� By Peter B. Chowka
(December 1, 2003) Medicare has become one of the sacred cows of modern American life. In the wake of the Democratic Party election landslide of 1964, it was overwhelmingly passed by the Congress in 1965 as a significant part of President Lyndon B. Johnson's plan for a "Great Society."
Four decades later, Medicare, which mainly provides health care for senior citizens, and Medicaid, another federal entitlement program from the mid-'60s intended to help the medically uninsured or underinsured, have grown into bureaucratic behemoths, paying for the health care of more than 40 million Americans. The costs of Medicare have exceeded original estimates by factors of five, ten, or more - running now into hundreds of billions of dollars annually. Overall, largely due to Medicare, Medicaid, and allied programs, the federal government now picks up the tab for almost one-half of all medical expenses in the U.S., which total $1.5 trillion a year, around 15 percent of the Gross National Product.
Above and beyond what the government actually pays for, the federal influence on American health care, via Medicare and other programs, has become determinative.
Interestingly, the original reasons that Medicare was sold to the public were largely fraudulent. For example, in the mid-1960s, there was not a widespread crisis in access to health care, as Medicare's proponents claimed. Rather, health care costs, as they had been for decades, were largely manageable, and relatively few Americans either lacked insurance or the ability to pay for their own medical care out of pocket. It was the era, hard to imagine now, of the family doctor, housecalls, affordable hospital stays, and reasonably priced prescription drugs. Most medical insurance back then was for catastrophic events, since routine care was inexpensive enough for people to pay for out of pocket.
Recently, supporters of Medicare's continued growth have insisted that there is another crisis in American health care that requires immediate attention. In response, in November the U.S. Congress, led by Republicans, passed the most sweeping "reform" and expansion of Medicare since 1965.
Are there ramifications in all of this for complementary alternative medicine (CAM)? Absolutely!
What Hath the Federal Government Wrought?
In reality, most of the crises - real or imagined - that exist in American medicine today are due mainly to the federal government's takeover of health care that began in the 1960s and the inflation, inefficiency, excessive paperwork, and other problems that this high level meddling has caused or exacerbated.
In 1994, Stan Liebowitz, a professor of managerial economics in the Management School of the University of Texas at Dallas, wrote an article, "Why Health Care Costs Too Much," which effectively deconstructs the Medicare system. Liebowitz convincingly shows how the federal government, in setting up a centralized system to pay for seniors' health care, has caused medical inflation overall to explode, with the increase in costs correlated most precisely in areas like hospitalization that are paid for most heavily by Medicare. Ironically, because of this inflation, supporters of further Medicare expansion can once again today cry "crisis." As another writer, Sue Blevins, director of the Institute for Health Freedom, has noted, in a bizarre twist it actually costs an American senior citizen today a greater percentage of his or her income to pay for health care (Medicare notwithstanding) than it did in the 1950s before Medicare.
These and other anomalies are explained by the fact that effectively resolving the health care needs of the eldery was not the primary purpose of Medicare's original designers at all. An indication of this fact came on July 30, 2003, the 38th anniversary of the signing of the Medicare law. On that morning, Robert Ball, an extremely influential high level policymaker in the fields of Social Security and Medicare - he was the Commissioner of Social Security Administration from 1962-1973 and was present when the Medicare law was signed by LBJ in1965 - was interviewed live on C-Span's Washington Journal. According to Ball, "Truman was the first president to advocate universal health insurance for the country as a whole [in the late 1940s]. But it was clear that the Congress would not pass his recommendation. So some of us who were interested in the universal plan kind of backed up and said, 'Well, what can we pass? Just from a practical standpoint.' And the answer was, coverage of a health insurance plan for the elderly. . .We thought, well, this is a plan and a group [the elderly] that could be covered politically so let's go with that. That's how it came about that we started the coverage under health insurance for the elderly group."
Speaking today, Ball, who is now 89, still hopes for Medicare's expansion: "Medicare needs of course to be expanded to prescription drugs. . .a real extension of prescription drugs. It needs what is called a stop loss provision [a health insurance policy provision specifying that the insurer will pay 100 percent of the insured's eligible medical expenses after the insured has incurred a specified amount of out-of-pocket expenses under the coinsurance feature]. . .I would bring together [Medicare] parts A and B - part B is a coverage of doctors on a voluntary basis. I would bring them together in a total compulsory plan [emphasis added]. . . I would propose expanding that to all children in the country, to bring down the age of eligibility below 65, first to 60 and then on lower and lower so in the end, you would be raising the age of eligibility, which would start out with the coverage of children, and bringing it down it down from Medicare's coverage of those 65 and older until you have a universal plan. Until we have what I call 'Medicare for all.'"
In November of this year, Ball got one of his wishes. The U.S. Congress passed legislation that represents the most significant change and expansion of Medicare since its inception. At the core of the new law is the provision that the federal government will soon start paying for prescription drugs for Medicare patients, hence the legislation's nickname as the "pill bill." In a classic political triangulation move to preempt a core Democratic Party issue prior to an important election year, the Bush administration pushed hard for the new law, while many leading Democrats, who normally favor expansion of social programs, objected to it.
