Thursday, January 19, 2006

Medicare drug coverage

The other day I blogged on the importance of discussing principles, not just policies. The Medicare drug debacle is a perfect microcosm.

Medicare is a promise to people that when they've put in their time on the job, there will be a life after retirement, not a tradeoff between eating and getting medical care. It's been remarkably successful at achieving that simple goal. It's a more efficient insurance system than private insurers. It covers anyone over a certain age. Like any sensible insurance system Medicare allows a certain amount of bargaining between the care providers and the insurer.

Extending that to drug makes sense, because pharmaceuticals are a more important part of medicine than they were back in the 1960s. It makes no more sense for seniors to be balancing between buying food or paying for a pacemaker than it makes sense for them to be deciding between their beta blockers or dinner.

Making the drug plan subject to collective bargaining would have made sense. Treating it as a government run insurer, just like the rest of Medicare, would have made sense, and it would work.

This contrasts with what was actually done. The Wichita Eagle has a fascinating commentary by David Rundle about Medicare Part D, the drug plan we got stuck with. It's the diary of an epileptic with Medicare and Medicaid coverage trying to get his medicines. The hoops he has to jump through, the meaningless incompetence, the incomprehensible bureaucracy would be funny if the underlying problem weren't so tragic.

Anyone old enough to be on Medicare or young enough to have a parent or grandparent on Medicare knows some version of what Rundle describes. A TfK correspondent who will remain anonymous to preserve the confidentiality of her age has to figure out whether union based health insurance should come before the Medicare, and how to negotiate between the Medicare drug coverage and the union's drug plan.

As Mark Schmitt says,

Every single thing that"s happened this month was entirely predictable at the time the bill passed. Not just predictable, it was predicted, not just by me, but by everyone who wasn"t engaged in trying to get the bill passed or profit from it.
This is a perfect example of the Bush administration's opposition not to government, but to good government. The problem is that it's a hard case to make. Schmitt writes:

Seniors struggling over a dining table covered with complicated forms, small-print prescriptions, and no-win choices weren"t going to be muttering, "Goddamn Dennis Hastert, I'm never voting for his party again." They would be muttering, "Damn government, can"t do anything right."
Of course, this is false, as Jon Cohn points out in the New Republic:

consider what happened when the Johnson administration rolled out Medicare for the first time in July 1966. [discussion of the hurdles omitted]…

So what happened on the day that this complex program was implemented? Thousands of senior citizens simply went to the hospital and got the health care they needed. "There were no crises that I remember," says Yale University political scientist Theodore Marmor, who worked in the office overseeing Medicare implementation and went on to write The Politics of Medicare, the program's definitive history. Newspaper accounts from the '60s back him up. Under the headline "medicare takes over easily," a Post writer described the program's first day as "a smooth transition, undramatic as a bed change." Three weeks later, the Times affirmed that "medicare's start has been smooth."
But most people on Medicare part D now have no experience with that transition.

More problematic though will be the problem of treating this as an opportunity to attack, rather than to lead.

Nathan Newman is right in saying that:

If the goal is demonizing the rightwing, [Schmitt] is right. For all but the poorest seniors, the plan replaces no coverage for prescription drugs with something, albeit a complicated and frustrating plan. So it's hard to sell it as an evil plot for most folks getting some help.

But that doesn't mean Democrats can't make political hay out of fighting to improve the plan.
The way to make hay is to talk about what we would do. What are the principles, what are the goals?

Keeping the elderly out of poverty is a worthy goal. Making the system efficient and simple are valid goals. Implementing a self-funding, self-sustaining system is worthy. That's what any Democratic plan will do. I don't know what compromises will be necessary to pass a bill reforming this exemplar of bad government, but I know what the Democrats will stand for in that fight.