Medicare is the 1965 Ford Mustang of healthcare. It was cutting-edge back in the day. But, like that half-century old car, Medicare no longer runs very well and needs a remake.
The real issue is not its finances, which is what most of Medicare’s 50th anniversary commentary is about. It’s about redesigning how it delivers care, which is what really matters to older Americans.
Don’t underestimate Medicare’s importance. In 1965, for the first time, it made health care available to millions of seniors who otherwise had no access to much beyond primary care. And it is no coincidence that life expectancy at age 65 has increased by a staggering five years, or by more than a third, between 1960 and 2013. We can’t lose sight of that.
But Medicare has been slow to adjust to its own success. In part thanks to the extraordinary advances in medical science that it helped make long lives possible, the program is hopelessly outdated. It was never built to care for people who live decades with multiple chronic conditions.
Nobody but an obsessed hobbyist would drive that 1965 Mustang today. To make it run safely and efficiently, you’d need to replace nearly everything: the brakes, the carburetor, the steering system, the transmission, the frame. You could do it, I suppose, but about all you’d keep is the wild horse logo.
Medicare suffers from a similar problem. The idea is great, but many of the parts are obsolete. In 1965, medical care was all about acute health episodes. People had heart attacks. They either died or, rarely, recovered.
Those days are long over. Now people live decades with heart failure. Dementia, which barely registered as a health problem in 1965, has become a major issue. In large part, that’s because people routinely live into their 80s, the age at which Alzheimer’s and similar diseases commonly strike. People didn’t get Alzheimer’s in 1965 because something else killed them first.
But Medicare is not set up to care for those with chronic disease. It does not provide long-term supports and services, which are critical to people with complex conditions. It has few mechanisms to help patients manage multiple chronic diseases. Much of the care these patients need isn’t strictly medical at all. Yet medical treatment is pretty much all Medicare will pay for.
Worse, the fee-for service Medicare system upon which two-thirds of beneficiaries rely still encourages aggressive treatment and tests even if they are likely to harm patients rather than help them.
The Affordable Care is helping to change that. But many of the innovations it drives, such as Accountable Care Organizations or bundled payments, are designed to better manage a single episode of care rather than an ongoing chronic condition.
There are a few programs that do focus on those with chronic disease. But they are often square pegs being heroically squeezed into round holes. Patients would be better served if Medicare is changed to fit the innovations rather than forcing the innovators to make what they do fit into Medicare.
Let’s not say “modernize” Medicare, a phrase that has taken on a mini-van of baggage. Liberals think its code for conservative efforts to slash the program. Conservatives are convinced that liberals will do anything to preserve benefits that help no one and waste billions of dollars. Both sides go into a defensive crouch. And nothing happens.
For a minute, forget about the federal budget. Think of Medicare from the perspective of an 85-year old with heart disease, arthritis, diabetes, and some memory loss. How does Medicare work for her? Could it be better?
The answer is self-evident. And there are creative ideas out there that policymakers could build on. Dr. Joanne Lynn at the Altarum Institute has developed a model she calls Medicaring that combines personal and social supports with appropriate medical care for those living at home. Another group of highly respected policy experts, including Marilyn Moon, Ilene Hollin, Lauren Nicholas, Cathy Schoen, and Karen Davis have proposed Complex Care Organizations, which are something like ACOs but for ongoing care for people with complex needs.
Last month, a group I’ve been participating in, the Long-Term Care Financing Collaborative, proposed a similar framework for caring for those with chronic illness.
The ideas are out there. On Medicare’s 50th anniversary, policymakers need to abandon the false choice between pure cost-cutting and protecting a benefit design that leads to inappropriate or even harmful care. They need to think about that 85-year-old and how to best get her the care she needs.