Don't Let Medicare Undermine the Health of Future Generations!

Zeke Emanuel, who is becoming the national educator-in-chief about health care in his new role at the University of Pennsylvania, preaches an excellent sermon in today's New York Times - "What We Give Up for Health Care."

Zeke's point is obvious, but, amazingly, it's one our political process has been oblivious to: what we spend on health care we can't spend for other purposes. That creates an ethical imperative to consider opportunity costs for health care expenditures. The proper question is - "does this health care expenditure create more human benefit than other possible expenditures?" - rather than the one we typically ask - "does this health care expenditure produce any benefit for the patient, no matter how small the benefit or how high the cost?" Zeke shows how health care costs have acted as an economic cancer, invading and obliterating investments we would otherwise make in wages (which have been stagnant or declining), education, and other crucial components of our lives.

As important as medical care can be, income and education are also crucial determinants of health. When we reduce wages to pay for health insurance, and reduce educational investments at every level to pay for Medicare and Medicaid, we're reducing overall health and well-being. The real "death panel" is our reflexive investment in medical interventions that produce minimal or no benefit at the cost of investments that would do more for us!

Zeke argues that "liberals" should be as concerned about health care costs as "conservatives" are:

There is an inevitable trade-off between rising health care costs and things liberals really care about, like access to college and good wages for working Americans. We cannot have it all. The health care reform act will help us save — mainly by changing how physicians and hospitals are paid and delivering better care to our most expensive patients. But more can be done: for starters, we could speed up the implementation of payment reform, stop Medicare payments for tests and treatments that provide no benefit and endorse competitive bidding for medical goods and services.

The premise of this blog is that many of us in the Medicare age group - whether we're "liberal" or "conservative" - share a concern about the future, and don't want current Medicare expenditures to undermine the health and well-being of future generations.

Avoiding overtreatment, and the moral imperative to consider opportunity costs, should be our relentless advocacy focus!

Raising the Age of Medicare Eligibility - First Prize Dumb Idea

This week the Congressional Budget Office released a report on proposals to raise the age of eligibility for Medicare and Social Security.

The CBO concludes that raising Medicare eligibility to 67 would reduce federal spending by $148 billion between 2012 through 2021. By 2030, Medicare's net spending would be reduced by 5% - 4.7% of GDP rather than 5%. Those numbers sound good.

But reducing federal expenditures doesn't reduce the need for medical care. Some lucky folks (I'm in that category) (a) have employment that provides health insurance and (b) are happy to continue working. Some who would rather retire will continue to work, increasing health care costs for their employer (and fellow employees). Some will scramble to find alternatives which will cost them more than Medicare would. And some will become uninsured, at an age when this is progressively risky. Overall costs - to individuals, employers and other government programs would probably go up more than the $148 billion reduction in Medicare outlays.

The CBO does not comment on the fact that employers are not clamoring for ready-to-retire employees to stay on the job simply to avoid being uninsured.

Raising the Medicare eligibility age isn't meaningful cost reduction - it's simply a form of hot potato, dumping the costs into other accounts. It intensifies the fragmentation of our health system, and worsens overall quality of care.

In my view, the proposal is born out of despair about achieving constructive Medicare reform in which health professionals, patients and families collaborate on behalf of improved care (basically more compassion and less technology) and reduced costs. From 35 years of practice in a not-for-profit HMO setting I know this kind of collaboration is possible. But it requires a spirit of cooperation and trust that is not easy to find in our toxic political environment. 

Seniors for Fair Medicare Reform

I started my first blog - health care organizational ethics - in August 2007. Here's how I described why I was doing it:

Medical ethics has traditionally focused on the individual patient, the individual doctor, and the patient-doctor relationship. But today most care occurs in organizational settings – group practices, HMOs, VA and more. Insurers and other third parties have a huge influence on the exam room. Medicare shapes care for the elderly and disabled. Medicaid does the same for the poor. Hospital cultures and policies affect what sick patients experience, for both better and worse.

All this means that the ethical quality of health care is profoundly influenced by the ethics of organizations. We can’t have ethical health care without ethical organizations.

Organizational ethics is what this blog is all about.

But my 2007 rationale for the "health care organizational ethics" blog overlooked a major problem. Organizations like hospitals and medical practices live in a mega-organization - the disastrously dysfunctional U.S. political system. With regard to Medicare, the "death panel" lies during the health reform "debate" and Republican refusal to confirm Don Berwick as CMS administrator showed just how toxic our political culture has become. This new blog will include politics.

Medicare has been called the third rail of politics. If you touch it, you're done for. A recent AARP advertisement, directed to the ill-fated "super Committee" reinforced the point. It shows an army of folks around my age marching and looking tough, while the narrator/leader intones:

"Washington, before you even think about cutting my Medicare benefits...here's a number you should remember - 50 million. We are 50 million seniors who earned our benefits, and you will be hearing from us, today, and on election day."

Here's what I thought an ethically grounded ad would have said:

"Washington, before you even think about cutting Medicare benefits, think about fairness. We 50 million seniors want to do our part to ensure a healthy future for America. We know that for that to happen, Medicare has to cost less. But we want to be part of a team, and that means everyone sharing the burden, including adding new revenues..."

I don't think politicians will get creative about Medicare until Medicare beneficiaries push them. So far there's been no voice from the many seniors who want to improve the care provided under Medicare and, at the same time, to reduce the costs. We're concerned about ourselves, but whether or not we have children and grandchildren we're also concerned about the health of future generations.

I'm insured through my employer, but I'm Medicare eligible. When I'm insured through Medicare, please tell me to wash my mouth out with soap if I call it "my Medicare." It's not just "mine," it's "ours." My payments into the Medicare fund from 1965 on paid for the care of my elders, including my parents. When I'm a beneficiary, my care will be paid for by the younger generation. Medicare is a matter of communal responsibility, not the private property of the 65+ generation.

Age is supposed to be a source of wisdom. Calling for teamwork and shared sacrifice is what my generation should be advocating for. The AARP advertisement invites definition of us seniors as "greedy geezers." I'm hoping this new "Seniors for Medicare Reform" blog will contribute to developing a strong voice from seniors on behalf of a more clinically sound, ethically justifiable, and fiscally prudent Medicare program.