The New Medical Marketplace: a Physician's Guide to the Health Care Revolution.
I have just completed reading Hugh Long's article in the January-February 1990 issue of Physician Executive, ("Medicare catastrophic coverage: A Postmortem," pp. 12-14.) As a rsults, I must comment and offer additional perspectives from close up.
In 1985, President reagan established the Private/Public Sector Advisory Committee on Catastrophic Illness. This committee developed much of the background that evolved into the Medicare Catastrophic Coverage Act. I testified before this group and attended all but one of the hearings held across the nation. The proposal was flawed from the beginning.
During the early days of the legislative process, in 1987, the National Alliance of Senior Citizens, Inc., commissioned Richard Wirthlin to conduct a nationwide random survey of senior citizens. The results showed overwhelming opposition (about 78 percent) to the proposed legislation. (A similar number of seniors were covered by supplemental insurance).
Copies of the results of the survey were provided to the 535 members of the U.S. Congress, but the results were ignored. Why? Simply put, the congress was determined to pass the legislation because the American Association of Retired Persons vigorously supported it, as did other liberal-minded organizations inside "the beltway." In addition, the late Claude Pepper, the seniors' advocate in Congress, backed the legislation.
I testified before and after passage of the legislation in opposition, in the knowledge that the majority of seniors opposed it because kf the surtax and the provision of coverage they did not want or need. Contrary to Dr. Long's contention that the opposition was not rational, these two basic reasons were ra tional enough to mobilize seniors when they finally awoke to appreciate what Congress had done to them. The fact that members of Congress persisted in labeling the surtax a "supplementary premium" gave the seniors added reason to rebel.
With respect to Dr. Long's discussion of the opposition by the pharmaceutical industry, it is necessary to note that AARP sponsored the drug payment provision in the law. Why? AARP operates one of the largest, if not the largest, mail order pharmacies in the nation. It stood to gain, clearly a profit motive.
I am not quite sure how Dr. Long makes the distinctions about "separating the various positions." From my close association with the law, the only position that was evident was that seniors had been taken advantage of and deplored the hypocrisy in Congress (i.e., the supplementary premium was viewed as a surtax and seniors felt betrayed).
A close-up view, postpassage, revealed numerous senior organizations across the country forming coalitions to repeal the law; many diverse retiree organizations were included, all for a common purpose. The grass roots spoke in unmistakable language to Congress, and they prevailed.
As Dr. Long searches for an "economic basis" for the all-out attack on the law, he would do well to consider that seniors had an economic basis, even if it was not compatible with an academic economic model. Missing from the law was coverage the majority of seniors had said (in the Wirthlin survey) that they needed the most--long-term nursing home coverage. This remains an unmet need.
I agree with Dr. Long when he concludes, "All in all, a sobering experience for Congress." It need not have been had Congress made a sincere effort to take testimony from many senior groups while maintaing an open mind. As so often happens in Congress, a preconceived notion is elevated to a forgone conclusion by minds that are already closed to opinions and observations that are at odds with e bers and their staffs. Now that the
Medicare Catastrophic Coverage Act no longer exists, it is a safe bet that Congress will tread more cautiously and will seek more diverse views before it tackles this problem. --Bedford H. Berrey, MD, FACPE, Midlothian, Va.
Dr. Long replies:
Dr. Berrey makes several interesting and insightful points concerning the history of the Medicare Catastrophic Coverage Act. Certainly there is little question that most seniors opposed the surtax, particularly if they were subject to paying it.
It is less clear that seniors affirmatively did not want the profferred coverage independent of having to pay for it. The fact that they wanted (and want) long-term custodial care (nursing home) coverage more than they wanted the features of the Catastrophic Act does not tell us that they eschew the latter.
As my original article states and as Dr. Berrey suggests, a significant portion of the Catastrophic Act's coverage was duplicative of coverage in private Medigap policies (supplemental insurance) that are purchased by the three-quarters or so of seniors who can afford to do so. The eight million Medicare eligibles who can't afford supplemental insurance are also those who can least afford the costs that the Act covered. And the ranks of seniors unable to afford private supplemental insurance are increasing as Medigap premiums again skyrocket, largely as the result of the repeal of the Catastrophic Act.
Not surprisingly, seniors of means are willing to accept Medicare benefits financed in part by the payroll taxes (Part A) and income taxes (Part B) of younger workers of far less means, but are unwilling to themselves subsidize their fellow seniors of lesser means. --Hugh W. Long, PhD.
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|Article Type:||Book Review|
|Date:||May 1, 1990|
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