Posted on March 14, 2003

"Lower class" not entitled to essentail benefits under Medicare?


The Washington Post
March 14, 2003

Medicine for Medicare

DO NOT BE MISLED by the loud noises coming from congressional Democrats and health care activists. The Medicare modernization plan the president has finally presented to Congress, after much hemming and hawing, is not radical. It does not force anyone to leave the current system. It does not make anyone switch doctors. It adds $400 billion over the next 10 years to pay for extra drug benefits, a number far higher than some have mentioned. Unlike leaked versions of the administration's proposal, this one does not even provide full details of what the reform would look like, instead leaving Congress to fill in many of the blanks. As a result, it's difficult to say whether the proposal would produce much change.

In essence, it adds options, instead of removing them. For those who want it, traditional "fee-for-service" Medicare would be preserved more or less intact, with the addition of a prescription drug discount card as well as some catastrophic insurance. No extra payments would be required, it seems. At the same time, Medicare recipients would also be able to opt into a new program -- "enhanced Medicare" -- that would look a lot like the current federal employee health insurance plan. Those who chose this option would pay a part of the cost themselves. In return, they would get a private plan and better benefits.

Both the administration and its supporters in Congress seem to hope that over time more people (and particularly younger people, by now accustomed to a plethora of health care choices) would select this second option. If this happened, the costs of Medicare to the federal government might not come down dramatically -- private insurance isn't necessarily cheaper, particularly for the elderly -- but at least Medicare recipients would have some incentive to choose plans more suited to their specific health needs. Because they pay for more than just emergency visits to the doctor, integrated plans could also care more sensibly for the chronically ill. As a recent report by the Progressive Policy Institute points out, Medicare currently will pay if you've been hospitalized for a stroke but will not pay for the anti-hypertension drugs to prevent it. This is the kind of absurdity that a plan designed specifically to meet the needs of older people could avoid.

"Could" and "might" are the operative words here, however. The president's proposal is not a panacea but rather a set of suggestions that reflect the politics of the moment. Clearly, this president does not want to be accused of "abandoning" Medicare. On the contrary, he wants to be able to say that "Medicare will always be there, just how it's always been, if you want it that way." If Congress chooses to stick too closely to this mantra, and to keep benefits the same across the board, there will be little incentive for anyone to opt out of the current system or to contribute to the costs of his or her care. However politically difficult it appears to be, Congress must make it possible for Medicare to change with the times.

Comment: Neither of the "either-or" options behind this editorial can be good news. Either the editorial staff has failed to do its homework in understanding the fundamental principles of social insurance, or the editorial position of The Washington Post is to support a system that ensures comprehensive services for those able to afford them, but relegates lower-income beneficiaries to a program that falls short on basic health care needs. Have the editors demonstrated incompetence by failing to inform themselves adequately on the issues, or, worse, are they suggesting that personal wealth should determine whether Medicare beneficiaries should have access to all essential services?

Adding a drug discount card to the program would cost nothing, which is exactly what it is worth under this "budget-neutral" administration. And the $6000 deductible catastrophic drug coverage would benefit only the affluent. Prohibiting any other improvements in the benefit package of the traditional program would perpetuate the impaired access to care for those who are unable to afford essential services that are not currently a benefit of the program. The most immediate need is for a bona fide prescription benefit.

The Washington Post supports the FEHBP model of "enhanced Medicare," making available a private plan, with BETTER BENEFITS, by PAYING A PART OF THE COST themselves, while still prohibiting coverage of the "better benefits" in the traditional program. This would end Medicare as an egalitarian program of social insurance.

The Washington Post is supporting the shift to "consumer-directed" Medicare, not only by shifting costs to beneficiaries when offering more plan options, but also by providing "incentive to choose plans more suited to their specific health needs." But it is impossible to select a plan that will be the best choice for medical events that cannot possibly be predicted. Also, for those with chronic disorders, providing options creates all of the inequities characteristic of risk segmentation. Lower-income beneficiaries with chronic disorders would be locked into the traditional program. The Washington Post states that covering a stroke but not covering the medications that would prevent it is "the kind of absurdity that a plan designed specifically to meet the needs of older people could avoid." Yet The Washington Post has endorsed precisely this type of absurdity.

Is this editorial incompetence, or is it support for the concept that there is a "lower class" that is not entitled to all essential health care? Perhaps The Washington Post does not want them to have their "cake," but, rather, "Let them have strokes."