A Third Opinion
In recent months, politicians and the media framed the Medicare debate as follows: Do you support the Bush-Republican pill bill plan, or the Democrats' more ambitious calls for even greater Medicare coverage?
A third point of view is possible, however. It is represented by a number of independent and principled health care policy experts and several organizations. Three of these organizations come immediately to mind. One of them is the Institute for Health Freedom, founded and directed by Sue Blevins, reported on here previously. Another is the American Association of Physicians and Surgeons. The third is the Citizens Council on Health Care, a not-for-profit group in Minnesota, founded and directed by Twila Brase, RN.
Ultimately, the issues that motivate these individuals and their organizations - in response to mountains of complex, difficult to follow, jargon-laden regulations and laws - are not theoretical. They are pragmatic and go to the heart of what kind of health care is and will be available in the United States and, for readers of this space, have extremely significant potential ramifications for issues like medical freedom, medical innovation, personal autonomy, and alternative medicine.
During an extensive conversation on November 25, Brase reminded me that the 2003 Medicare reform legislation "is a 681-page bill. Most of the debate," she added, "was around whether to give prescription drug coverage or not and whether to so-called privatize Medicare or not. There were significant other things in the bill that were never discussed. . .Lots of the provisions that are in the bill [will] move us more toward the government having greater involvement in our health care and in our health care decisions. It gives the government essentially a reason to start determining what kind of medications will be available to seniors in anything that happens in Medicare, going right down into the private sector. So it gives them a reason to be involved in making medication decisions for seniors, what kind of medications will be available, and what kind of medications will be produced, because unless they [the drugs] are going to be available to the Medicare population, there's less likelihood that a drug will be produced for that group unless it's assured that the government's going to cover it. So at that point, Medicare gets into the free market and the actual development of medications.
"You take this huge population called 'Medicare' that's going to get only huger - double in size, basically - when the 77 million baby boomers get in there. You just wind up with more government involvement, more government intereference, and fewer choices for individuals."
One of the features of the pill bill is an experiment, involving demonstration projects in four to six cities, that will allow a small number of seniors to select quasi-privately run Medicare plans (so-called Medicare HMOs - Health Maintenance Organizations), with the outcomes and costs of care for these patients ultimately compared with people who are still in the traditional Medicare program. Most Democrats are attacking that provision as "privatizing" Medicare. But according to Brase, "Traditional Medicare is closer to privatized I think than forcing [patients] into managed care" which is how she describes what the new law will do.
The situation is complicated, especially given the avalanche of positive spin heaped on the Medicare reform plan by its supporters. In some areas of life, the word choice (as in "a woman's right to choose" to have an abortion) has achieved near mythic proportions. Brase and others point out that real choice for patients, however, is limited under Medicare and will be even more restricted after Medicare reform kicks in.
Incredibly, people in Medicare will not be able to access - even to pay out of their own pockets for - choices or therapies that are not part of Medicare. As Brase says, "Medicare patients cannot pay cash for care. A 1997 law (the Balanced Budget Act, section 4507) forbids private contracts between patients and doctors. With few exceptions, Medicare recipients cannot pay cash for a Medicare-covered service that Medicare denies." Braise adds, "That's not privatizing. Privatizing is to give [patients] the cash and let them figure out where they want to use it."
Of Medicare itself, Brase said, "It's a terrible system. It's a socialized system. It's a system that's bent on rationing care. It will be required to ration more care as more people come into it and fewer taxpayers are available to fund it. . .Their [the government's] idea is to do the rationing at a distance. That's the whole idea for putting [patients] into HMOs, so the HMOs will ration the care and they [the government] can wash their hands of it because they're not doing it.
"It's really moving the entire country to rationing of health care services by really building up the HMOs with all of this taxpayer money and so really eliminating traditional insurance systems.
"I give a speech called 'Slipping into Socialism in America,'" Brase continued. "Medicare is America's version of socialism, of socialized medicine. It's a socialized health care system sort of through the back door. It's the approved managed care organizations, highly regulated and funded by the govenment. In some ways that's very similar to Germany's socialized system where they have something like 1200 health plans (I don't think they actually call them 'plans'). They're all funded by the government. All the money comes through them. It has the look and feel of being private but it isn't. The Germans don't actually pay money [for health care] except for extra services. The government has these 1200 entities that are doling out the health care dollars. The prediction several years ago here was that we're moving to the point where there might be like four to five large managed care organizations that run health care for the entire country. And of course they would do it with the approval of the federal government and Congress and of course they'll be HMOs and there will be managed care and so it'll have a private name but there will be a very public feel to it because the choices won't be available.
"The [2003] Medicare bill moves us further in that direction."
