In January, as this is written, I have just read the text of President Bush’s state-of-the-union speech and I pondered over what his health care proposals might mean if they ever see legislative language. I have the same curiosity about state initiatives in Massachusetts and California for mandated universal health care insurance coverage.
We know that in the past few years, the total cost of health care has resumed its annual double-digit increase. This is not withstanding the 2007 cuts in Medicare reimbursement to all physicians and the drastic slash in the technical costs of imaging procedures outside of hospitals.
Now that Diana and I are Medicare beneficiaries, we are much more aware of the observation that old people need more health care than youngsters, if only to keep our body systems functional and to ward off the drastic and expensive effects of degenerative disease. We are more fortunate than many of our neighbors, whose problems are much more overt.
One of the points made by President Bush is the use of tax relief as an incentive for those now lacking any health insurance to buy some. The issue is not quite so simple as that. Two decades ago, the Congress discussed “first dollar coverage” on the premise that the health system should encourage patients to get checkups and tend to small problems which could be prevented from becoming larger ones by timely attention. That never flew and since then, most political rhetoric has been devoted to dissuading us from using the health system. Most of those efforts to dissuade us have been directed to passing costs to us at the time we need medical services, rather than leaving them covered by whatever health insurance we may have. Health savings plans provide a small tax advantage and the promise that if we avoid spending all of our designated savings for health, we can spend it for something more fun. The president said his plan would help 5 million people get health insurance. At last count, some 45 million Americans lacked any coverage.
Another problem with tax cuts as a boon to health spending is the reality that many of those lacking any health insurance are poor and do not pay any taxes. The range of coverage and costs of available health insurance plans varies from marginally tolerable to relatively comprehensive. Medicare is one of the better programs, even with its system of coinsurance and deductibles.
Medicare was “a way of using government money to pay doctor and hospitals bills for old people,” observed its chief sponsor, Rep. Wilbur Mills of Arkansas, when he introduced the legislation. All of us in medicine urged that Medicare rely upon Blue Cross/Blue Shield and other private health insurance carriers and intermediaries, rather than creating a massive bureaucracy. That was the way Medicare was planned and continues to operate. The designated carriers treated Medicare patients the same as their own subscribers, with the difference being that the carriers drew a quarterly allowance from the government and thus were not at risk for Medicare patient spending. The result was a massive surge in consumption with no inherent curbs on patients or doctors or hospitals. Most of the changes since the 1960s have been legislative and regulatory efforts to restrain Medicare and Medicaid spending. None of the proposals has been notably successful.
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