Wednesday, July 16, 2008

The Untold Health Care Story: How They Crippled Medicare

The Untold Health Care Story: How They Crippled Medicare

Until recently, my husband and I had been seeing one of those “Oh-I’m-so-glad-he’s-my-doctor” physicians for two decades. Then one day the mail brought the announcement that the office was closing its doors and that the four doctors who had been in the practice were either retiring or leaving San Francisco. They enclosed a list of doctors who, they said, had indicated they had room in their practices. So started my search for a new primary-care physician.

I looked the list over, saw a familiar name, and dialed the number. “Yes,” the receptionist assured me, “doctor is taking new patients.” It was all very friendly; I made an appointment; she set about recording the necessary information, and then the crucial question. “What insurance do you have?” “Medicare and AARP” (one of the several medi-gap insurance plans to which those of us who can afford it subscribe), I replied. I heard a small intake of breath, a ten-second silence that felt like much more, and then, “Oh, you should have told me before that you’re Medicare; doctor isn’t taking new Medicare patients.” And with that she severed the connection and, I assume, wiped my appointment off the book.

I was surprised at the brusque refusal, shaken a bit, but not yet worried. San Francisco is a city that seduces with its charms, and with a major medical school within its borders and two more less than an hour’s drive away, we have plenty of well-trained physicians practicing here. How hard could it be to find a good internist? Very hard, it turned out, as I worked my way down a list of a dozen doctors—some referred by my retiring internist, some recommended by friends or friends of friends.

Since the medical community in the city knew of the shuttering of the office where I’d been cared for, they were prepared for calls like mine. Some announced on their voice mail: “The doctor isn’t taking any new Medicare patients”; some asked the fatal question about insurance before responding to my request for an appointment; and a few waited until they had noted all my personal information before asking the question. Twelve calls; twelve refusals to take Medicare.

Stunned, I sat at my desk looking at the list and wondering, What happened to the Medicare I once knew, to the physicians for whom it was simply another part of their practice, to the government that once supported it fully before the right-wing mania for privatization set in? Big questions. But my immediate concern was to find a doctor who would be available when my husband or I needed her or him.

Because I’m reasonably well-known in this community, I decided to get past the front desk by writing to each of these physicians directly. I laid out my credentials and accomplishments as if I were applying for a grant or a job; I dropped some reputable names of people, lay and professional, who had given me permission to do so, while at the same time assuring the doctors to whom I was pleading my case that I continued to be very active and was in vigorous good health. It was an exercise in the absurd. There I was, looking for a doctor to oversee my health and at the same time assuring any who would listen that I wouldn’t need them.

Two weeks later, I was getting desperate. The actual closure of the medical office was looming, and I still had not heard from a single physician on my list. I began to call the offices to ask if the doctor had received and read the letter I sent. I was brushed off in the first five with a curt reminder that “The doctor isn’t taking new Medicare patients.” Finally, on the sixth call, the woman on the other end of the line said she’d ask the doctor and call me back. An hour later, she called to say that he had read my letter, was “intrigued,” and would like to meet me.

We met, he agreed to take us on, and finally we had a doctor. But what, I wondered, happens to ordinary folk who don’t write letters and who, if they did, wouldn’t “intrigue” the person at the other end? Was this just something happening here in San Francisco where some doctors are charging a thousand-dollar fee for the privilege of becoming a patient and an annual membership payment of $500 thereafter?

As my story got out, the answers came pouring in. Friends and acquaintances around the country had similar tales to tell, sometimes their own experiences, sometimes about a friend or family member. Doctors from New York to California were either refusing to take new Medicare patients or making it so hard to get into their offices that it was no better than a direct refusal.

While this Medicare drama played out in my own life, health care was center stage in the long, drawn-out political theater known as the Democratic Party’s primaries. As Senators Barack Obama and Hillary Clinton argued about the fine points of their respective universal-health-care promises, President George W. Bush released plans to reduce budget deficits on the backs of America’s old folks by calling for $208 billion in mandatory budget reductions, with Medicare taking the biggest hit. In addition to cutting services and doctors’ payments, the administration seeks to slow the pace of Medicare growth from 7 percent to 5 percent over the next five years—cuts that come during the very period when Medicare rolls will grow exponentially as the first of the baby boomers become eligible for coverage, and about which no candidate of either party has expressed any outrage.


THE HISTORY of the struggle for health care in the United States is a long and bitter one, going back to 1945 when President Harry Truman asked the Congress to enact a national insurance program “to assure the right to adequate medical care and protection from the economic fears of sickness.” A coalition of conservative groups, led by the implacable opposition of the American Medical Association (AMA) and fueled by the insurance and pharmaceutical industries, denounced the Truman plan as “socialistic,” stoked public fears about freedom and choice, and defeated the legislation.

