Medicare Reform Must Begin Now

March-April 1997

By Clarke E. Cochran

LUBBOCK, Texas—Whatever else transpires in health-care policy, the next four years will witness changes in Medicare—national health insurance for the aged and disabled. This for two reasons: Medicare politics helped determine the outcome of the 1996 elections, and the Hospital Insurance Trust Fund (Part A of Medicare) will be bankrupt shortly after the inauguration of the next president unless changes are made by 2001.

Medicare spending during 1996 was estimated at $194 billion, a growth of nearly 10 percent over 1995. Medicare covers approximately 37 million people. Part A, funded by payroll taxes, covers about two-thirds of Medicare spending, chiefly on hospital and skilled nursing care. Part B, funded by a premium paid by recipients and federal revenues, covers physician, outpatient, and laboratory services.

Given the failure of health-care reform in 1994, a fundamental restructuring of Medicare is unlikely to occur for some time. In the meantime, short-term changes, designed primarily to save money and keep the system solvent, need to be made by combining some of the following options.

1. Shift some of Medicare's Part A services to Part B. This means slowing expenditures from the soon-to-be-bankrupt trust fund by shifting the costs to recipient premiums and general federal revenues.

2. Reduce payments 10 hospitals, physicians, and other service providers. The danger here is that the impact would hit urban and rural hospitals, and thus our poorest citizens, the hardest.

3. Accelerate the movement of Medicare recipients into managed care plans. The trend is already in this direction, yet at best this will provide only a small part of the savings needed.

4. Increase premiums to seniors. If this is to be just, the premium increase should be targeted to those in higher income brackets, but that is administratively difficult to do and undermines the premise that Medicare should treat all beneficiaries equally.

5. Reduce services. Again, properly targeted, this makes sense with regard to some services to some people, but at present such reductions would probably affect the poorest recipients most severely.

Each of these five changes has advantages and disadvantages. None represents a fundamental change in the structure of Medicare. Comprehensive reform should not be undertaken lightly, because Medicare has been highly successful in many respects. But all of the changes above will solve the financial crisis of Medicare only temporarily.

If we do turn to consider long-term restructuring of Medicare as a health insurance program, we must do so by seeing it in relation to other aspects of health-care reform, including Medicaid, coverage for immigrants, and the expansion of health insurance opportunities to those not now covered.

From a Christian standpoint, health-care reform should be as much about challenging the very culture of American health care as it is about specific policy proposals. Instead of promoting a faith in technological miracles that encourages people to avoid facing the reality of death, health care ought to address the need for a continuum of long-term (including preventive) care without unduly prolonging life or unnaturally hastening death. Americans do not need better technologies of (physician-assisted) death. Rather, they need to learn how to speak and act humanly at the end of life and to establish communities of "respect, love, and support" around those in long-term care and those near death.

Among other things, fundamental reform should encourage the training of more primary-care physicians and fewer specialists. Research programs should place less emphasis on miracle cures and more on the treatment of chronic and debilitating conditions. Christians must learn to challenge the disease-focused medical system. We owe to one another the kind of care that affirms our common humanity and our God- ordained purpose. We do not owe one another the false promise of a cure for every insult to the body.

Congregations, parishes, and Christian organizations should work with the medical establishment to explore the meaning of health itself. They should also help reform the American way of dying. Government cannot teach us how to die well, but neither can the church by itself respond to all the health-care needs of the terminally ill. Partnership is required.

The challenge to Christians concerned with health care, whether as providers or as citizens, has always been to find the gaps, to meet the needs of those in them, and to advocate with government for those abandoned in the gaps. People of faith are called to "read the signs of the times" (Mt. 16:3) and to bring the presence of Christ to the times.

[Dr. Cochran is professor of political science at Texas Tech University.]