Make Medicare 'Big as Americans Want It to Be'
Health care reform is fantastically messy. No matter how bad and cruel
the current system, it won't be tossed out for something sleek and
efficient. Reform will be more like adding rooms to a sagging bungalow.
The latest carrier of that message is surgeon and writer Atul Gawande,
in a can't-stop-reading essay
in the New Yorker, "Getting From There to Here." It's bad news for
full-blown single-payer healthcare. But as Consumer Watchdog's Jamie
Court argues persuasively in an OpEd in the Los Angeles Times, it's all the more reason to allow anyone to buy into Medicare--the familiar and comfortable choice.
Gawande begins and ends with cruelty: the Canadian woman in labor turned away at hospital doors, the Australian girl with a lung condition, near death because she can't afford a tank of oxygen.
"In every industrialized nation, the movement to reform health care has begun with stories about cruelty," he writes. "The stories become unconscionable in any society that purports to serve the needs of ordinary people, and, at some alchemical point, they combine with opportunity and leadership to produce change." The rest of the industrialized world arrived at universal health care in fits and starts that "branched" from what was already begun.
The U.S. has not pushed forward, and now is falling back, in part because opponents of change keep dragging out the Bolshevik card.
From Gawande:
"[W]herever the prospect of universal health insurance has been considered, it has been widely attacked as a Bolshevik fantasy—a coercive system to be imposed upon people by benighted socialist master planners. People fear the unintended consequences of drastic change, the blunt force of government. However terrible the system may seem, we all know that it could be worse—especially for those who already have dependable coverage and access to good doctors and hospitals."
What, then, could be more dependable and offer more choice than Medicare? It's not perfect, it's got financial issues, but almost no one over 65 would give it up. It's also fixable, far short of a complete makeover.
As Court says:
"My parents can get Medicare, so why not me? Americans should not have to turn 65 years old or become disabled to have access to a public healthcare program that controls overhead costs, provides broad, affordable access to care and protects patients against big bills. President Obama should open Medicare to all Americans who lose their jobs, cannot afford private health insurance or simply prefer it to private insurance or an HMO."
"Critics contend that Medicare pays doctors so little that most physicians won't accept the coverage, and that it is too bureaucratic and financially unstable. Medicare does use its size to drive down what doctors and hospitals are paid. However, the Medicare Payment Advisory Commission reports that 97% of physicians accept new Medicare patients, with 80% taking all or most patients, which is comparable to HMO acceptance rates. And with the massive consolidation of insurance companies and of HMOs, doctors and hospitals report to our group that Medicare payments are often as generous, if not more generous, than those of HMOs and private plans -- and received with less hassle and more consistency. Studies by AARP and the Commonwealth Fund also show that Medicare patients are more satisfied with every aspect of their care than patients with private plans."
Patient satisfaction is what scares the dickens out of private, for-profit insurance companies and their army of lobbyists, who know that they can't keep their excess profits, bloated corporate pay and armies of care-denying middlemen in a competition with Medicare. So they'll pound on the financial issues, issuing warnings of Medicare's impending bankruptcy. Not likely, says Court, because the solutions are in front of us, and President Obama:
"Predictions of its impending bankruptcy mostly have to do with the fact
that the program serves the sickest and neediest patients in the system
without a proper revenue base and in an era of costly techno-medicine.
There are a number of ways to help solve the funding problem.
First, Obama's promise of new technology for better medical record keeping should limit unnecessary or duplicative procedures. Obama also must grapple with Medicare's unintended incentives to doctors to do too many costly procedures at the end of life that only prolong life but do not improve quality of life. Tom Daschle, the new secretary of Health and Human Services, has already made this a priority by calling for doctors and hospitals to be paid for performance rather than by the number of procedures they perform or drugs they prescribe."Bringing younger and healthier patients into the Medicare risk pool also would stabilize the program's funding. They don't use as much medical care as older and sicker patients, so their payments would offset the cost of care for the sicker ones. Allowing employers to offer Medicare is one way to widen the risk pool. Payroll deductions for Medicare would be less than what the average employer and employee now pay, according to congressional research."
Gawande lives and works in Massachusetts, and admires the state's attempt to insure everyone within a partially regulated system of private insurers. He must have read, and drawn from, a 2007 academic book by history professor Paul Dutton, "Differential Diagnoses," comparing the similar health insurance problems--and sharply diverging solutions--of France and the United States.
Dutton shows at length how France also "branched" from an individualistic, private and and employment-based health care system into one that cares for nearly all residents, regardless of job status. But France started with mostly public or university-based hospitals--and without the intense Cold War baggage that reduced U.S. arguments for government responsibility to "Socialism vs. Americanism."
Though Dutton doesn't make much note of it, France subsidizes doctor education, allowing physicians to begin practice without hundred of thousands of dollars in debt. France also ducked the bane of the U.S. system: the increasing and uncriticized ability of private insurers to price out of the market--or exclude altogether--anyone ill or likely to become ill.
So instead of France's highly regulated and only semi-private health insurance aimed at inclusion, judged by U.N. health experts to be the the world's best, the U.S. has a sharply split and incomplete system. There's government-funded care for the the very poor (Medicaid) and the elderly, with private, for-profit and very choosy corporations controlling the rest. The middle class ends up badly insured, uninsured or clinging to disappearing employer policies.
Gawande's admiration of the Massachusetts experiment stems from its reductions of personal agony:
"For the past year, I haven’t had a single Massachusetts patient who has had to ask how much the necessary tests will cost; not one who has told me he needed to put off his cancer operation until he found a job that provided insurance coverage. And that’s a remarkable change: a glimpse of American health care without the routine cruelty."
But Massachusetts started with a much smaller percentage of uninsured residents than the nation as a whole, and Gawande acknowledges that rising unemployement and insurers' constantly rising premiums threaten the reforms. And he sees a mix of private and public, messy as it would be, as an improved branch on a familiar path. It's change Americans can accept personally, not just believe in abstractly.
Or, as Jamie Court concludes:
"With Medicare as the public option in his healthcare plan, the president could increase its buying power to further reduce expenditures. Obama-care should make Medicare as big as Americans want it to be."