PROJECTED PROBLEMS
A report to Congress from the National Bipartisan Commission on the Future of Medicare is due on March 1. Preliminary material from the commission contains the following predictions based on current trends:
* The Balanced Budget Act of 1997 will ensure solvency of the Medicare Part A trust fund until the year 2008; then the fund will be bankrupt unless reforms are enacted.
* Annual Medicare spending will climb from $207 billion in 1997 to $2.2-$3 trillion by the year 2030 - - more than the entire current federal budget.
* Out-of-pocket expenses of Medicare beneficiaries will
rise.
* 77 million "baby boomers" (born 1946-1964) will begin entering the
Medicare system in the year 2011.
* The number of workers per beneficiary will drop from about 3.9 in the year 2000 to 2.2 in 2040.
* Without changes, Medicare payroll taxes would have to rise from 2.9% to 5.6% by the year 2030 for full funding of in-patient hospital services.
NRLC'S POSITION
Before I list our main concerns, let me make it clear that NRLC does not oppose restructuring Medicare in order to save the taxpayer money and improve health care services. As a single-issue organization, NRLC takes no position on whether government or private agencies should provide health insurance. The guiding principle for NRLC's position on any Medicare reforms is that changes to Medicare should not endanger the life of the beneficiaries. Therefore, NRLC opposes
* any "reforms" to Medicare that force health care rationing on beneficiaries and thus make them potential victims of involuntary euthanasia through the denial of care;
* any "reforms" to Medicare that allow, promote, or fund assisted suicide and euthanasia; and
* any "reforms" to Medicare that, by law or practical effect, prohibit beneficiaries from using their own funds to pay for lifesaving health care.
WHAT NOW?
The choices to fix the problems are limited.
* Obviously, taxes could be raised in order to meet the projected demand on the federal budget. NRLC has no position on taxation as such. Given the size of the projected shortfall, the political feasibility of that approach appears to be limited.
* The most objectionable "reform" would be the curbing of benefits through rationing of health care. Rationing comes in many guises, foremost in the form of "managed care" plans and the outright limitation or denial of benefits by government edict.
An extreme example of the latter is Oregon's health care program for low-income citizens. It not only restricts or denies care for a large group of health problems and disabilities, it also pays for physician-assisted suicide as a "health care benefit." That is the ultimate perversion of the mission of the healing professions: abandonment and killing instead of caring and healing.
"Managed care" plans and HMOs are currently the main vehicles of health care rationing.
"Managed care" turns the traditional arrangement between patient and physician on its head. Traditionally, physicians earn money by providing care. Under "managed care" they may make money by denying care - - either because they get a fixed monthly "capitation" fee per enrolled patient (and thus lose money if they provide care that costs more) or, as employees of an HMO, they receive a bonus for keeping treatment costs down. Alternatively, managed care plans may employ "utilization review." That means that before a doctor can order a particular treatment or test for a patient, the managed care company must be called for permission. The company may deny authorization for the care altogether, or it may require that a less effective - - but less costly - - alternative be used.
"Managed care" also uses "gatekeepers." Instead of you and your physician deciding on the best course of treatment for you, the managed care plan's gatekeeper (who may not even be a physician) decides whether the proposed treatment is "cost effective." Do you want an insurance bureaucrat, with the power of government behind him, to make life-and-death decisions for you?
* Last year, the Balanced Budget Act created the new option of annually choosing a private health insurance plan, called a "private fee-for-service" plan. The plan would not ration care because it would allow people to choose their own doctors and other health care providers and then leave medical treatment decisions to the patients and doctors. Older people are allowed to add their own money to the basic government Medicare payment in order to cover the premium cost of such a plan. It is critical that Congress preserve this option in any new restructuring. In the meantime, insurance companies should be urged actually to offer such plans within Medicare.
Vocal opponents to such arrangements argue that "justice" requires that all people get the same health care and that the use of private funds creates inequities to the detriment of low-income people. This argument is wrong on two counts.
First, to argue that you must be prohibited by law from using your own resources for health care (that might, in fact, save your life) is akin to arguing that you may derive retirement income only from Social Security and not from your private savings. That is plainly absurd.
Second, to prevent people from spending their own money beyond what Medicare provides actually hurts those with low income or limited health insurance.
The reason is simple. Health care providers have direct costs for every treatment, like an antibiotic or IV bag, but also indirect, fixed costs, like employee salaries and office rent. If those with average incomes are allowed to choose insurance that pays a fair price for adequate, unrationed treatment, then both direct costs and an appropriate share of indirect fixed costs are covered. If providers' fixed costs are covered by such insurance, they can afford to provide discounted care to poorer patients by not charging them for a share of the fixed costs. If not, they must ration.
Any Medicare "reform" that would prohibit you from spending your own money on lifesaving health care would not only be an arrogant and unjust denial of your fundamental rights, it would also take billions of dollars out of the health care economy and, therefore, hurt the less well-off - - unjustly.