Under normal laboratory conditions, adult fruit flies have an average lifespan of seven days. The average fruit fly would have therefore outlived the tentative Medicare buy-in compromise presented by the gang of 10 Senators this last week.
Senator Lieberman was the immediate and proud killer. Yet as Amy Goldstein makes plain, other assassins waited in the wings, including physician groups, community hospitals, otherwise-progressive senators from rural states. There is a useful lesson here. Democrats have cast insurers as the all-purpose villain in health care reform. There are sound political reasons to do so. Particularly in the non-group market, the industry certainly lives down to its villainous stage role.
We should recognize, however, that strategic imperatives and message discipline can cloud analytic clarity. Virtually the entire supply side of the medical economy has a strong economic interest in constraining the growth and bargaining power of Medicare. This includes traditional targets of liberal wrath such as big Pharma and device manufacturers. It also includes warmer and fuzzier constituencies, too: community hospitals, the Mayo Clinic, academic medical centers and many others. Effective cost control requires us to stringently bargain with these institutions. They will resist efforts to strengthen government's bargaining leverage to accomplish this task. As we saw in the demise of this modest but worthy Medicare compromise, our failure to confront this political fact brings real human and financial costs.
A few words about the substance. Near-seniors age 55-64 face serious risks that make them a natural constituency for health reform. Too young for Medicare, but old enough to face marked health risks, this group includes the most immediate victims of preexisting condition exclusions, large medical expenses and accompanying bankruptcies, chronic illness and disabilities. Not surprisingly, then, polls indicate that this group ranks among the most enthusiastic supporters of health reform. Equally unsurprising, support for health reform plummets at age 65, once seniors secure Medicare coverage.
Based on what we know, the proposed Medicare buy-in would have been helpful, but it would have had a very small immediate effect. Over the next several years, the main beneficiaries would apparently have been a small population of men and women with chronic illnesses eligible for high-risk pools, who suffer costly conditions and who have been uninsured. High-risk pools can be a useful stop-gap. They are not an effective or humane long-term policy. We don;'t know enough details to evaluate Medicare buy-in as a specific policy. Over the long-term, liberal hopes matched provider and conservative fears about where this might head. These possibilities were enough to prove fatal in a world in which reform requires 60 Senate votes.
Now that the buy-in is dead, those who favor reform should move on to address the serious problems millions of near-seniors face, and would have faced even if the buy-in had become law. Near-seniors need strong regulation to prevent insurer discrimination on the basis of illness or disability. They need generous affordability credits and better protections against high out-of-pocket costs, particularly for those with incomes around 300 percent of the poverty line. They need rapid implementation of health insurance exchanges, which are several years off.
The buy-in deserves an honest obituary. We should mourn its quick death and what might have been. It's now time to pass the bill, and to focus on essential details that remain to be done. In doing so, we should remember who killed the buy-in, and others who were happy to see it dead. As we move to secure the rudiments of universal coverage, we can't wage every fight. When the current health reform is done and we look more seriously to control costs, we'll be fighting other battles soon enough.