As Medicare reaches age 50, we see periodic signs of limited efforts to move beyond its youthful exuberance as a full-fledged pay-as-you-go, fee-for-service, universal entitlement program and toward a somewhat more market-oriented direction. Most notably, the last decade since the passage of the Medicare Modernization Act of 2003 has produced rapid growth in enrollment in Medicare Advantage private plan options. Over 30% of Medicare beneficiaries are enrolled in these more market-based alternatives to the traditional Medicare fee-for-service program. Give or take 50 years, that might be considered modest progress in moving back toward a path not taken by Medicare’s original architects, even as they needed to maintain more of a “private market” face to cover such an unprecedented expansion of the federal government’s role in health care financing and regulation.
A 40th anniversary article on Medicare in the winter 2005-2006 issue of Health Care Financing Review by Edward Berkowitz of George Washington University provides an excellent summary of the key history, including several options discarded along the way to final enactment of Medicare:
- In somewhat earlier congressional efforts to enact a Medicare compromise proposal in 1962, Senator Jacob Javits (R-NY) helped to negotiate a feature, accepted by the Kennedy administration, which allowed elderly people with private health insurance coverage to keep their coverage. Medicare would reimburse the private carriers for benefits that coincided with those covered by the program.
- In 1964, Representative Wilbur Mills (D-AR), the chairman of the Ways and Means Committee and chief legislative architect of the final Medicare law, asked the Social Security Administration to develop a plan that allowed the use of the Blue Cross® plans to administer hospital insurance and Medicare’s billing operations as “fiscal intermediaries.” This served the initial political objective of keeping the federal government removed from getting involved in the routines of health care finance. (But not for long!)
- In further debate over proposed Medicare legislation in 1964, Javits also proposed the creation of what he termed “complementary private health insurance” for elderly individuals. His goal was to limit the federal role to covering the costs of hospitalization and skilled nursing home care, while covering doctors’ bills and outpatient care through what he described as “…low-cost private insurance plans to be developed on a nonprofit, tax-free basis with special provision for concerted selling and risk pooling.”
- Under another consumer-choice proposal by then-Representative and future New York City mayor John Lindsay (R-NY), elderly beneficiaries could either accept government health insurance, to be run by the States, or a private health care plan. If they chose the private health plan, they would receive an increase in their social security benefits.
- Some portions of these concepts actually were incorporated in the Johnson administration’s Social Security proposals at the end of 1964 and the beginning of 1965, but they faced opposition from many Democrats. They ultimately took the more limited form of a “voluntary” Medicare Part B program for non-hospital medical costs, funded equally by beneficiary premiums and general revenues.
The final Medicare legislation of 1965 delivered a comprehensive public entitlement program for almost everyone age 65 and above, instead of more targeted assistance to more vulnerable seniors that might have relied primarily on subsidized private markets. Younger taxpayers were conscripted to cover most of the higher costs that followed. As they say, the rest is history. It offers some useful lessons in comparing Medicare’s past with the possible future of the five-year-old Affordable Care Act (ACA) version of “Obamacare.”
First, temporary supermajorities in Congress can have a longer lasting impact by enabling enactment of unique legislation that institutionalizes sweeping changes in national policy and then becomes hard to modify significantly for decades. The 89th Congress of 1965 and the Johnson administration had far greater leeway to overcome past resistance to the role of the federal government in health policy and the practice of medicine after winning landslide victories in the 1964 election. Even though those supermajorities in Congress and popular support for Great Society initiatives eroded substantially within a few years (see, e.g., Vietnam War, civil unrest, etc.), the key elements of a vastly expanded welfare state fueled by entitlement programs – including Medicare – took root and largely remain (in somewhat modified form) five decades later.
Lesson: Repealing and replacing Obamacare is not going to happen quickly or easily, or even substantially, without much more concerted effort and detailed strategy than opponents have displayed thus far.
Second, economic cycles are not simplistically predictive of political ones, but big swings in either direction matter. Medicare was propelled ahead during an optimistic era of rapid economic growth that assumed few limits to future prosperity. Obamacare was pushed through the national political arena in the midst of the Great Recesssion and economic pessimism about the future of the USeconomic system.
Lesson: Economic cycles can drive political change when they accentuate major electoral swings that favor incumbent officeholders (during good times) or depose them (during suddenly disruptive downturns). The Obama administration did not “let a good crisis go to waste,” even if doing so subsequently cost it control of both houses of Congress.
Third, opportunities to address chronic national policy problems in more market-based directions need to be advanced more aggressively and positively before the effective window for action closes. Just saying no and minimizing concerns eventually loses out to the political impulse to do something, even if it’s not well-designed or effective. A sad reflection on the stance of conservative political leaders in the early 1960s is that only the limited efforts of a handful of more moderate/liberal Republicans serving in Congress at that time tried to deflect the full force of a government-centric mass entitlement program like Medicare, rather than just offer what became largely rearguard resistance that failed to offer anything more attractive.
Lesson: The time to provide better alternatives when major health policy issues are framed for national debate is sooner, not later. Next time, critics of the ACA must bring something more than shallow alternatives to Obamacare to the national debate and insist on earlier, consequential votes on them on Capitol Hill. Just winning subsequent elections and then finding excuses for further delay and inaction won’t ever accomplish substantial policy reversals when it comes to health care entitlement programs.
Fourth, states failed to step up the plate in the early 1960s after passage of the Kerr-Mills program, which then added strength to the case for a more nationalized Medicare program approach. It’s 50 years later and conservatives are still counting on (red) state governments to help fill national policy vacuums and handle complex issues that Washington policymakers can’t, or won’t, resolve. How much has changed since 1965?
Lesson: Delegation to state government officials and decentralized decision making will need to become more realistic and accountable, and less rhetorically evasive, to succeed.
Fifth, we are no longer living with all of the illusions of the 1965 Great Society vision. Even the ACA debate of 2009-2010 acknowledged some of the limits of taxpayer resources and the federal government’s administrative machinery. (But not all of them, to be sure). Obamacare discarded early gestures toward a public option. The ACA targeted its still-massive subsidies to only the relatively lower-income portion of the population, rather than spread them across the board. ACA dollars primarily flowed through privately owned entities, albeit in hopes of coopting them politically. The ACA even pretended to achieve budget neutrality. Unfortunately, it tried to achieve this balancing act through accounting tricks, regulatory coercion, poorly disguised tax hikes, and improvisational administrative rewrites of the law that transcended past legal bounds.
Lesson: American political culture still seems to prefer choice and competition – even in health care matters – that is channeled more comfortably through mechanisms that look more private than public, and recognize that resources are not unlimited. However, establishing clear alternatives to Obamacare will require a stronger case for less generous, needs-based targeting of public subsidies and development of robust market alternatives that work better and more transparently. Those elements were not sufficiently on hand when Medicare was enacted.
Finally, our political system not only takes a long time to enact major policy changes that implement national programs like Medicare and the ACA. It then also takes far too long to reconsider and modify them substantially, let alone fully replace them. But we really don’t have any more years left to truly begin fixing more comprehensively the chronic problems and imbalances first launched in 1965, as well as those started in the ACA just five years ago.
I’m still looking forward to celebrating the first anniversary of that more important achievement, hopefully far sooner than today’s milestone took to reach.
from AEI » Latest Content http://ift.tt/1De40ne
0 التعليقات:
Post a Comment