But even if we adjust for these concerns, Medicare is still much more efficient.

Among the other obstacles, some have the specific intention of driving Medicare to bankruptcy – and discrediting the idea of any public approach to insurance:
 A steadfast refusal to adapt the funding model to address the looming demographic imbalances listed above. A system designed in the 1960s, with contemporary life-span and treatment expectations, needs updating to reflect current and future realities.
 Medicare Part D. (See Below)

What’s Wrong with Medicare Part D (prescription drug coverage)

From its inception, Medicare supporters have tried to add prescription drug benefits to the plan. This was always blocked by the pharmaceutical lobby, because it posed a threat to their profits.

But when the Republican Party gained control of both houses of Congress and the administration in 2002, the pharmaceutical industry was able to customize an plan that would create a cash cow. They literally wrote the Medicare Part D law that was then passed with virtually no amendments. It contains a key provision which prohibits Medicare from negotiating prescription drugs prices. This means that the pharmaceutical industry was to be given a huge captive base of high usage customers, who pay retail. This would have been a budget-buster – except that there was no budget to pay for Medicare Part D in the first place. This exorbitant expense was piled on top of an already fiscally challenged program.

The plan has another bizarre provision, commonly known as the ‘donut hole’. Above a certain annual spending threshold, the program stops paying for drugs until a second threshold is reached. This was presented as a way of controlling costs – but in reality it was a way of placating the insurance industry, which immediately moved in with a whole new portfolio of products to ‘fill the gap’ which had been created for them.
Medicare Part D was a perfect finesse for the national Republican Party:
 It was designed to be difficult to vote against—despite the poison pill—because it provides a needed benefit to seniors.
 It tremendously increased the profits of the pharmaceutical industry, who wrote the law. These increased profits now bankroll resistance to any meaningful modifications.
 Created an entirely new, highly profitable category of insurance (‘donut hole’ coverage).
 Greatly accelerates the insolvency of the overall Medicare program, setting it up as an example of government inefficiency, and justifying continued resistance to any public insurance plan.

Despite the finesse, House Democrats were nearly unanimous in opposition to this fiscally irresponsible program. And despite incredible pressure from their leadership, many conscientious House Republicans opposed it as well. Despite a large Republican majority in the House, passage was only achieved after an unprecedented three-hour roll-call vote in the middle of the night (roll-call votes normally last 15 minutes), during which some members of the Republican caucus were blackmailed to change their votes. Rep. Walter Jones (R-N.C.) refers to this as the ‘ugliest night’ he has ever seen in politics. Check out this interview with him and fellow House Republican Dan Burton (R-Indiana):
http://www.cbsnews.com/stories/2007/03/29/60minutes/main2625305.shtml

Two months after passage of Medicare Part D, the man who steered it through the House, Rep Billy Tauzin (R-LA), left government to become the President and CEO of the pharmaceutical lobbying group PhRMA.  This was a job change for Tauzin in name only.  His seven-figure salary was a small thanks for the billions in profit they will reap from his efforts. 

The blatant corruption of this act, and the perpetrators, presupposes that the American people—distracted as we were by the War on Terror®—were not paying attention, or would soon forget.  They were wrong.  We were watching every corrupt step, and we will not forget.

William Safire

William Safire died Sunday.
http://www.nytimes.com/2009/09/28/us/28safire.html
I almost always disagreed with him on issues—sometimes less than politely—but I admired and learned from his style. He was of a disappearing breed of commentators who would listen carefully to opposing views, then fully incorporate them in his rebuttal. If his opponent needed more verbal rope to hang himself, Safire was confident enough in his position to play it out for them. I don’t know if it’s out of my own love for a healthy exchange of opposing ideas, or the fact that he reminds me so much of my Dad, but I have always had affection for him.

Safire had the respect for his the other speaker and his audience—as well as the confidence in his own position and ability to communicate it—to truly match wits.  This is such a sad contrast to the excuse for political discourse that dominates today. It seems that success now hinges upon making one’s point within the bounds of what can be printed on a bumper sticker, and repeating it until supporters learn it by rote – a methodology more useful in training a hunting dog than trying to resolve complex societal issues.

I shared, and continue to share Bill Safire’s love of the English language.  Though I learned from opposition to him politically, I learned in harmony with him linguistically.  He knew that—as a living language—English must nourish and maintain the strength of its fundamental structure, even as we encourage it to breathe in the fresh air of new learning.  And, lest there be any doubt, he would not tolerate that word (learning) being used as a noun, with the risk of an ‘s’ being appended to make it plural. There are some basics that cross party lines.

But I digress – as, I dare say, Mr. Safire may have done on occasion.

I will sign off with two quotes attributed to this worthy gentleman. His sense of skepticism and subtle wit are present in each:
 ‘Never assume the obvious is true.’
 ‘Last, but not least, avoid cliches like the plague.’


It is not for me to judge whether the world is a better place because William Safire lived and achieved prominence. But I know my life is richer for witnessing his.

Preventable Chronic Disease

The United States cannot drive down the cost of health care if nothing is done to address preventing many of the preventable chronic diseases that account for a large percentage of the health care costs in this country. According to the CDC "The medical care costs of people with chronic diseases account for more than 75% of the nation’s $2 trillion medical care costs". Lifestyle choices result in many preventable chronic diseases, and result in the associated medical care costs. The prevention of these chronic diseases cannot be medical intervention alone, but must include lifestyle change if health care costs are to be driven down. None of the health care reform proposals being considered address encouraging life style change, or penalizing poor choices with respect to one's health, and perhaps they should not. But without such changes, won't health care costs continue to rise? So, should the legislature attempt mandate personal responsibility? Can it?

Issue with Comments - Hopefully Resolved

Hey Tonya, I noticed that there was no way to respond to your posting with a comment.  I went into the system and made some changes, and it looks like new posts may allow that, but something must have been temporarily reset to prevent it. 

Will another bureaucracy be better?

Michael you act as if a public option is the only solution to this problem. A public option is not the only solution to the problem your friend's patient faces, and, in fact, it may not be a solution at all - a government option can, and probably will deny coverage in certain cases as well. It is likely that today your friend's patient can appeal the insurance company's denial, and it is likely the appeal can be "fast-tracked". If he does not have this option today, regulations can be changed such that patients have a recourse when coverage is denied. To answer your FB response, "The difference between non-medical people making treatment decisions in a public system vs. our current profit-driven system has to do with the fiduciary responsibility of the decision maker. In a public system, that duty is to the patient, rather than the company shareholder." I don't find your argument persuasive. Just because an insurance company has a duty to its shareholders does not mean that it cannot also have a duty to those people it covers. In fact, insurance companies do have that duty. All companies serve multiple stakeholders. And many insurance companies serve their customers and shaeholders well (a large percentage of people with private insurance are very happy with their insurance companies). Regarding the insurance company's denial of your friend's patients colonoscopy - I don't have enough information to determine if I would agree or disagree with the coverage denial. Perhaps there are alternatives to a colonoscopy for younger patients. Perhaps the body of doctors that make recommendations on pediatric oncology has guidelines that recommend against colonoscopies for young patients. Etc.

The Bureaucracy we've Got

The father of one of the kids on the soccer team I used to coach is a primary care doc. He has a patient whom he suspects may have colon cancer, and ordered screenings, including a colonoscopy. But the patient is younger than the age threshold for his insurance company to cover a colonoscopy, so they’ve overruled his doc, and won’t pay.

My friend deals wtih this kind of crap all the time. That's part of why he is among the 72% of physicians support AT LEAST a public option.

http://healthcarereform.nejm.org/?p=1790#more-1790