Medicine, politics and the 2000 campaign

Ask Ted Marmor a question about medicine and public policy and you’ll get a ready answer. After all, this is the author of The Politics of Medicare, a much-cited 1973 analysis of America’s largest and longest-running health program. A professor of management, public policy and political science at the School of Management, Marmor has been at work revising the book’s content for its second edition for publication this fall by Aldine de Gruyter.

He began his career in the mid-1960s as a special assistant to Wilbur Cohen, secretary of the U.S. Department of Health, Education and Welfare, and later served as an advisor to President Carter and to 1984 presidential candidate Walter Mondale. A former faculty member at the Universities of Wisconsin, Minnesota and Chicago, Marmor is a member of the Institute of Medicine and, since 1993, has directed the Robert Wood Johnson Foundation’s postdoctoral program at Yale in health policy and social science. He has testified before Congress on health care reform, Social Security and related issues, and is a regular contributor to the op-ed pages of major U.S. newspapers, including the Wall Street Journal, New York Times, Boston Globe and Los Angeles Times. In addition to more than 100 scholarly articles, he is the author or co-author of 11 books, including the 1992 volume America’s Misunderstood Welfare State, with colleagues Jerry Mashaw and Phillip Harvey.

Yale Medicine Editor Michael Fitzsousa interviewed Marmor in early September. The night before, Marmor had given a lecture to doctors enrolled in the Yale Management Program for Physicians, a new course offered jointly by the Yale Faculty Practice, the School of Management and the School of Public Health. On this day, he is hosting Jean de Kervasdoué, a visiting fellow from the Conservatoire National des Arts et Métiers in Paris and former head of the French hospital system. After work the two will face off on the tennis court; Marmor plays squash daily and won the national championship for over-60 earlier this year. We asked him to comment on the debate raging over Medicare in Washington, the prospects for health care reform and managed care, and the role that issues in health and medicine are likely to play in the coming 2000 presidential campaign.

Looking at the intersection of health care, politics and economics in September 1999, what do you see on the horizon?

Turbulence is the dominant feature. And to everyone’s surprise, medical care has come back on the agenda of American politics. Not only in the context of Medicare reform or prescription drugs or the regulation of so-called managed care firms in the various states, but also as a likely topic of the presidential race of 2000. That, just a few years ago, would have been thought impossible. The prognosticators in 1995 were saying that the debacle of the Clinton health care reform meant that universal health insurance was off the agenda for another generation.

The most surprising issue is whether or not the United States is going to move decisively towards universal health insurance in the way that President Clinton proposed in 1993. That’s being suggested by candidate Bradley, circled by candidate Gore, and ignored at the moment by contender Bush. But I don’t think it’s going to remain that way. The question of the state of the uninsured in America — as well as the state of the underinsured — will be topic number one in the public debates.

What are the other leading issues in health care, in terms of public interest? Which of them do you think have the potential to affect the 2000 presidential race?

A second topic on the agenda is that of a so-called patient’s bill of rights, which is really a crie de coeur about the regulation of patient choice. In a surrogate way, it’s about the regulation of professional choice, of what services to give to whom under various insurance plans. It’s an extremely complicated alignment in Washington now, with the Democrats struggling to get 15 to 20 Republicans to favor their more interventionist line. The physician-politicians on the Republican side in this case are unwilling to follow party loyalty because they feel aggrieved by the same phenomenon that has aggrieved consumer groups and professional groups within medical care.

The third topic, which was on the agenda in April, May and June and has for a moment fallen off, is the dispute about how to adjust Medicare both to the changing demography of America and to changing conceptions about what Medicare ought to provide and how it ought to be organized. There’s no possibility that Medicare will not be an issue of contention in the 2000 election. The interesting thing is that, because it’s being presented as a matter of fiscal politics, conservative Democrats like [Sen.] John Breaux [D-La.] have joined forces with ideological opponents of Medicare like [Rep.] Bill Thomas [R-Calif.]. It’s a reminder of the alignment that took place in the 1950s and early 1960s between Southern Democrats and Republicans opposed by the bulk of the Democratic party. Medicare was born as a product of the ’64 election that broke that conservative coalition.

The fourth is a topic that may or may not arise, but all the ingredients are there. Namely, the sense of American physicians that their lives have been transformed by the events of the 1990s in ways that they could not have imagined at the start of the decade. I can’t think of a more important theme for medical education, medical discussion and medical care than this. The elliptical way of describing this is that the early 1990s was a period of choice without change, and that the rest of the 1990s has been a period of change without choice. The Clinton debate raised every issue you could possibly imagine. Choice was everywhere. Choice about regulation. Choice about delivery. Choice about financing. And it was stalemated. In the wake of that stalemate, American doctors, instead of being hit on the left by a hammer, were hit on the right by 10 sledgehammers, as intermediary organizations realized that the savings the Clintonites had assumed would come from negotiations with the physicians and other providers could be found through the use of their market power as buyers. The only way you actually generate savings is by reducing the income of people on the other side of the receipt. The most important law of medical economics is that expenditures always equal somebody’s income.

