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.

Author: Harold Pollack

Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago. He has served on three expert committees of the National Academies of Science. His recent research appears in such journals as Addiction, Journal of the American Medical Association, and American Journal of Public Health. He writes regularly on HIV prevention, crime and drug policy, health reform, and disability policy for American Prospect,, and other news outlets. His essay, "Lessons from an Emergency Room Nightmare" was selected for the collection The Best American Medical Writing, 2009. He recently participated, with zero critical acclaim, in the University of Chicago's annual Latke-Hamentaschen debate.

4 thoughts on “Strengthening Medicare* in the States”

  1. Yah. I remember listening to an evil Republican federal judge (do they come in any other variety nowadays?) once talk about bankruptcy reform. She was advocating what eventually turned into the 2005 legislation. She characterized it as a redistributionist social program, which isn’t technically inaccurate, I suppose. I don’t recall if she used the term “safety net” or “welfare”, but either term allowed her to say “means-tested,” which of course was her goal. The only reason I bother posting this is that she was speaking in front of a sophisticated legal audience, that couldn’t easily be snowed if it didn’t want to be. So this “welfare” rhetoric isn’t only for the rubes.

  2. “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.”

    Can you explain “earned benefit”? If you simply mean, “we made promises that if they did X and Y, that we would pay them benefits,” it’s pretty hard to argue with that; but I don’t see how that addresses the problem that the promises were made under assumptions that have proven to be faulty.

    1. “Earned benefit” in this case might mean “there is a tax paid by some people that covers some of the cost of the benefit” or perhaps just “You have to survive to 65 to get it.” But in any case, it means “Something we deserve, rather than that other thing they don’t.” How the GOP is going to thread the needle of saying “defined-benefit” without reminding every wage-earner in the country of what happens to a 401K in a bad year I leave as an exercise for the mainstream press…

      And of course, this means that everyone who tried to dissect what would happen to Medicare under Ryan’s bid-but-not-really plan was wasting their time, as he and his friends no doubt intended.

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