In 1965, a decades-long legislative and social battle culminated in the passage of one of America’s most enduring and populist social programs: government-sponsored health coverage for the elderly and disabled that you know by the name Medicare. So devastatingly popular is this subsidized coverage that it has spawned one of the iconic moments of irony in the decades-long battle over the soul of American health care reform: all the variations – self-deprecating and entirely serious – of the “Government hands off my Medicare!” genre of political protest.
Medicare is a foundationally popular social program for good reason. Along with Social Security, it has transformed the retirement years. Once the province of poverty and privation, the elder demographic has evolved from an unrepresented minority to a powerful force with its own lobby in Washington. Federal subsidies for health care and retirement funding in no small part facilitated the development of the nuclear family – transferring the financial care of elders from the family unit to the government dole and freeing the nuclear unit from in-home care of elders that has shaped the family structure for most of human history; the net benefits and losses of this radical restructuring are arguable, but the effect on the American social landscape is nevertheless marked. The combined forces of Medicare and Social Security have – somewhat unintentionally – helped make the retirement years a golden age, a second life, a well-deserved respite from long years of work before the senescent years of true old age.
Set all of these successes aside for a moment (as well as the fact that Medicare is precisely as socialist as Canada’s wildly successfully experiment with government-sponsored health care), as there is a sinister underbelly to Medicare that is seldom if ever acknowledged in the health care reform debate.
Medicare is designed to pick up two general populations that the bulk of insurers are not fond of: those over the age of 65, and the disabled. (Medicaid, contrarily, is designed to cover the poor.) Medicare cherry-picks its patients in the reverse manner of the majority of insurers: whereas private insurers cull these two expensive, resource-intensive populations from the rolls, Medicare preferentially takes on these same difficult groups by legal mandate. This is a welcome relief for these patients, who would indeed find it very difficult to obtain coverage on the open market; almost by definition, these are the patients who have spent a lifetime acquiring a variety of pre-existing conditions and other red flags that would certainly land their applications for private insurance in the rejection pile.
Medicare serves as a relief valve for private insurance. Private insurers maintain profitability under the guarantee that the most cost-ineffective patients will eventually shift elsewhere. Insurers are safe in the knowledge that their entire client roles are only temporary burdens – the onset of age or permanent infirmity means an automatic shift off the private insurance rolls and onto the public dole. This is a phenomenon known as “cost-shifting.” It has some profound influences on the way that private insurers treat their patients and the way that patients behave in the years leading up to Medicare coverage.
First and foremost, the promise of Medicare means that private insurers have very little incentive to emphasize or pay for preventive care and early effective care for chronic conditions. Appropriately applied preventive care has been shown to reduce cost again and again, but this financial principle only works if the long-term cost of care falls onto the same agency. If cost shifts off an agency as soon as a person becomes elderly or truly debilitated, the return on investment for preventive care becomes very minimal, and private insurers thus have a minimal impetus to pay for preventive care or early care for diabetes, heart disease, obesity, and the like.
Systems where a single agency cares for patients from birth to death have no means of cost-shifting; they absorb the consequences – positive or negative – of all health policy. When I lived in Britain for a year, I established myself at a local National Health Service clinic for routine care. I honestly answered a health history questionnaire by noting that I had suffered some bouts with asthma; it just so happens that I have the variety of asthma that causes a prolonged and persistent cough with every passing virus – the kind of cough that makes people on the subway glare at you and move several seats away – but I have never required emergency care for this mild condition. Nevertheless, every time I stopped into my local clinic for any incidental issue, time was taken to inquire about the frequency of inhaler use, peak flow measurements, and even my knowledge of the quickest route between my home and the nearest Accident & Emergency facility; adjustments were made to improve control of the condition and prevent admissions to the hospital. These inquiries were boiler-plate for asthmatics, and I watched my GP tick boxes on a pre-set template as I answered; this was just one small part of the NHS goal to reduce costs at all points of care possible. In the United States, I have never been asked about my asthma unless I brought it up. Because the NHS takes care of all British citizens from birth to death under a single budgetary umbrella, they have taken preventive measures to new heights – and have been rewarded for these efforts with an average life span a year longer than the average in the United States, achieved while spending half the GDP by percentage on health care as does the United States.