By 1952, Truman, acknowledging that he couldn’t win health care for all, tried softening the opposition with a compromise proposal, one that would provide care only for those age sixty-five and over who were receiving Social Security. But if the universal health care plan was outright socialism, the new, more limited legislation was nothing less than a foot in the socialist door, and the same forces that had fought so fiercely before joined once again to defeat the scaled-back proposal.

The same scenario was repeated in 1960 when, with the support of President John F. Kennedy, Medicare’s backers introduced yet another bill to provide health care for America’s aged. Only this time, the AMA, with the help of the wives of physicians across the country, organized what was known as “Operation Coffee Cup” and enlisted a B-movie actor named Ronald Reagan, who was then host of the popular Sunday night television program General Electric Theater, to warn, “One of the traditional methods of imposing statism or socialism on a people has been by way of medicine.”

Reflecting on the campaign against Medicare, Drew Pearson, a well-known Washington columnist at the time, wrote

Ronald Reagan of Hollywood has pitted his mellifluous voice against President Kennedy in the battle for medical aid for the elderly. As a result it looks as if the old folks would lose out. He has caused such a deluge of mail to swamp Congress that Congressmen want to postpone action on the medical bill until 1962. What they don’t know, of course, is that Ron Reagan is behind the mail; also that the American Medical Association is paying for it. . . . Just how [Reagan’s] background qualifies him as an expert on medical care for the elderly remains a mystery. Nevertheless, thanks to a deal with the AMA, and the acquiescence of General Electric, Ronald may be able to out influence the President of the United States with Congress.



It took President Lyndon Johnson, a former Senate leader who knew where all the congressional bodies were buried, to twist enough arms in Congress to stiffen its spine. On July 30, 1965, the years of struggle finally paid off. President Johnson signed into law Title XVIII of the Social Security Act establishing Medicare and its companion program, Medicaid, which insures indigent Americans. The nation had its first (and still only) government-sponsored, single-payer medical system. Former President Harry Truman was the first person to enroll in the program. The fee for Medicare Part B, which covers doctors visits (Part A covers hospital care), was $3 a month. Today, there’s a deductible of $135 before Medicare picks up 80 percent of the bill, and a monthly premium of $96.40 for those earning up to $82,000, ($164,000 for a couple filing a joint return). After that, the premiums go up proportionate to income.

While Medicare was a bare-bones program at first, covering hospital and doctor visits, it was expanded repeatedly over the next twenty-five years to cover disabled persons of any age, people with end-stage renal disease, recipients of the Supplemental Security Income (SSI) program for the elderly and disabled poor, chiropractic services, home health care, hospice, and more.


DESPITE THE immense popular support for Medicare, the program continued to grate on conservative sensibilities, and by the early 1980s the conservatism of the Reagan administration—its distaste for what it called “social engineering,” which meant any federally financed benefit programs—began to make itself felt. But the same voices that were railing against entitlements like Medicare were silent when the program was amended to cover the federal judiciary, members of Congress, and the president. No cries of socialism arose, no concerns about the cost of entitlements, no jeremiads about freedom and choice were heard from the congressional opposition or President Reagan when it was their turn to get government-sponsored health care.

With all the controversy, however, it wasn’t until 1995, after the Clinton administration’s failed attempt at universal health care, that the Republican Congress, urged on by Speaker of the House Newt Gingrich and backed strongly by the insurance companies, passed the Medicare Reform Bill, which was much less a step toward reform than a walk toward privatization. But it couldn’t have happened without the support from some Democrats and the signature of President Bill Clinton, who seemed to have lost his veto pen that day. True, he didn’t have the votes to sustain a veto, but that hasn’t stopped George W. Bush from sending back to Congress legislation that offends his principles, leaving those bills to languish on the stalemated congressional back burner with no hope of passage anytime soon.

Ultimately, the alleged reforms meant, among other things, an increased reliance on private insurance companies—subsidized by the federal government—for the delivery of care. It looked like a good deal at first, with grand promises from the insurance companies of more care for less money, and Medicare recipients flocked to the health maintenance organizations, my husband and I among them. But it wasn’t long before many of us found out that an insurance company’s public relations campaign has little relation to reality, and their promises melted away before the imperative of the bottom line. So, for example, when my husband developed a persistent urinary-tract infection that our primary care doctor kept treating unsuccessfully, I finally asked him why he wasn’t referring the problem to a urologist. He hemmed and hawed, shifted his feet, dropped his eyes, and finally said almost shamefacedly, “These HMOs are making it harder and harder to make that kind of referral.” I immediately switched back to Medicare, where a physician’s judgment is still generally the deciding factor in specialist care.

