The Devil In Mr. Johnson
2007; Project HOPE; Volume: 26; Issue: 4 Linguagem: Inglês
10.1377/hlthaff.26.4.1194
ISSN2694-233X
Autores Tópico(s)Theater, Performance, and Music History
ResumoBook Review Health AffairsVol. 26, No. 4 The Devil In Mr. JohnsonWilliam M. SagePUBLISHED:July/August 2007Free Accesshttps://doi.org/10.1377/hlthaff.26.4.1194AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSMedicareMedicare Part DMedicare Part BSystems of careHealth servicesCosts and spendingOrganization of careUniversal coverageFederal health plans Medicare as morality play is the organizing theme for David Hyman’s blunt and biting satire, Medicare Meets Mephistopheles. Modeled on C.S. Lewis’s Screwtape Letters as correspondence between a junior tempter and the Lord of the Underworld, the book catalogs America’s descent into sin in the forty years since Medicare’s enactment and reveals the program as a demonic plot rather than a crowning achievement of the Great Society. Medicare, we learn, is Satan’s device to subvert American virtues of thrift and truthfulness. Providers turn to avarice, beneficiaries to gluttony, and administrators to sloth. Those whom Medicare rewards less envy those it rewards more. Medicare feeds Democratic politicians’ lust for power and stokes Republicans’ anger—except when, as recently, the Republicans lust while the Democrats fume. Vanity? Medicare’s gift to health policy gurus (like me, presumably), who bask in its reflected glory.There is no arguing with Hyman’s facts or first-pass explanations for the phenomena he describes. Nearly all of the key teaching points about Medicare’s history, politics, structure, and vulnerabilities are laid out clearly and concisely. The author’s considerable wit and charm are on full display, making the book a fun as well as an informative read. Also valuable are photographic nuggets Hyman has unearthed from Medicare’s past: Harry S. Truman’s application for Part B (the first submitted, with LBJ signing as witness), senior Leona Kozien about to be hit by Dan Rostenkowski’s limousine as she protests the Medicare Catastrophic Coverage Act, a “licorice pizza” of American Medical Association propaganda from 1961 called “Ronald Reagan Speaks Out Against Socialized Medicine,” and more. Hyman’s well-known opposition to making policy by anecdote does not protect him from its spell—or perhaps the engaging stories in the book are yet another example of the devil’s handiwork. Ditto for editorial cartoons through the years illustrating the program’s foibles.For a book like this—and it would be a plus for policymakers, journalists, and the public if more books backed firm views with accurate facts and good humor—a description of its weaknesses would miss the point. The book is nearly flawless for what it is. Better then to alert readers to what it is not.First, the book is not really a crusade against Medicare. It is a teaching tool for recognizing Medicare’s faults and improving the program. Most of the sins portrayed seem venial rather than mortal. The prescriptions it offers—maintaining irony by calling them “angelic forces to be resisted”—are familiar favorites of the “policy right” such as premium support, competitive bidding, and pay-for-performance. The metaphor is exorcism, not immolation.The most persistent accusation leveled at Medicare—by Hyman in the body, Richard Epstein in the foreword, and the publisher on the dust jacket—is that it is “a mediocre government program.” Mediocrity is seldom Satan’s calling card. He is, after all, the Prince of Darkness, not one of twilight’s assistant vice presidents. If Medicare is evil, shouldn’t it be abolished? Hyman does not go that far, except (half-heartedly) for Part D.By not seriously considering life without Medicare, the book avoids giving benefits the same hard look it applies to costs. This “Medicare counterfactual” is challenging to model because the program has become such an important driver of the U.S. health care system.Medicare’s most obvious effects have been on the supply of medical services, partly because of explicit subsidies, partly because it assures new suppliers predictable revenues. Without Medicare, there would be fewer physicians and far fewer specialists. Fewer hospitals would offer technologically sophisticated services, and many technologies might not exist because the market for them would be speculative.The distribution of access would also be altered. Elderly patients would have reduced command over health system resources and would be sicker and poorer. Financial stress from health needs—a common occurrence even with Medicare—would be widespread. A welfare safety net might cover catastrophic care after spending down, as Medicaid does, but would not support prevention or basic treatment. Geographic patterns would change also, with many patients outside of metropolitan areas finding only basic services available, especially in the Sun Belt states.It is not clear, however, that health service prices would be lower, quality higher, or competition greater. Medicare never overcame professional control over service delivery, but neither did private managed care in the 1990s. Medicare allowed physician and hospital prices to rise unconstrained for nearly two decades, but outpatient pharmaceutical prices (not part of Medicare until recently) rose also. The mix of services might be different without Medicare, as might be production models for delivering them, but it is hard to blame Medicare for inefficiency and variable quality (as opposed to criticizing the program for not forcing improvements).Without Medicare, aggregate health care costs would be lower, and the federal budget would not be held hostage to an unsustainable financing model that, in combination with Social Security, severely constrains annual discretionary spending. But shielding the federal government from financial risk associated with caring for the elderly would increase risk for state governments, private employers offering retiree health benefits, and charitable providers, all of which lack the feds’ capacity to incur debt. Second, Medicare Meets Mephistopheles is not really about morality. C.S. Lewis wrote Screwtape to help readers understand God and virtue in time of war. Hyman uses the deadly sins to deadly effect but equates temptation with regulatory incentives rather than exploring how Medicare furthers (or fails to further) moral purposes. The latter inquiry is particularly relevant to the debate over universal health coverage, which Hyman touches on as “Medicare for all.” Libertarians such as Richard Epstein and Milton Friedman (quoted in Hyman’s book) argue against compulsory transfer programs, including social insurance, on three grounds: first, that voluntary charity gets better value for money; second, that societies with limited government become wealthier, benefiting everyone; and third, that self-determination is inherently good.These assertions raise parallel questions about the desirability of government-mandated health insurance. One argument for universal coverage is avoidance of waste—that money spent on emergency departments and end-stage chronic diseases would go farther if spent on prevention and early treatment. A second argument (particularly for the non-elderly) is productivity—that collective investment in human capital through health will pay dividends in economic growth. The third argument is compassion—that it is inherently good for a wealthy society to help its ailing, less fortunate members.Today’s political climate is far more hospitable to the first and second arguments for government health insurance than to the third. But all three are worth debating with their libertarian counterpoints for both empirical and moral persuasiveness. Maybe in Hyman’s sequel. Bill Sage ( [email protected] ) is vice provost for health affairs at the University of Texas at Austin, where he holds the James R. Dougherty Chair for Faculty Excellence in the School of Law. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 1 July 2007 InformationCopyright 2007 by Project HOPE - The People-to-People Health Foundation, Inc.PDF download
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