Beyond the lack of incentive for insurers to institute top-notch systems for prevention, many middle-aged people – especially in the recession era circumstance of reduced employment leading up to the retirement years – simply minimize their insurance coverage and cross their fingers that nothing devastating blow out of the winds of fate before Medicare kicks in on the magical date of their 65th birthday. Under-insurance (especially high-deductible indemnity plans) in this demographic often results in delayed care for burgeoning issues of routine age-related conditions like high blood pressure, an issue compounded by missed targets for preventive care like colonoscopies and mammogram. Because private insurers are not invested in the health of individuals beyond the age of 65 – and because the agency that is responsible for health after the age of 65 has no access to patients before that age – many Americans roll into the retirement years far behind the eightball, battling back years of marginally neglected health with only the voodoo insurance of crossed fingers. The promise of Medicare at 65 results in complacency in the years when age-related conditions are rearing their heads and preventive care should be ramping up.
Worse yet, the understated promise of disability-based Medicare means that private insurers have far less incentive than they should to provide services to help with strict control of chronic diseases like diabetes. This problem is particularly pointed in the case of renal dialysis (for which uncontrolled diabetes is the leading indication); by a strange quirk of history, the phenomenally expensive condition of being dialysis-dependent automatically qualifies an individual for Medicare coverage, and as soon as this condition arises, the entire cost shifts off the private insurer. One can bet that if private insurers were looking down the barrel of paying the total cost for every current diabetic who may potentially need renal dialysis in the future, their incentive to get every diabetic under control would rise in grand proportion to those costs that they presently shift to the government. The existence of Medicare – by allowing cost-shifting at most critical moments of age and infirmity – allows for a health care pseudo-system that banks and profits on the avoidance of preventive and early care for all manner of disease, dumping the resultant cost on the public dime.
Medicare, by all measure, is a false god – a shell game built on good intent but a 19th-century understanding of health care and aging, a system drawn from a time when rescuing seniors from poverty was a reasonable goal but building a functioning health care system was not yet on the radar. Medicare is a safety net, and America loves safety nets. We love soup kitchens, homeless shelters, free clinics, and used clothes bins for poor kids in the basement of local churches. We like to base our systems of wealth redistribution on charity instead of the justice of equal access, blindingly forgetting to notice that every other wealthy industrial nation has long-since ceased to rely on charity, instead building a common and formal system for social good – and that our charity-based model is the hallmark of third-world nations. Safety nets are stopgaps only; they do not replace modern, streamlined systems for the delivery of common social goods.
But in the end, I will contradict myself: Medicare is not truly a social evil. Its wild popularity from the far-flung right to the liberal left bespeaks an effectiveness and a commonality that could be used to build a universal health care system – a much-vaunted public option, a Medicare-for-all – via a quiet expansion of the system to a point where all could buy in for a premium that matches proportionally to one’s income. Medicare’s sole fatal flaw is its limited scope, its inadvertent function as the whipping child of a privatized system that allows cost-shifting onto the public dole in the name of profit-making in the private sector. As well as being the crutch that enables America to keep hobbling along while being beaten down by the rapacious system of for-profit health insurers, Medicare is also the genius child of a different era, a time when the vision of common-cause caretaking was not only acceptable but actually embraced, and politicking was slightly less contentious than today. Medicare may be a place where we can regain that common ground, and bring the far right, the far left, and the majority center together to carve out a zone of peace and quiet where the hammering out of a unified national health coverage policy can finally begin.
Cross-posted from my newly relocated and relaunched blog at America, Love It or Heal It.