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Real Problems

In the short term, I think saying "Medicare's the real problem" has a certain value in terms of the Social Security debate. If we learn anything from the Social Security debate, however, it's that long-term rhetoric matters. This Bushian effort wouldn't even be able to get off the ground if not for twenty years of mystification and mal-framing on the part of would-be privatizers. So I have some concerns about the light in which the "blame Medicare" line casts things.

It's quite true, of course, that current projections show Medicare on an unsustainable path. But if you look at just about any entity (be it a person, a corporation, a non-profit, a government at any level) that spends money on health care in the United States you'll find that entity on an unsustainable path. Medicare per se could be easily enough rendered sustainable by just making it less generous, but that would simply make every non-Medicare entity's path less sustainable and not really solve anything. The health care problem is a sticky one, but it's a health care problem. There's not a "Medicare problem" and a "Medicaid problem" and a "Veterans Administration problem" etc., etc., etc. Lots of folks pay for health care in various ways in this country and we're all looking at a not-so-far-off abyss.

December 16, 2004 | Permalink


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Why bother to make this argument? We'd be better off calling for the privatization of the missile defense shield. It's ability to work is exponentially less than SS and Medicare and it's costing us billions.

If they're itching to privatize...why not force them to go with missile defense?

Posted by: Carla | Dec 16, 2004 8:07:14 PM

Trust me, "fixing Medicare" is not far from the Bushian mind. Medicare is about the only provider that actually checks to see how the money is spent and can actually enforce fair pricing. Turn the Medicare accounts over to private companies and you can watch your charges skyrocket and the provision of care plummet.

What we're really seeing are major systemic failures that can't be cured by reforming a single agency. If there's any truth to rents and house prices being related, you can imagine why people on Social Security need regular raises to stay in the market. A health care "system" using twice as big a share of the GNP as universal coverage would is simply going to break any insurer that provides adequate coverage.

Maybe the French do some of this better because they've already tried five republics, while we're still on our first one.

Posted by: serial catowner | Dec 16, 2004 8:34:05 PM

Entitlement programs are Social Security, Medicare and Medicaid. These precious programs have insured that we would build and could sustain a middle class America. Now, we are listening to "jeremiads" about entitlement spending to set the stage for dramatic changes that will threaten Social Security and Medicaid. We should be most alarmed, but so many of us have grown so used to hearing how impossibly expensive is a Social Security program that is actually in surplus that we may find the program undermined and even deem it for the better. Medicaid is already being limited in several states, with no political price being exacted. Oh dear.

Posted by: anne | Dec 16, 2004 8:58:41 PM

The correct frame is, "the War on Social Security," not "saving Social Security." That is honestly what is happening.

Posted by: Jon Stopa | Dec 16, 2004 9:04:58 PM

Right, thanks for pointing out that "Health Care" is our major next problem.

The rationals among us have to tell our government that we do not want to be side tracked by:

1) Social Security -- It can be fixed by reasonable growth of the society, and if not some minor benefit and tax adjustments.

2) Tort reform -- a minor cost of health care, even including the cost of defensive medicine that allows use to be more sure of what we are sick with.

3) Medicare or other Insurance plans -- most of us don't like going to the hospital or the doctor, so whether there is a low co-pay or not, most of us don't over use it.

4) Efficiencies -- yes technology can save some money, and we should upgrade the medical treatment facilities and make them more efficient, but that is only a blip, and is still not a solution.

(NOTE: I did read that some people were going abroad to get less expensive treatment, so outsourcing may help us reduce the cost of care.)


But finally, we need to recognize that, in fact, the Medical Treatment that we want costs more than we are willing to pay for it, and unless we deal with that directly, the problem will NOT be fixed.

Either we dedicate 25% -- 50% of our GDP to health as we age and medicine becomes more capable or,

We limit the amount of care that we expect, except for the Ultra Rich.

My guess is, that since I heard that the major costs seem to be for the last days of treatment, we will evolve into a situation that says that we can expect care (paid for by Medicare/Insurance) for most of the treatment we get, but that the very end of life treatment will be outside of that.

More generally, Medical Care will HAVE to be rationed, either by the free market, or our society, with the Ulta Rich of cours being able to buy above any social rationing. As a society, I expect we will decide to spend, say 10% of our GDP for medical care and then "rank" treatments in cost/effectiveness order and purchase those that are most cost effective up to the 10% we are willing to pay for.

Posted by: Mike Liveright | Dec 16, 2004 9:22:53 PM

"Medicare's the real crisis" is a great argument. An especially great trick would be to say "Hey, Medicare's the problem. Why is Medicare such a problem, you ask? Because healthcare is a huge problem!" Then we're doing two very good things: a) increasing public pressure to deal with an real problem and not a made-up one and b) moving the domestic policy debate back onto turf where we have more credibility.

This is a very good road to be on.

Also, if I may blogwhore, I have a suggestion for the Bush plan that was probably subconsciously inspired from your "forced investment" phrase: "forced gambling."

