The Medicare solution.

• Author: Marmor, Ted
• Position: Medicare reform ideas

Political amnesia-abandoning overnight the position you once staked your political capital on--is nothing new in Washington, but rarely have the reversals been as bold as in the recent debates over health care reform. Throughout the 1993 fight over Clinton's reform plan, Republicans kept Medicare off the table and proclaimed the horrors of managed care. This year, suddenly, they discovered the Medicare crisis. "The choice we face is simple," says Representative John Kasich. "We can either strengthen Medicare and preserve it for current and future beneficiaries, or we can do nothing ... and ensure Medicare's demise." And as a solution, they are trumpeting--you guessed it--managed care.

Democrats who advocated health care reform, meanwhile, are trying to stymie radical change this year by using dire rhetoric that also ends up feeding beneficiaries' fears. "Those who want to gamble with Medicare are asking Americans to bet their lives," President Clinton warned during a celebration of Medicare's 30th anniversary. Congressional Democrats have taken a page straight from Republican strategist Bill Kristol's health care playbook: Deny the problem's seriousness and block your opponents' solution.

For observers of health care politics, the images of politicians thriving on conflict--and journalists obligingly covering every jab and duck--evoke an unshakable sense of deja vu. The target is narrower. The party in the driver's seat is different. Controlling the deficit, rather than expanding access, is the engine driving reform. But in many respects, the fight over Medicare is shaping up to be much like the last Congress's fight over health care reform. Even many of the same interest groups are squaring off with overblown rhetoric.

Irrational fears based on misinformation helped derail last year's debate. To prevent that this time around, a whole new set of Medicare myths needs debunking. For starters, Medicare doesn't need "saving" or "rescuing" or any of the other hyperbolic turns of phrase the press and politicians use to discuss the program's future. To borrow from Twain, reports of a crisis are greatly exaggerated. Medicare needs fixing, to be sure, both to contain costs and to expand the range of covered services. But that's hard to do rationally in a climate of confusion. As political temperatures run high, deficit pressures mount, and the whole process collides with presidential politics, what's best for Medicare and American medical care as a whole may get short shrift.

The Republicans assume that the market--in the form of vouchers for private HMOs--will save Medicare. But in truth, it is possible to control Medicare's costs and improve its coverage without a wholesale conversion to HMOs. The stakes here are enormous. Medicare reform done badly will only worsen the problems of the elderly, the uninsured, and the underinsured. No reform at all will worsen the problems of the federal budget. But done right, Medicare reform could be a first step toward universal health insurance, showing that not only is the government the only party willing to cover people private insurers won't touch, but that it can control costs and quality when it does so.

The Road to Nowhere

Medicare's enactment 30 years ago, in fact, was to lead to universal health coverage. Since before World War I, the idea of national health insurance had fallen in and out of favor as America's economic fortunes fluctuated. With strong public support, New Deal liberals had come close to incorporating universal health insurance into the emerging welfare state, but conservatives in Congress blocked the effort. So reformers revised their approach, adopting an incremental strategy that at first would cover only Social Security beneficiaries, and the idea of Medicare was born.

Restricting the program to the elderly was not what social reformers really wanted--it was what they believed they could get. The same pragmatism shaped the program itself. In the face of opposition from the medical establishment, Medicare was to begin with only 60-day hospital insurance; physician services were at first excluded. When doctor visits finally were included...