By FRED BROCK
THE Associated Press reported late last month that the Bush administration was "stunned" by sharp criticism of its original plan to provide prescription drug benefits for Medicare recipients only if they enroll in private health maintenance organizations. So the plan was altered last week to offer limited drug benefits to those enrolled in traditional fee-for-service Medicare, though H.M.O. members would still receive much more extensive coverage.
But that modification, still part of a broader effort to recast Medicare so that its members have strong incentives to join managed-care plans
, was derided by Democrats on Capitol Hill and received a lukewarm reception at best from Republicans.
If the folks in the White House think that forcing older people to join H.M.O.'s and perhaps give up their family doctors is a popular move, they clearly need to get out more. Maybe rent a movie. I recommend "As Good as It Gets," a 1997 film starring Jack Nicholson and Helen Hunt. At one point in the film, the character played by Ms. Hunt is struggling with the runaround she's getting from her H.M.O. in treating her sick son. In frustration, she lets fly a profane invective that could peel paint. That attack, clearly reflecting a level of popular sentiment about H.M.O's, drew spontaneous cheers and applause from theater audiences.
Any litany of complaints against H.M.O.'s usually bemoans the difficulty of getting approval for expensive treatments, the restrictions on selecting a doctor or a hospital, and the rising premiums and co-payments. In addition, H.M.O.'s sometimes pull out of an area if they start losing money-leaving patients to scramble for another insurer or return to traditional Medicare. Of course, there are co-payments with Medicare, too, but members can buy Medigap insurance to help with them. Whether you're better off paying premiums or co-payments to an H.M.O. or buying Medigap insurance depends on individual circumstances and the H.M.O plans available in your area.
Still, the public's misgivings about H.M.O.'s, and the fact that they are simply not available in many rural areas of the country, pose real problems for the White House effort to increasingly push Medicare patients into managed care, mainly provided by private insurers. In 2002, only 5 million, or 12.5 percent, of 40 million Medicare patients were enrolled in H.M.O.'s, according to the Centers for Medicare and Medicaid Services. This despite the fact that as of 2001, some 82 percent of urban residents with Medicare had access to H.M.O.'s, according to the Rural Policy Research Institute in Columbia, Mo. The absence of H.M.O.'s in many rural areas-fewer than 20 percent of rural residents had access to these insurers, the institute found-is giving some Republican members of Congress heartburn over the president's prescription drug proposal.
Deane Beebe, spokeswoman for the Medicare Rights Center, a nonprofit group based in New York that helps people deal with Medicare and Medicare H.M.O. problems, said history should be a guide.
"Remember, Medicare was started in 1965 because insurance companies would not sell older people health insurance policies that anyone could afford," she said. "Old people are not very profitable when it comes to health care."
That is one reason Robert M. Hayes, the president of the Medicare Rights Center, does not want to see the medical care of older Americans returned to the private market, as some conservatives would like. "In the years leading up to Medicare, the private market was simply not working for older Americans," he said. "The fundamental Medicare program is the greatest domestic success story of the 20th century. Life is so much better for millions of Americans because of it."
But Medicare has not improved the lot of older Americans alone. It has also benefited younger people, who no longer have to worry about their parents' medical bills. Before 1965, young adults faced the real possibility that caring for a sick parent, retired and no longer covered by health insurance, could ruin them financially. In many cases, it did.
Ms. Beebe also points out that the administrative costs of Medicare are only about 2 percent, compared with 15 to 18 percent for private insurers. That's because those insurers, unlike Medicare, have advertising and marketing costs-not to mention higher executive salaries.
Administration officials have said they want to encourage Medicare beneficiaries to enroll in private plans because such plans offer more choices to the elderly and can adapt more quickly to changes in medicine, including new technology.
But the choice most people want is to be able to choose their own doctor.
Henry J. Aaron, a senior fellow at the Brookings Institution and an authority on health care financing, sees "a certain irony" in claims over choice. "With private insurance, you have a choice of plans but not of doctors and hospitals," he said. "Medicare gives you no choice of plans, but an unlimited choice of doctors and hospitals."
R. AARON calls traditional Medicare "creaky" because of its narrow coverage and high cost-sharing-thus the need for Medigap policies. He agrees with President Bush that "systemic reform" is needed as well as prescription drug coverage, and he does not object to private insurers' involvement.
"But such a market has to be regulated very aggressively," he said. "If the elderly have to choose among private plans, the opportunity for mis-selling and marketing abuse is very great. The problem with private plans is that they try to cream-skim by advertising to the healthy elderly. I don't have the feeling that this administration is as sensitive to the potential for abuse, and indeed for waste, among competitive private insurers as it should be. If it were, I'd be much more sympathetic."
He also thinks that there is a mood of hysteria over Medicare's problems. "The sooner we fix Medicare, the better," he said, but he added that a little perspective could help.
"Over the next 75 years, the size of the Bush tax cut that has been enacted would be enough to fill in the entire projected deficits in Social Security and Medicare for that period," he said. "If you think these are such big problems, then maybe we shouldn't have been cutting taxes so much."