The politics and realities of Medicare

Public Interest, Summer, 2004 by Eric Cohen

This last question is an important one. One of the strongest arguments for adding a prescription drug benefit to Medicare was that doing so would prevent beneficiaries from needing or using more expensive therapies for ailments that could be ameliorated or prevented using less expensive drugs. This is certainly true in some cases, but it is also difficult to quantify for Medicare as a whole. Drugs that keep people alive or prevent certain diseases also mean new costs for new diseases down the road that never would have existed. (Early death, after all, would be the best way to solve Medicare's economic woes.) Some drug therapies may indeed cut costs or allow individuals to remain self-sufficient. But the notion that we will cure our way out of the economic problems involved in caring for the elderly is a fallacy. People will simply be sicker later in life; they will die from chronic conditions instead of acute episodes.

Such questions--unanswerable for now, but important to ask--point to the grave shortcomings of the new law. MMA puts off any serious confrontation with the pending financial problems of Medicare as a whole, and it fails to reckon with the deeper human, generational, and medical realities that underlie our sense of impending "crisis." More deeply, it fails to grasp or even consider the novelty of the world to come: a world of aging baby-boomers, with fewer children, geographically scattered, with high rates of divorce, and a greater likelihood of living long enough to suffer diseases (like Alzheimer's) that create long-term states of dependence.

The hardest decisions about Medicare in the future may ultimately be faced by the middle-class members of the middle-aged generation--and specifically, by members of Generation X in their 40s and 50s. They will have to decide what they are willing to pay and what they are willing to give up, and they will have to balance the demands of aging parents and dependent children. When the financial balance finally hits, they may have to choose between higher taxes or lower benefits; between sending their child to Harvard or their parent to Sunrise Assisted Living; between raising their own retirement age or cutting funding for national defense; between forcing their proud father to become eligible for Medicaid or giving up their inheritance to pay for the nursing home.

The dilemmas of progress

Despite the bitter disagreements over Medicare, liberals and conservatives share two basic assumptions: the ideal of self-determination and the ideal of medical progress. They both want more choice for the aging, and they both believe that more drugs for more people is an unequivocal good, even if they disagree about how best to achieve these goals. And so they are both, in different ways, prone to utopianism, believing that the right policies will create a world where the Medicare crisis is largely solved. This is a fantasy shared by liberal and conservative thinkers alike, whether packaged in the rhetoric of new vouchers or new entitlements.