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Caring and curing: a Medicare proposal.

When the Medicare program for the elderly was enacted in 1965, it provided well and amply for their acute care medical needs, and it did so regardless of income. That was not true of their long-term care, which was put under the Medicaid program and its recipients subjected to an income means test.

That bifurcation remains the perfect symbol of a health care system that has always given priority to cure over care--as if the preservation of life were more important to the elderly than how they would live that life. That has never been the stance of the elderly themselves, who invariably report that they fear impoverishment and dependency more than death. The time has come to correct the imbalance.

The most straightforward way to do that would be to change radically the present Medicaid program for long-term care, fully subsidizing it. Yet there is, unfortunately, little likelihood that President Clinton and Congress, under great pressure to provide for those with no health insurance at all, will advance any ambitious program to reform, much less substantially expand, the long-term care program. I may be wrong about this (writing as I do prior to the 1 May date set to announce a new health care plan), but given the expected price tag of genuine reform of long-term care (the figures range from $30 to $50 billion additional funds a year) it is improbable. The greatest pressure is likely to be that of finding ways to lessen the Medicare burden on the federal government.

I want to propose an exchange, which I will call Medicare: Part C. Part A of Medicare now covers hospital costs, while Part B covers physician charges (at a modest monthly cost). Part C, as I propose it, would provide the voluntary option of allowing the elderly to exchange their mandated right to extended hospital acute care coverage for enhanced long-term care coverage. At a certain age, say eighty, elderly persons could choose restricted hospital coverage and receive in return improved long-term care support. Ideally, they would be allowed to balance the two forms of coverage in any way they saw fit.

The attraction of such a plan for the elderly is that it would allow them to decide what they feared most about their old age and to make a choice about the kind of care they wanted. There is simply no likelihood in the future that they are going to get both care and cure to a substantial and acceptable degree; so they could make their own determination about which mattered the most for them. For the government, it would allow a way out of the now almost impossible dilemma of trying both to maintain decent Medicare benefits and also to expand and improve long-term care coverage--and to do that while at the same time adding new programs to cover the 35 million or so uninsured Americans.

There are a number of alternative way such a Medicare Part C exchange program could be organized. First, it would be important to insure that the elderly would always have access to primary care and to simple emergency care, and of course to hospice and all forms of palliative medicine. Second, the choice to be made at age eighty could be structured in different ways to suit different inclinations: (a) a total long-term care coverage in return for giving up almost all acute care hospital coverage; (b) a very high deductible for acute care medicine in return for a comparable subsidy of long-term care; or (c) the possibility of choosing Part C at an even earlier age than eighty and increasing the long-term care benefits accordingly.

I will not here try to develop further the possible details of such a plan. That would require some economic calculations and cost projections for the different alternatives not now available. Moreover, at the present time the gains to either individuals or the government might not be all that great. The impact of a Medicare Part C would increase over the years as the number and proportion of the elderly increase and as the array of expensive technologies to extend their lives increases as well. Even now, as can be seen with the rising age of those receiving such high-technology medicine as dialysis and coronary artery bypass surgery, the combined force of old people and new technology is taking its toll: double-digit inflation for the Medicare program, with no immediate end in sight.

My proposal for a Medicare Part C assumes that we will increasingly ration health care for the elderly. That is already happening by the traditionally covert means of nibbling away at benefits and forcing the elderly to pay more out of their own pockets. That way seems to make legislators happy, sidestepping an all-out war with elderly lobby groups and at the same time misleading the elderly and the general public into thinking that rationing has been avoided. We cannot avoid it. We can only make it less nasty.

My plan concedes the necessity of limits, assumes the reality principle that in the years ahead we will not be alble to afford the highest levels of both cure and care, and then tries to find a viable alternative. By allowing the elderly themselves to choose a way out, it gives them a new power, and it would allow them to have at hand a way of improving their later years, not extending them, which is exactly what most elderly say they want. No one would be forced to choose Part C. Those elderly who reject it could take their chances with the present program.

This plan would no doubt be of far greater advantage to middle income people than to the poor. But it is middle income elderly who are most disadvantaged by the present system, which now requires them to pauperize themselves (or to fake that state) to qualify for Medicaid long-term care coverage. Millions of people would have a major anxiety allayed. The pervasive fear of financial indignities is as virulent as fear of the indignity of a technological death.
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Author:Callahan, Daniel
Publication:The Hastings Center Report
Date:May 1, 1993
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