Both Sides of the Fence

A Tosa resident since 1991, Christine walks the dog, cooks but avoids housework, writes and reads, and enjoys the company of friends and strangers. Her job takes her around the state, learning about people's health. A Quaker (no, they don't wear blue hats or sell oatmeal or motor oil), she has been known to stand on both sides of the political and philosophic fence at the same time, which is very uncomfortable when you think about it. She writes about pretty much whatever stops in to visit her busy mind at the moment. One reader described her as "incredibly opinionated but not judgmental." That sounds like a good thing to strive for!

Sometimes, Bush is right: Medicare reform

Medicare, Politics

Not all the way, maybe. But partly.

On February 15, the Bush administration proposed changes to Medicare that have made almost everyone unhappy. Like most legislation, it’s a mixed bag. But two ideas in the plan, already pronounced “dead on arrival,” are no-brainer necessities.

The first: raising the premiums more affluent seniors (those with yearly incomes above $82,000 for an individual, twice that for a couple) pay for Medicare Part D drug coverage. The change would affect about 4.5% of all Medicare beneficiaries.

The second: requiring doctors and hospitals to use electronic medical record systems. This should have been done a long time ago, not only for cost and efficiency, but because it can improve health care and reduce medical errors.

According to AP reports, “The administration's proposal is part of a first-of-its-kind response to a warning about Medicare's strain on the federal treasury.”

Democrat Pete Stark, representative from California, says the proposal is part of “a political ploy to foster a panic that Medicare is unsustainable.” Health and Human Services Secretary Mike Leavitt says, "This is an emergency that grows by the day."

Both are probably right. Medicare is a fixable and incredibly successful program. But Medicare spending needs to be held in line, the costs of health care along with it.  When Medicare was signed into law in 1965, the average life expectancy was 67. Now that people live a decade longer, it’s  become an entitlement to support an extended period of healthy “retirement,” an idea that didn’t even exist before the 1950s. What's more, inflation-adjusted costs of medical care  tripled  between 1965 and 2005.

Too many budget policies create a bitter balance, robbing from the poor to pay the rich, a Republican notion; robbing the rich to pay the poor, a Democratic notion; and robbing from children and the future to support older people and the past, a position supported by both parties in their refusal to do the hard work of creating legislation that’s both fair and sustainable.

Something has to give.

Should means testing enter the Medicare equation? Of course.  Should the proven efficiencies of electronic medical records be required practice? Of course.

Now comes the tricky part. The Bush proposal also includes more limits on financial and other punitive measures for medical malpractice and other system abuses. There's plenty of evidence that the carrot doesn't work without a little help from a stick.

Worse, the Administration's cost reforms cut reimbursement from everything but the problem-fraught private Medicare Advantage plans, which are clearly in need of reform. Rewarding what doesn’t work is just bad practice.

Finally, the use of medical records to track “quality” and reward “better” physicians and hospitals, while a good idea, is subject to scary manipulation. I attended a HRSA conference in Washington DC a few years ago. It was clear that Leavitt’s quality measures for outcomes of medical training were all but impossible to demonstrate. That seemed to be the point—not rewarding quality, but making it incredibly difficult to get the money dangling at the end of the stick.

Here’s a Canadian slant on the dilemma: "Democrats also have offered ways to slow Medicare spending. But their preference is to trim payments to private insurers serving the elderly through a program called Medicare Advantage. The administration has opposed any substantial cuts to the insurers, so the two sides are basically at a standstill over how to slow the program's growth."

To do it right, we need to draw on all the best ideas out there.

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