Posted by: theorajones | Dec 16, 2004 9:48:17 PM

I just thought of something I think is fairly important. Generally, we're not bad at explaining in general terms why our plans are better than Bush's plans. Not great, but not bad. But we are very bad at explaining, in very precise and no-bullshit terms, what the negatives consequences for a specific voter would be if Bush's plan was adopted in preference to our plan. That is, we're pretty good at arguing "We're right, they're wrong". But we're very bad at answering the question "So what? What's the bottom-line for me?"

So take a voter 26 years old making 30,000 dollars a year. What are the consequences if Bush'd plan is adopted, versus our plan? What about a 49 year old making 100,000 a year? A 55 year old "near-retired" person making 60,000?

In general, the Republicans have developed much better, plausible-sounding answers to these hypothetical scenarios than we have (not least because their answers involve implicitly borrowing large amounts of money from the future and giving it to people in the present). And if we can't develop answers to questions like these in very precise, no-bullshit, credible ways, we're going to get our clocks cleaned. Again.

Also, I think its a mistake to make too much of analogies between health care in 1992 and Social Security in 2004. Mainly, we should not take any false comfort from such analogies. If the Republicans play their cards right, they can make *huge* inroads into the minority vote, which along with their apparently very secure and culturally entrenched hold on the white vote, could push the Democratic party into true irrelevance. As a party, we are staring into the abyss, and we cannot blindly assume that what worked for Gingrich is going to work for us.

Posted by: roublen vesseau | Dec 17, 2004 12:01:19 AM

Not really. Most of the cost increases are from new treatments and drugs. This is a GOOD problem to have.

One way to make it sustainable is to simply not adopt new treatments and drugs. Make Medicare the best health care that the 1990s can provide. Even if it's 2040. Best way to control costs.

Posted by: Adam Herman | Dec 17, 2004 1:55:22 AM

Mike Livewright - The US already spents way more than 10% of GDP on health care.

The trouble here is market failure: trying to fit the facts into something representing a free market where it cannot be done. A single-player system would be cheaper. But anything non-market is anathema. Just read David Brooks on Social Security:

It's about the market. People who instinctively trust the markets support the Bush reform ideas, and people who are suspicious oppose them.

I love markets. When they work. But insurance, wether SS or health care, is about risk-pooling. Unless you accept that some people will lose out altogether, it's almost impossible to have an insurance market that can compete with a single-player system.

Posted by: jasper emmering | Dec 17, 2004 5:53:02 AM

How true it is- health care monopolists are rewarded as though "the market" would restrain greed or monopolistic piracy. But there is no free market.

Doctors strictly limit entry into their field, have for decades. No free market there. But wait, there's more- they also keep Public Health and other ways of decreasing health problems on the back burner. In any big university the Medical School has a huge and disproportionate influence.

As most of us know, the drug industry is regulated for one purpose- to maintain the monopoly of the big drug companies that can afford to buy elections. No free market there.

The hospitals are, in theory, regulated about how many beds they can add. This is because overbuilding results in empty beds, and the cost of the waste is charged against actual patients. In practice, major hospitals can simply ignore these regulations, and fight it out with a fragmented market. Occasionally patient rooms are converted into offices, more often smaller hospitals in the area are absorbed by the larger.

In short, there is no "free market" in healthcare, never has been since the Flexner Report, and never will be. We'll have problems until we deal with this reality.

Posted by: serial catowner | Dec 17, 2004 10:06:44 AM

The Medicare Board is a price fixing scheme. They set the fee schedule for any and all medical services provided by any provider who accepts medicare or medicaid patients. They have now reached the position that they do a better job of protecting the provider than the user -- that is why we are seeing 40% annually increases in medical costs. To keep giving fee increases in excess of inflation, other than for new treatments, is an absurdity that will keep medical services expanding as a percentage of GNP.

And it is a separate problem than Social Security benefits. I think just about everyone realizes that SS is needed program. There just needs to be changes in the way that it is funded.

Posted by: tomas | Dec 17, 2004 10:17:00 AM

There is only one way to frame this. "The President is lying when he says there is a crisis. The Republicans want to smash Social Security and will say anything to do it." Anything less plays into their hands.

Posted by: jr | Dec 17, 2004 10:24:12 AM

If somebody thinks Medicare is RAISING prices, I sure wonder if they've ever looked at what Medicare pays the provider. The last statement I looked at the provider had been paid about $27 for a 20-minute office visit. The treatments and injections the doctor had provided were denied- those all came out of the doctor's own pocket.

Vying in importance is the Medicare ability to go after fraudulent billing, which apparently no other insurance company can effectively do.

In long term care Medicare is just as important in restraining costs. Well over half of the LTC patients in Washington state are Medicaid patients, which is just the state administration of the SS insurance. Medicare provides the basic funding to keep the NH industry stable, and we mean BASIC- providing about 2.5 hours of care per day for gravely disabled patients.

In short, Medicare is about the only piece of the puzzle that's working, but their extremely low rates of reimbursement make most providers very unwilling to accept new Medicare patients.

It's a funny thing, I just look at the thread to see if there are any glaring mistakes that need to be corrected- and there always are.

Posted by: serial catowner | Dec 17, 2004 2:48:21 PM

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