Brase was working as a public health nurse in a school in the early 1990s when she became concerned that "the government was going to take over health care." Her organization, the CCHC, which she helped to start in late 1994, explores health policy issues relating to both Minnesota and the nation as a whole. No longer in clinical practice now, she works with the CCHC full time. The CCHC, she said, "deals with lots of issues that we discovered really have lots of national - the federal government has a lot of influence in what happens in the states. So we have to deal with issues not just in the state but at the federal level because that's what drives what happens in the states." In 1998, the CCHC was approved as a tax exempt, not for profit, 501(c)3 organization. "We're a citizen's group based in one of the medical meccas, right in here with Mayo," she joked.
I asked Brase what, in her view, the 2003 Medicare reform law will mean to complementary alternative medicine (CAM). "The real concern for anything the government decides to cover is that they will ration it. They will decide what's available. They will limit choices. And so as the government increases its strength in health care and as the baby boomers, who are used to and more involved in complementary and alternative medicine than the current generation of Medicare patients, come into it, the thrust will be to get the government to pay for it. And if ever Medicare decides to cover alternative and complementary medicine, then there will be less available. And I particularly say that because in 1997 Congress passed a law to prohibit seniors from paying cash for care that Medicare covers but denies. So if ever Medicare covers CAM, the public can be assured that there will be less [CAM therapies] available and people will not be allowed to use their own dollars for that which is promised by Medicare but which is denied."
Sue Blevins' group, the Institute for Health Freedom in Washington, D.C., has also focused a lot of attention on Medicare and current political efforts to expand it. For example, in a news release on November 19, Blevins comments, "Proposed Medicare reform is going to strip away citizens' health freedom and medical privacy. Medicare is a nationalized health care program that dictates coverage and rations care through its more than 100,000 pages of federal rules and regulations. Many seniors currently are denied the freedom to pay privately for Medicare-covered services. Infringements on our freedom of choice and medical privacy are only going to increase with federally dictated prescription drug coverage and a new policy of physical examinations upon enrolling in Medicare."
According to the news release, "Many people think Medicare is voluntary, but all seniors have to enroll in Medicare Part Athe hospital programor forgo their Social Security benefits. . . the reason all citizensnot just seniorshave lost their medical privacy is because of Medicare." Blevins is quoted in the release: "The new federal rule that eliminates citizens' freedom to give or withhold their consent before their medical information is released was created to make Medicare more efficient. In other words, all citizens are losing control over the flow of their personal health information because of Medicare's inefficiencies."
Federal Health Care "Reform" - Then and Now
A decade ago, another massive political proposal for federal health care reform was on the table, pitched by the then newly elected president Bill Clinton and his wife, Hillary Rodham Clinton. In researching the Clinton National Health Care Reform, as it was called, for an article published in 1994, several leaders of alternative medicine offered their opinions, which are quoted below. Their comments seem appropriate to the Medicare reform that passed the Congress in the fall of 2003.
As I wrote in 1994:
A larger concern among many alternative proponents is that any kind of mandatory, government-based reform plan will inevitably and adversely impact the otherwise promising future of healing alternatives. According to Nicholas Gonzalez, M.D., a New York specialist in nutritional cancer therapy, national health care reform "could be the end of alternative medicine." The government health care reformers, according to Gonzalez, "think that the reason people are sick is that they don't have enough high-tech medicine. But high-tech medicine doesn't even work for rich people! The real reason that people are sick is that orthodox medicine is asking the wrong questions."
Robert Maver, former vice president and director of research of Mutual Benefit and Life, a major insurance company, agrees with Gonzalez. "The popular wisdom," Maver says, "is that American health care is the best in the world, and that we just have to figure out a more efficient way of delivering that health care. Alternatives really start from a completely different point. They say, 'There's a far better health care that's possible.'"
Maver notes, "The purpose of this 'reform' is not to manage care, although that's what the proponents are saying. What they're really trying to do is just to manage costs."
Once this kind of national health care reform has cleared the Congress, there will be, as in an existential play, "No Exit." We'll all have to be part of -- and pay for -- conventional medicine, whether we agree with and want it or not.
In Nicholas Gonzalez's view, "The goal of health care reform is to have a dictionary in Washington listing 'acceptable' treatments. If you look up 'breast cancer,' there are the 'acceptable' treatments -- and anything else will be disallowed. They essentially want all doctors to conform to government standards." Journalist Jon Rappoport (author of AIDS, Inc.) adds, "The main strategy [of the reformers] is excommunication into the outer darkness. If you're a holistic doctor and they don't like what you're doing, you'll be guilty of practicing 'illegal medicine' and they can just disconnect you from the plan and banish you completely. Then you're no longer in the grid, you're just out there somewhere."
Jane M. Orient writes, "Medicine is about healing the sick and the injured.
The heart of medicine is the relationship of one doctor to one patient. The
patient is the center of the universe. Not the 'health care delivery system'
and its ruling bureaucracy."