Ten years from now, do you think the health care system will be in better shape or worse?

It depends in part who wins in 2000 and in 2004. It depends on the continuation of this boom. If the boom continues or is not reversed substantially, I think the circumstances of American health care patients, physicians and nurses will actually improve. That is, I think we’re at the end of a trough and at the beginning of a period of realignment of forces in American medicine, much helped by the general well-being of Americans. If, on the other hand, we have a reversal, it will make a huge difference as to whether or not the reform forces will be on the side of cost-cutting, or whether they will be on the side of protecting the patients from restraints on their options arising from largely financial goals rather than medical care goals.

And I think there’s no way of putting this other than bluntly, which is to say that American medicine is now the most highly regulated in the world, except it’s not regulated primarily by the government. These are blunt points that are masked by the prominence in American political discussion of the ideology of anti-government sentiment. It’s one of the reasons it’s taken much of this decade for the population to catch up with these changes. But there’s another reason which physicians and hospital administrators and educators in medical schools need to know about: Most people are not sick most of the time.

If the changes in medical care that have taken place in the ’90s had taken place in American schools or in grocery stores, there would have been a much more rapid response. It’s physicians and nurses and patients who have the largest, day-to-day stakes. Most people aren’t patients most of the time. So there’s an imbalance in the representation between the fiscal stakes of payors, the fiscal stakes of providers and the fluctuating stakes of the citizenry who from time to time experience the enormous hassle of American medical care.

The second edition of your book The Politics of Medicare will be published this fall. What has changed and what has remained the same since Medicare was established?

The biggest change is that Medicare, from 1960 to 1966, was regularly a front-page issue. It was a first-order question about the role of government — how that role ought to be financed and for whom its benefits should be given. And the fight was between two dramatically contending conceptions of the proper role of government and the proper kind of medical insurance protection. That was settled decisively by the election in 1964 and the enactment in 1965. And what’s been true from 1966 to 1996 was that Medicare became largely a second-page issue in American life, of first-order significance to a medical school, to a hospital, to doctors, but not something that presidential elections were fought over. In 1968 we were talking about Vietnam. In 1972 when Nixon won, national health insurance was on the agenda, not Medicare reform. Likewise in 1976, Carter didn’t talk about Medicare, nor in 1980 was it an issue. Nor 1984. Nor 1988-then it was children’s health insurance on the Dukakis side. In 1992 it was Clinton not saying a word about Medicare except when forced. By 1996, he rediscovered Medicare as a partisan issue and beat the hell out of the Republicans with it.

The great story of 1999 is the popularization of several myths about Medicare, which are announced in Washington as if they were obviously true, and they have nothing to do with the truth. Myth number one is that Medicare is unsustainable and unaffordable because of the aging of America. There is no reason to believe that aging explains very much of the increases in Medicare’s outlays between 1966 and the present. The population increase of the elderly is a relatively small component. If demography were destiny, then northern Europe already would have had a transformation of all their medical care schemes, since they aged in the 1980s and early ’90s as much as we plan to age over the next 15 years. Why is this the case? Because what you spend is not simply a matter of how many people are in any age group or in your society. We now know from the last three years of economic growth that it’s not the number of people working, but the wealth they produce. That is central to the “affordability” of any program. There is a crazy idea that ratios of workers to the elderly is the only thing you need to know. By this standard, Switzerland would be very poor and Swedes would be positively impoverished.

A second myth about Medicare is that the answer to this affordability problem is to give all elderly people a voucher equal to the average Medicare expenditure per capita, and therefore to put a financial border around the Medicare program. Well, that doesn’t reduce the cost of medical care to the elderly. It constrains the cost of the Medicare program to the federal government. It’s a perfect example of shifting of financial risk. It shifts the risk onto employers, on elderly people and on plans.

And finally the notion that the reason we’re going to have to change things is that the rest of Americans are facing more constraints on their medical care choices than Medicare beneficiaries are. The reasoning then follows: Medicare will be unsustainable because older and disabled Americans experience freedom that their children don’t have and therefore are resentful. There is not one shred of evidence from public opinion surveys or focus groups to support this cliché. But there are many people in Washington who claim this to be true. With these three myths going around, it’s hard to find the truth.