By 1997, two years after the so-called reforms were instituted, Senator Ted Kennedy and Representative Richard Gephardt were so outraged by the continued assault on Medicare that they wrote in a Washington Post op-ed piece,

Republicans in Congress—and, unfortunately, a few Democrats too—want to go beyond the bipartisan budget agreement and subject Medicare to death by countless cuts by increasing the cost of care, skimming off the healthiest and wealthiest participants, raising the age of eligibility, means-testing the program and turning major parts of Medicare over to the tender mercies of private insurance companies and managed-care firms.


Then came the Bush years. From its earliest days, this administration’s hostility to Medicare and Social Security has been no secret. It lost the fight to privatize Social Security, but the war against Medicare continues as it pushes people into HMOs by increasing the monthly cost for Medicare, cutting services, and reducing payments to hospitals and doctors until the very existence of the program is threatened. As long ago as 2005, an AMA survey reported that nearly 40 percent of 5,486 physicians said that if the projected 5 percent cuts were to pass, they would “curtail the number of new Medicare patients they accept into their practices.”

In the intervening years the situation has only gotten worse. A recent national survey of a thousand practicing physicians, released by the Medical Group Management Association, reports that in anticipation of the proposed 10.6 percent further payment reductions to take effect on July 1, 2008, 60 percent of the respondents reported that they were either limiting the number of Medicare patients or refusing to accept them altogether. One Oregon physician reported that he was “routinely turning away Medicare patients so desperate to find a doctor that they offered to pay for excess charges out-of-pocket,” a practice prohibited by Medicare law. Another whose Florida practice is made up of over 50 percent Medicare patients, agonized over dropping people who, he said, had become “like old friends after 28 years in practice.” But if the payments are slashed again, he explained, “I’ll have no choice. It’s a business, and if I can’t pay the bills, I can’t survive.” Chilling news for those of us now in Medicare, and worse yet for the Baby Boomers who will become eligible in the next few years.

True, some may argue that doctors already make more money than most Americans, and it’s hard to listen to their grievances with much sympathy. But doctors are at the heart of the success of Medicare, and until the Bush administration’s escalation of the war against the program, they took care of the nation’s elders without complaint. Moreover, their grievances gain force and legitimacy when we notice that the administration’s proposed budget cuts target doctors, hospitals, and a variety of patient services but don’t lay a glove on payments to the private insurance companies and their HMOs, even though many independent experts say federal payments to those plans are far too high and the service they provide much too low.

Unfortunately, the election campaign now under way offers little hope of substantial improvement in the health care crisis that now afflicts this nation. For despite what the privatization of Medicare has taught us about the incompatibility of for-profit insurance companies with quality patient care, and despite the fact that federal subsidies to these corporations are substantially more costly to taxpayers than the government-run Medicare, no candidate dares to propose the only universal health care plan that will work: a government-sponsored, single-payer system along the lines of the original Medicare [1]
Ironically, a recent study conducted by the Indiana University School of Medicine’s Center for Health Policy and Professionalism Research Policy and published in the Annals of Internal Medicine (April 2008) reports that in a survey of 2,200 physicians, 59 percent now support legislation to establish national health insurance. Reflecting on his analysis of the data, Dr. Ronald Ackerman, co-author of the study, concluded that “across the board, physicians feel that our fragmented and for-profit insurance system is obstructing good patient care, and a majority now support national insurance as the remedy.”
—a program that worked just fine until a coalition of conservative forces, insurance companies, the pharmaceutical industry, and right-leaning and/or fearful Democrats disassembled it. [2]
All this, and I haven't even mentioned the huge multi-billion-dollar boondoggle the federal government handed the insurance companies and the pharmaceutical industry with Medicare Part D, the prescription drug benefit that went into effect on January 1, 2006. It would take another whole article to discuss the many-tiered problems with this program.


Lillian B. Rubin is with the Institute for the Study of Social Change, University of California, Berkeley. She is a sociologist, psychologist, and author of numerous books, including, most recently, 60 on Up: The Truth about Aging in America (Beacon Press, 2007).
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FOOTNOTES:

  • [1] Ironically, a recent study conducted by the Indiana University School of Medicine’s Center for Health Policy and Professionalism Research Policy and published in the Annals of Internal Medicine (April 2008) reports that in a survey of 2,200 physicians, 59 percent now support legislation to establish national health insurance. Reflecting on his analysis of the data, Dr. Ronald Ackerman, co-author of the study, concluded that “across the board, physicians feel that our fragmented and for-profit insurance system is obstructing good patient care, and a majority now support national insurance as the remedy.”
  • [2] All this, and I haven't even mentioned the huge multi-billion-dollar boondoggle the federal government handed the insurance companies and the pharmaceutical industry with Medicare Part D, the prescription drug benefit that went into effect on January 1, 2006. It would take another whole article to discuss the many-tiered problems with this program.

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