This roundtable offers perspectives from two former Medicare administrators, Bruce Vladeck, who is currently a senior advisor for the healthcare consulting firm Nexera, Inc., in New York City, and Gail Wilensky, who is an economist and senior fellow at Project HOPE, an international health foundation in Washington, D.C. What are their frustrations with Medicare and what are their prescriptions for improvement? Generations Guest Editors Tricia Neuman and John Rother moderated this discussion.
Medicare was born of interest group politics. The hostility of the American Medical Association (AMA)—the fiercest lobby in Washington from the 1930s to the 1960s—convinced advocates of public health insurance to start with the most vulnerable and difficult-to-insure segment of the population, the elderly. It also convinced Medicare’s advocates and early administrators to foreswear serious instruments for cost control that were in use in other rich democracies, such as fee schedules and restrictions on capital expenditures.
There’s a wistful story noised about among gerontologists that everyone should live in good health to a ripe old age, well into their nineties, and then have life end with a quick bullet—fired by a jealous lover. But we all know that is not the way most people in America head off into the Great Beyond. Too much of the time, in our current American culture, dying can be protracted and especially painful, isolating, and costly.
The exciting news is that people living to age 65 in the United States will have an average life expectancy of an additional twenty years (Administration for Community Living, 2013). Less exciting is that even if remaining independent and living at home, seven out of ten of us will likely need assistance for three of those years (Redfoot, Feinberg, and Houser, 2013; Lynn, 2013). This assistance would include help with everyday activities such as bathing, dressing, preparing meals, or paying bills.
Private plans have been part of the Medicare program, and an alternative to traditional Medicare, since the program’s inception. A hallmark of the Medicare program has always been that enrollment in private Medicare plans is voluntary. When people become eligible for Medicare, the default is enrollment in traditional Medicare.
Medicare, the healthcare program long relied upon by older adults, also covers 9 million people who are younger than age 65 living with disabilities, and who comprise 17 percent of the Medicare population (Kaiser Family Founda-tion, 2010). While the disability population has always existed in the shadow of older adults—at least in the public’s conception of the program—Medicare has long been critical to supporting the health of people with disabilities.