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Andrew Coates: Medicare And Medicine As A Profession

Medicare is the publicly funded health benefit package that covers most necessary care for older Americans and people with disabilities.

Medicine (with education, law, and divinity) is one of the traditional professions. The American College of Physicians explains that our profession is characterized by its "specialized body of knowledge that its members must teach and expand, by a code of ethics and a duty of service that put patient care above self-interest." The College's Ethics Manual goes on to say "Physicians must individually and collectively fulfill the duties of the profession."

Medicare covers nearly one of every six people in the United States.

When it was established in 1965 it opened new possibilities for physicians to treat patients. One of my retired physician friends recalls that before Medicare many of his elderly patients from a rural upstate village simply had no way to pay for care. Physicians would treat elderly patients of limited means for free. Often patients would bring homespun gifts or produce to the office as a tribute and a payment.

Today many patients remain unable to pay for care. Many physicians continue to volunteer their services (there are over 1,200 free clinics in the United States). Yet by its very existence, including that this popular public program has worked for 48 years, Medicare reminds us that there is really no excuse for anyone to be denied access to care. Medicare Advantage, a program that gave private insurance companies an extra payment to offer  and provide benefits to Medicare recipients, was enacted at the end of the Clinton Administration.

Meanwhile medicine has been buffeted by an explosion of technology together with the steady infiltration of market forces in all aspect of caregiving. In turn our profession has sought to understand as well as fulfill its obligations to society.  For example the American College of Physicians tells us that "All physicians must fulfill the profession's collective responsibility to advocate for the health, human rights, and well-being of the public."

This week Senator Chuck Grassley, the Iowa Republican, asked Marilyn Tavenner, acting administrator of the Centers for Medicare and Medicaid Services (CMS), about a leak of information from CMS that caused health insurance stocks to soar. The occasion of Ms. Tavenner's testimony before the Senate Finance Committee was part of her progression toward Senate confirmation as President Obama's nominee to be CMS Administrator.

The scandal was the leak of a decision by to raise federal payments to private insurance companies that run Medicare Advantage plans, publicly subsidized private benefit packages that are a private alternative to traditional public Medicare. The Obama Administration, which once talked about cutting support to Medicare Advantage companies, reversed itself.

40 minutes before the official CMS announcement health insurance stocks began trading furiously. In the 20 minutes between the official announcement and the market close, hundreds of millions of dollars of shares changed hands, driving the insurance company stock values skyward. Over the next few days the value of private insurance stocks rose by billions of dollars.

Because of the decision, UnitedHealth Group, the nations largest insurer and the one with the greatest market share in Medicare Advantage, will receive an extra $1.49 billion from Medicare for its Medicare Advantage plans in 2014. On this news, UnitedHealth stock surged in value by over $5 billion -- in just one week!

The larger scandal is that we have allowed profiteering into health care.

Medicare Advantage has been a means to privatize the public program of Medicare, a way to divert public resources to insurance company profits. Calling attention to cheating on stock trades neglects the larger scandal:  resources meant to go to the care of the sick should not be the source of profits for anyone.

According to an analysis by Drs. Hellander and Himmelstein at Physicians for a National Health Program, the total taxpayer cost of the extra subsidy to Medicare Advantage insurers, will be $71.5 billion to $104.5 billion over the next decade, depending on the number of Medicare beneficiaries who enroll in the private plans.

Within the Medicare population the healthy tend to be enrolled in Medicare Advantage, the sick tend to remain -- or return -- to traditional Medicare.

The tradeoff works like this:  patients with Medicare Advantage may enjoy the benefit of a free health club membership (something only the healthy can really enjoy)-- but the tradeoff comes when, after a hospitalization for example, some patients with Medicare Advantage find out that daily co-pays for rehabilitation services, for example, are simply unaffordable. They have to forgo benefits that would have been covered under traditional Medicare.

Medicare Advantage works well for insurance company profits. For patients, not so much. As a program it should really be abolished and its resources redirected to traditional, public Medicare. Meanwhile bipartisan efforts to undermine the traditional, public Medicare program gain momentum.

Curiously this is happening a mainstream debate has again focused upon the insanity -- and unaffordabitlity -- of health care. Steven Brill's Time magazine article "The Bitter Pill" continues to gain readers. 

Just this week Bloomberg Businessweek ran an article by JeffryPfeffer titled: "The Reason Health Care Is So Expensive: Insurance Companies."

Where are the doctors? We have an individual and a collective obligation to the duties of our profession. No longer should we allow the care of our patients to form a substrate for profiteering and enormous bureaucratic waste. We know what it means for our patients when we allow profit-seeking to direct the allocation of resources.

I believe we physicians have a professional duty to protect and expand Medicare as a public program. Medicare is far from perfect, but an expanded and improved Medicare-for-all finance system would not only help our patients. It would help restore our profession to a place where we can better meet our social obligations.

Dr. Andrew Coates practices internal medicine in upstate New York. He is President of Physicians for a National Health Program.

The views expressed by commentators are solely those of the authors. They do not necessarily reflect the views of this station or its management.

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