With friends like these ...

Maybe it's just me, but the Bush administration as of early 2005 has me thoroughly confused. There is the extraordinary sight of a President of the United States barnstorming the nation to head off a "crisis" in Social Security, a crisis that not only Democrats but many Republicans fail to perceive. But for the programs that really are approaching a crisis state--namely, Medicare and Medicaid--the administration is sending out profoundly mixed messages.

On one hand, despite all the gloomy talk about "massive government deficits," the administration has been spending on Medicare like a drunken sailor. It's not just the projected $1 trillion (after ten years) prescription drug program. Last year saw the administration expanding several Medicare benefits, most notably an additional $2 billion over five years for implantable cardioverter defibrillators (like the one keeping Dick Cheney alive). The administration has even recommended adding "medically necessary" Viagra to the list of Medicare-covered drugs.

None of this--not even the Viagra coverage--can be criticized as medically irresponsible. Anything that helps people gain access to needed healthcare is a good thing; many lives will be saved and improved, thanks to such expenditures. But fiscal responsibility is another thing. After all, there is that pesky half-trillion-dollar deficit, coupled with the administration's stated determination to perpetuate its tax cuts.

Here is where you come in. You have been drafted into the front lines--the National Guard, as it were--for the war on budget deficits. Many of the needed cuts will come from institutional long-term care, to the tune of tens of billions of dollars over the next ten years.

Far from being patriotically flattered by their recruitment in this fight, LTC's professional associations are screaming betrayal. Their members' good-faith efforts toward quality improvement have been ignored, they claim, and there could be a price to pay. (You might recall, for example, former American Health Care Association President Chip Roadman's comment about the quality improvement drive in a Nursing Homes/Long Term Care Management interview in August 2004 [p. 32]: "[I]f government doesn't continue to recognize its responsibilities in this, the whole thing could be derailed pretty quickly.")

One could say that institutional long-term care has simply fallen victim to historical trends, that the Bush administration is joining a growing number of states in a rush toward home-based care. Indeed, both the feds and the states are looking to spend more on that in hopes of saving money overall. But the question of how far home care can go in sustaining an aging society, and at what price, has never been answered satisfactorily.

The fact is, government healthcare programs are in such fiscal disarray and have become so perilous to providers that it will be a wonder if the programs are functioning at all in a few years. Some say that is the Bush administration's ulterior motive, to destroy programs that some Americans as long ago as the birth of Social Security deemed "too socialistic."

I don't know about that. All I can say is that if the Bush administration really did want to destroy these programs, it couldn't do a much better job than it is right now. The administration says it wants to "reform" Social Security, Medicare, and Medicaid. But with friends like these....

BY RICHARD L. PECK, EDITOR-IN-CHIEF

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