Generally speaking, I’ve tried to steer clear of too much political discussion hereabouts. With the exception of marriage equality and other gay rights issues that are of particular interest to me, I’ve made an effort to leave political analysis to my betters over at the main page and elsewhere. That said, and with your indulgence, I don’t think I can stop myself today.
If the (please, sweet Jesus) soon-to-be-resolved debt ceiling brouhaha has not been the absolute nadir of American civics, at least since Watergate, then I shudder to think of what would be. One side has been willing to drive the world’s economy off a cliff in a blatant show of ideological insanity, and the other side’s failure to deal effectively with this willingness has resulted in an utter shambles of leadership. I’m still mostly on Team Obama, but I’m sure as hell not waving my banner with much gusto for reasons that are laid out perfectly by Jonathan Chait.
So, then, what are we left with? I heard Sen. Claire McCaskill interviewed on NPR this morning, and she sounded rather sanguine about how Medicare had been spared from too much cutting. In particular, she was happy that what cuts had been made would be directed at providers, not patients. And that’s just dandy, as far as it goes. But let’s not all break into our dances of joy just yet.
Here’s Jonathan Cohn:
Those automatic cuts would be divided equally between security and non-security spending–with Medicaid, Social Security, and programs serving the poor protected from reductions. Medicare benefits would be off-limits too, although Medicare providers and producers (doctors, device makers, etc.) would see their reimbursements fall. Those protections represent a key achievement by the administration: For much of Sunday, it appeared (to me, among other people) that Medicare was in line for sweeping, potentially severe cuts.
I’m glad that there won’t be huge cuts to the program, but that doesn’t mean the cuts that will be coming don’t have the potential to harm patients.
It probably bears mentioning that I probably won’t be affected directly by any cuts to Medicare. Precious few children are covered under the program. Further, I’m not employed by a hospital, so I don’t have to worry that my salary would have to take a hit because of losses in another department. This conversation remains academic for me, at least for now.
As I’ve said recently, doctors like to get paid. I know I do. And I’m pretty sure that the family practitioners and internists who do see a lot of Medicare patients like to get paid, too. Perhaps you think that family practitioners and internists are, for some reason, the subpopulation who should be expected to take a haircut on Medicare reform. I’m not sure why they among the middle class should take a financial hit; neither specialty hits the magical $250,000 average salary threshold to be worth taxing more (according to Obama). But let’s say you think they should take the cut because they make too much money, dammit.
What’s to stop providers from opting out of accepting Medicare? At a certain point, physicians who care for the elderly may look at the bottom line and determine that they’re better served by refusing the accept Medicare reimbursement. Given how much volume Medicare patients provide to family practice and internal medicine practices, we’re probably not close to that point just yet. But if too many cuts are made to the program, it won’t make sense to keep enrolling in it. And (as the embedded link shows) patients then have a bear a much higher proportion of the costs, even if they independently submit their medical bills for reimbursement through Medicare.
Unless we’re going to force providers to accept Medicare no matter what it pays (and thus force me to recant my mockery of Rand Paul), there’s a limit to have much savings can be wrung from the program by focusing on reimbursement to physicians alone. Medicine may still be a good gig, but people really will stop choosing it if it loses too much of its appeal. We like to help people, but we also like to get paid.
Update: I see (via TPM) that this reality has occured to at least one legislator:
Latecomer Eliot Engel (D-NY) was hard pressed to find a single thing in the plan that Democrats like. He wasn’t even convinced by the argument that Medicare beneficiaries are initially protected from Medicare provider cuts. “It filters down to the beneficiaries,” he said. “It’s disingenuous to say that.”
Yes. Yes, Rep. Engel, it is.
Update II (Son of Update): A characteristically thoughtful follow-up post from Will Truman here.
I’m not sure why they among the middle class should take a financial hit; neither specialty hits the magical $250,000 average salary threshold to be worth taxing more (according to Obama).
There aren’t enough of the rich to eat.
If the government can claim it’s legal to force us to buy health insurance, I don’t see why they can’t claim it’s legal to force providers to accept it.
That quote jumped out at me, too. The notion that hits to providers won’t negatively impact patients is absurd. It could create a system where Medicare covers a lot, but you only really get care either in the ER or if you happen to have a doctor.
Even under the status quo, a lot of doctors don’t accept new Medicare patients. It’s not really either/or when it comes to docs no longer accepting it. What you will have, I think, is Medicare patients getting pushed to the end of a long line. Doctors only accepting as many Medicare patients as they need to in order to fill their schedule.
This wouldn’t be a problem if there were enough docs, of course. And the areas where the shortage is greatest are likely the areas most negatively impacted.
There are two very effective ways to ration:
1) by money
2) by queue
Unfortunately, only the first is proven effective at tempting folks to join the gravy train.
Well yeah, but what has to be part of cutting our health care costs is some of the key stakeholders getting less of something. Of course the solution many people of offered is not doing anything or at least not worrying about those stupid uninsured people, but any actual reform means people who like the current system are not going to like some of the solutions. The same people pushing for the cuts under threat of destroying the economy were the same ones who screamed bloody murder when the Obama HCR cut 500 mil of medicare waste.
I’m not sure what I think about cuts to providers, although I acknowledge that these cuts are not “costless” to the patients or to the providers. (For one thing, why not have means testing for the medicare premiums?)
But I think at least some of the rationale for cutting what’s supplied to providers goes beyond the “they make too much money, dammit” trope. Like Greginak said, if I read him correctly: cutting costs means something will have to give somewhere.
My objection to cuts only to providers is two-fold. First, as I tried to make clear, cuts to providers won’t really be limited to providers. Pretending consumers will be spared the costs is silly. They’ll have to pay more or wait longer or have less time with the doctor, but there will be a cost.
Also, on that note, this is patently a way for Congress to have it both ways (or try). They’re trying to cut Medicare without any change in services, and apparently think doctors should be OK with taking the hit for everyone. That way, voters won’t feel the reality of cuts and direct their ire toward their MOCs.