Medicare Offers Lessons For National Health Care Reform

August 18, 2009|By Dr. John R. Burton

Our national experience with the Medicare program can provide guidance to the choices our legislators must make regarding health care reform. If one favors more or less government in health care, positive and negative lessons emerge from the nearly 50-year Medicare experience of providing universal health care coverage for all those age 65 and older.

Medicare eliminated the fragmented, episodic and often dehumanizing care that many retired seniors were forced to seek through emergency departments or charitable sources because they no longer had coverage from an employer. I witnessed this phenomenon first hand, and I don't believe anyone who has experienced such care as a patient or a provider would argue that it should be acceptable. The implementation of Medicare increased the demand for primary care from physicians in private practice. With access to comprehensive primary care, overall health care quality went up, and average per-patient costs went down.

Patients generally like Medicare and the freedom of choice it provides. Admiration seems to hold even if individuals had private insurance before retirement. It seems to be admired by individuals of nearly all political persuasions. It is a largely government-run program then does seem acceptable to many Americans.

Medicare was designed in the 1960s when life expectancy was only around age 68 and acute health care problems dominated. Now, the life expectancy is closer to 80 years and chronic diseases are most prominent. Some argue updating of Medicare has been slow. Yet it has adapted partially to the changes of the past 50 years. Improved coverage for prevention, counseling/education and house calls and, most recently, partial drug coverage show such improvement.

But there are problems. Primary care in Medicare has become unattractive to providers in recent years. Increasingly, seniors and especially those with multiple chronic diseases can't find a primary care provider. Experts argue this is because of the increasing complexity of illness, mostly in the very old.

Many patients find they must participate in a concierge program or the like or join a practice. Caring for older patients with multiple chronic diseases does take more provider time.

Team care is ideal in such situations, yet it is inadequately compensated and, therefore, not widely available. Accordingly, any health care reform must include strategies for recruiting professionals of all disciplines to primary care and sponsor the creation of innovative models of care delivery.

Medicare is a successful public/private partnership. In the fee-for-service Medicare program, most individuals have a co-payment or purchase supplemental private insurance in the form of a MediGap policy or they participate in the Medicare drug program.

Seniors in the Medicare Advantage program essentially have private insurance that is paid for by Medicare. In the 1980s, most experts predicted the vast majority of seniors would enroll in Medicare Advantage plans. This didn't happen, and many argue that some private insurers didn't recognize that the very old and those with multiple diseases could not be treated as if they were well 50-year-olds. There are stories of private insurance companies or groups subcontracted to them not allowing physicians the time to provide proper care.

However, some private insurance companies used this opportunity to create innovative programs to provide care for the chronically ill and disabled. But still proven innovations are not widely available in either the Medicare Advantage or fee-for-service programs. If one finds fault with government programs, there seems to be opportunity to do the same with private companies.

The Medicare program has been a godsend to American seniors. I shudder to think of their plight had it not been enacted. Without regard to one's political persuasion, lessons from our Medicare program, both its government and private components, could serve as a guide to doing what we must do: assure that all Americans have some form of adequate health insurance.

Dr. John Burton is a professor of medicine and director of the Johns Hopkins Geriatric Education Center and Consortium. His e-mail is

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