Perhaps no other health issue is as important to so many Americans now and in the future as Medicare. In this new series, “Covering Medicare,” we will follow the reportage and offer Medicare beat memos from time to time.
NPR’s All Things Considered came forth over the weekend with a piece on Medicare. That’s not a bad choice of subjects, considering that Medicare and Paul Ryan’s proposal are the health care topics at the moment. The problem is that the story relied on a predictable anecdote (okay, I guess), and was built around the position of a single source representing one side of a very touchy issue (not okay).
The anecdote, which appeared a bit contrived, offered up quotes from three Medicare beneficiaries, and all of them, as if on cue, talked about benefits they earned because they had paid taxes into the system. A man said he “paid taxes all my life.” A woman who had cancer said: “I was taken care of. I’ve always paid my taxes.” Another said she used to tell her employees who didn’t like paying Medicare taxes: “That’s your prepaid medical care for when you are a senior citizen.” These quotes seemed to set the direction that weekend host Guy Raz wanted to go. There’s a reason the current system is unsustainable, said Eugene Steuerle, a senior fellow at the Urban Institute in Washington. It’s because an average couple retiring today paid in a bit more than $100,000 in Medicare taxes and gets back “about $300,000 in benefits,” even after adjusting for inflation.
“How did the current system become so unbalanced?” Raz asked. Steuerle replied that it has to do with how Medicare was built—that it passed along an individual retiree’s health care costs to a wide pool of current taxpayers. Specifically, he said:
The incentive for me as a consumer to worry about the cost isn’t very high. But the incentive for providers have this incentive to keep listing as many services as possible. The more services the hospital can list, the more they can collect.”
Steuerle went on with his message, and Raz offered no background or context, allowing the show to convey that Steuerle had all the answers. He argued that the system worked well until health costs really zoomed up. Steuerle told NPR that no one is in charge of saying “no” to medical-cost inflation, leaving the impression that no one has tried. Raz shortchanged NPR listeners by failing to challenge his guest.
A bit of history is in order here. The fee-for-service/pass-along system was part of Medicare from the get-go, and doctors and hospitals fully exploited it. The costs of the program began rising quickly. By the time Ronald Reagan came to the White House, costs were so out of line that Medicare changed the way hospitals were paid. Still costs rose.
Through the years Medicare has tried to say “no” to providers seeking reimbursement for this treatment or that—often new ones for which there is little or no evidence for their effectiveness. A few years back, Julie Appleby, now with Kaiser Health News, wrote in Health Affairs the best account of how pressure from medical sellers results in higher costs for Medicare. Her description of the sales job for CT angiography should be required reading for any reporter interested in accurately covering Medicare. And earlier this year the Center for Public Integrity showed how clever marketing, public relations, and campaign contributions from manufacturers of imaging machines succeeded in getting Medicare to pay for digital mammograms for older women, even though the scientific evidence suggests that digital mammography does not improve detection of breast cancer in this age group. Every time Congress has tried to cut doctors’ fees in accordance with a 1997 law, the docs have mounted a press initiative and a political campaign to get a reprieve.
What Steuerle says about Medicare represents one point of view, but there’s another take, too, which was not part of this NPR discussion. Its omission gave listeners a lopsided picture of Medicare’s troubles. So I rang up Yale professor emeritus Theodore Marmor, who wrote a seminal book called The Politics of Medicare and who sees Medicare very differently. “Some analysts believe that using medical care is like buying bread—the more you get, the more you want. That is true only of hypochondriacs,” he said. “By repeating this interpretation again and again, these analysts act like marketers imagining that saying so will make it so. But that isn’t so, as the experience of other countries illustrate. The reason Canada spends less per capita on medical care is not because of the way it raises funds, but rather the way it controls its expenditures.”
Marmor pointed out that there are “two dramatically different ways of approaching Medicare.” One, he says, presumes that medical care is like other industries subject to market forces. The other relies on the experiences of other industrial democracies, which use the countervailing power of government to restrain inflation. “These are incompatible positions,” he explained, “and any reporter should be aware of how incompatible they are and to understand both.” The public needs to understand both, as well. NPR’s segment did not help.