The Politics of Medicare, Part 2: What the candidates are saying.

Given the spiraling and often unnecessary expenses with which Medicare must grapple, it is no surprise that this essential bastion of health care delivery for the elderly is rapidly going bankrupt. Currently the average Medicare recipient takes far more out of the system than he/she has put in during his/her lifetime, meaning that there is a constant draining of funds. Also, the aging of our population is placing more people under Medicare’s auspices. Therefore, Congress really has two choices to save Medicare. Either it can increase the money going in by imposing higher taxes. Or it can curtail how much Medicare is spending. If it chooses the latter, it can ration care, meaning that it only pays for certain services and put restrictions on access. Or, as I have advocated in my book, it can spend its money more wisely, by giving patients the choice of home care vs the hospital, by requiring doctors to provide patients with accurate risks and benefits of medical interventions, and by cutting reimbursement for procedures and paying more for primary care. I spend a large part of my book laying out both what Medicare is doing now to fix the problems, as well as what I think can be done that would be more effective and be better received by our elders. We certainly do not have to ration care; in fact, by giving patients more choice and better information, and by not giving doctors incentives to be medically aggressive, we can fix the system tomorrow. But more about that in the next blog.

For now, the question is how our two major Presidential candidates are addressing the Medicare crisis. First we must admit it is a crisis. If Medicare hits a tipping point and it starts to become depleted of funds, our elderly patients will be left with uncertainty as to whether they can still count on adequate medical care, and the government will have to make rapid and rash decisions about how to shore up its funds. Second, Medicare is draining the government of its financial coffers, and to stabilize our economy we have to first stop Medicare’s collapse. What many republicans such as Paul Ryan have suggested—privatizing Medicare and giving elders vouchers to buy private insurance—is not feasible because private insurances are even less efficient than Medicare, and the cost of such vouchers may exceed what the government is paying now. But at least Paul Ryan and a few quiet voices in both parties have acknowledged that there is a problem with Medicare. What may democrats are proposing—nationalizing Medicare so everyone can have access to it—ignores the reality that Medicare is not financially viable; expanding it with only exacerbate its woes. So, with so much double talk and pandering bouncing around the walls of Congress, what are the candidates saying?

I will mention that I sent both of them my book with a note that I would be happy to speak to anyone on their staff about health care issues. As a primary care doctor who has studied and worked in the trenches of Medicare, I can offer some insight into what is effective and what is not, what other doctors and patients are saying about the system and its reforms, and what needs to be addressed. Predictably, neither candidate’s staff responded. I then sent a message via email to them through their websites, and all I am receiving now are multiple pleas for me to donate to the campaigns. Neither candidate talks about Medicare on the stump, and neither has outlined a cogent policy. For two candidates who seek to improve our economy and who claim to value Medicare, this omission is glaring. But it is also understandable. Talking about Medicare is political suicide; whatever a candidate says will be construed by the other side as an attack on the elderly. Thus we as voters are being given a tiny window as to what these candidates may do if elected. For now, we have to only try to guess what they may do, and be insistent that they tell us more.

Hillary Clinton: No one is more versed in health care policy than Hillary Clinton. Still, she has little to say about how she would fix Medicare. In fact, her website makes it clear that she will “expand Medicare by allowing people 55 years or older to opt in while protecting the traditional Medicare program.” Thus, not only does she plan to allow Medicare to persevere as is, but she wants to expand it. That will only accelerate its financial peril. Her plan offers no details or suggestions regarding how to assure that Medicare stays financially viable. She does not even acknowledge that it is in trouble.

Her website also offers specific proposals about certain medical conditions, and analyzing them may help better understand what her overall plan may be. For instance, regarding Alzheimer’s disease she suggests putting more money into research and providing tax breaks to help with out of pocket care. But the only substantive plan to help patients and their caregivers is to advocate for a single office visit to discuss care plan options (something I already do under Medicare), and to raise awareness of services that already exist. In other words, under the Clinton plan, Medicare will allow a few “novel” types of physician visits that already exist, and there will be some tax breaks for the large amount that Medicare does not cover. Medicare will continue to pay for and encourage an infinitude of specialist visits, unnecessary tests/consults, and ineffective meds. Medicare will continue not to pay for day care, for additional care givers, for exercise programs, and for meaningful home care; in other words, for all the services so many families with dementia want and need. When they are ill or have a medical decline, dementia patients will still be forced into the hospital instead of being treated at home due to Medicare rules that Hillary Clinton has not stated she plans to change. In other words, other than expanding research, Clinton’s Medicare program will do nothing to help people with dementia.

At least Hillary Clinton has at least made some attempt to discuss Medicare and health care for the elderly. It is unfortunate she has not said enough about Medicare’s problems and to offer some realistic solutions. Perhaps more details will emerge in the final two months of the campaign.

Donald Trump: There is little to say here. Donald Trump offers no suggestions about how to help Medicare. In fact, he does not think it needs help. He believes that by blocking illegal immigrants, repealing Obamacare, expanding the economy, and cutting fraud, Medicare will fix itself. Of course this is not a reasonable course, but it is all that he has consistently offered as a plan. His website offers no insight, and he clearly states that Medicare can survive in perpetuity without any changes needed.

Congress: Ultimately, the nuts and bolts of Medicare live in the bowels of Congress. As with our Presidential nominees, the vast majority of those running for Congress say nothing about Medicare. But Congress has reshaped Medicare over the past few years, and our congressmen/women are responsible for these changes. Requiring electronic medical records, replacing individualized care with protocols under the guise of “quality,” enacting HIPAA laws that do not live in the universe of common sense, increasing financially painful audits, and tossing pages of paperwork and rules upon the laps of physicians are all the results of Congressional action designed to fix Medicare. As I have explained in my blogs, and in my book, the result of such reforms is higher cost, lower quality, and worse patient satisfaction. Meanwhile, Congress has not addressed the real drivers of cost: the inability of elderly people to be treated at home, a plague of overtreatment driven by Medicare’s payment system and the lack of accurate information about risks/benefits, and a shortage of primary care doctors. While those running for Congress are saying very little about Medicare, their voting records speak for themselves.

These elections mean a lot. Unfortunately, since the candidates greet us only with empty promises and platitudes, it is difficult to make a rational decision. Medicare is failing, and the government has to fix it. It is up to us to insist on that change. In our final blog, we will discuss how that can be done.