Friday, September 7, 2012
Two Presidents: Two Lessons on Two Important Programs: Medicaid in the Spotlight—And an Unintended Truth About Private Health Insurance
This is not a post about fact checking or elections. It’s about two programs that most of us know far too little about—Medicare and Medicaid. Bill Clinton’s Speech and the one made the next day by President Obama at the Democratic are already old news. However, since not everyone watched, three days later, two things stand out. One came from the remarks President Clinton made about Medicaid and the other remarks President Obama made about Medicare. First, President Clinton. The most striking thing to me as a health law professor about his speech is his putting not just a human face on Medicaid, but a middle and even upper class one. He showed people who might imagine they would never need Medicaid how wrong they were. Because for all the visible good Medicaid does for low income pregnant women women and children, it’s the invisible role it plays in the health care of those with disabilities and for the elderly in nursing homes, people who are duly eligible for both Medicare and Medicaid, which makes it the true safety net. It’s really Medicaid that stands between us and a Dickensian landscape of people dying in the street because it pays for the residential care of those who do not need hospitalization but who cannot live at home. It’s possible to pretend that hard work and good fortune could prevent your income from falling to Medicaid eligibility levels, but no one can claim vulnerability from the scenarios President Clinton painted of having a child with autism or a parent who needs nursing home care.
Even people who know the difference between Medicare and Medicaid—the threshold for passing any health law class I teach—do not fully understand the phenomena of dual eligibility in which the two programs work together to take care of people with health care needs, including children with disabilities, of a magnitude beyond what any level of savings or family support can handle.
President Obama, on the other hand, spoke very little about health care, but one phrase jumped out at me—talking about the importance of preserving Medicare he said, “No American should ever have to spend their golden years at the mercy of insurance companies. They should retire with the care and dignity they have earned. “He didn’t say, deserved health care—he said deserved Medicare. And that too isn’t sufficiently understood. Most of us with private insurance have pretty poor care. High deductibles, high co-pays, limits on the prescriptions we can get, and even in more generous plans restrictions on the doctors we can see. In contrast, Medicare offers fantastic coverage with very little hassle and total choice. There are no “Medicare,” or for that matter “Medicaid” doctors. Both programs pay for using the same doctors everyone else does.
If you remember that every American over the age of 65 has to have Medicare as his or her primary payer, you can imagine how likely it is that we would hear of quality and access problems. But we don’t. Not much. Sure, from the physician’s perspectives reimbursements have gotten very low and some practices are closed. But that’s not Medicare’s fault—that’s Congress’s. It’s people on Medicare who can get the foreign prince kind of health care that we hear about so much as proof that our system works. A Medicare patient can go to the Mayo Clinic or MD Anderson or Sloan-Kettering no matter where they live or what kind of job they ever had. Anyone with private insurance knows full well that their options are far more limited.
My point is not to endorse these presidents as it is to emphasize the points they made about these programs. They’re good ones, people eligible for them like them, and they work well. Their problems come from under-funding, not from restrictions on care or lack of choice. Medicare gets the spotlight in a political year—mainly because a good portion of the people enjoying it are well enough to advocate for it. Medicaid recipients are far less articulate because many of them are either very young, very poor or very, very sick. These are people of all ages, including those sustained on life support in vegetative states from which it is unlikely they will ever emerge, children with severe and expensive to manage medical conditions, and the frail elderly who need support to live at home or nursing home care so expensive that it quickly drains the resources of all but the wealthiest families. It’s entirely possible to have serious disagreements with how any entitlement program is run or structured. But before we consider fundamental change, it’s important to understand these two programs and for all their flaws and gaps—where we’d be without them.