Strengthening Medicare* in the States

The Republican draft platform (h/t Politico) is out. Its Medicare* passages on are noteworthy:

Medicare*, as the dominant payer in the health market…. is the next frontier of welfare reform. It is simply too big and too flawed to be managed in its current condition from Washington. Republican governors have taken the lead in proposing a host regulatory changes that could make the program more flexible, innovative, and accountable. There should be alternatives to hospitalization for chronic health problems. Patients could be rewarded for participating in disease prevention activities. Excessive mandates on coverage should be eliminated….

As these and other specific proposals show, Republican Governors and state legislators are ready to do the hard work of modernizing Medicare* for the twenty-first century. We propose to let them do all that and more by block-granting the program to the States with the flexibility to design programs that meet the needs of their [senior] citizens….

*Please read below the fold….

Okay, I did a global replace to change the word “Medicaid” to “Medicare” throughout. Of course no sane politician would really write about Medicare in the way I just described.

Why is that?

Medicare recipients might become a tad nervous at the thought that their state governments in Illinois, South Carolina, or Florida would assume responsibility for care traditionally financed by the federal government. Allowing states greater flexibility by eliminating “excessive mandates on coverage” is not so reassuring, either.

A block grant might even be interpreted as an effort to save money by giving states strong incentives to cut eligibility, provider reimbursements, and the range of services that people receive. Sun City seniors requiring prostate surgery might worry that they would be subject to the same notorious rationing practiced by Arizona Medicaid. The fact that such proposals would be abruptly implemented—with no grandfather clauses for current beneficiaries or those born before 1957, say—would be no less concerning. Reading the local paper, suggestions that state governments are more likely to produce serious quality improvement and technological innovations aren’t so intuitive, either.

Medicare recipients might also become a tad insulted to see their health care benefits described under the rubric of “welfare,” whether or not the word “reform” appears nearby. The use of that term comes perilously close to communicating the view that (a) Medicare recipients are rather undeserving, or (b) it’s unbecoming for tens of millions of current Medicare recipients to stridently oppose benefits for other people in equal need, especially when they themselves receive benefits that exceed their actuarial contributions to the program. In reality, only (b) is true. For various reasons good and bad, this generational accounting reality is rather downplayed in public discourse.

Although Medicare poses far more serious fiscal difficulties than Medicaid and the other coverage expansions in health reform do, Medicare is an earned benefit to a valued, powerful constituency. The American public wants Medicare done right. It’s politically unthinkable that it would be devolved to the states, or that Medicare recipients would be presented with immediate program cuts of the sorts contemplated for Medicaid by Republicans. Nobody laments the fact that we impose some one-size-fits-all solution whereby Florida and South Carolina seniors get the same cardiac care as those in Boston, Massachusetts.

Many Americans view Medicaid rather differently. This program is welfare medicine. We provide it to poor people, i.e. other people, out of the goodness of our hearts. At least we do this to the extent that states and localities can afford it and wish to do so.

The language of this major political document highlights our contrasting views of the two programs. It’s not pretty. It’s not something to overlook, either.

[Cross-posted at The Reality-based Community]

Harold Pollack

Harold Pollack is the Helen Ross Professor at the School of Social Service Administration at the University of Chicago.