The Happy Hospitalist: All for one and none for all

The following is a reader take by The Happy Hospitalist.

All for one and none for all. That is the state of the current government program called Medicare. The entitlement program that threatens the financial security of our nation. On March 25, 2008 the Boards of Trustees released their Annual Report of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. In this 43rd edition, the Trustees note a government program covering just over 44 million people at an expense of $425 billion dollars during 2007. That equates to approximately $10,000 per beneficiary.

Ten thousand bucks. A cost accelerating at an unsustainable rate. In fact, the Hospital Insurance (HI) trust fund component of Medicare will be exhausted by 2019, with a payroll cost of 2.11% in 2007 rising to an astronomical 11.40 percent by 2082. This represents a tripling from 1.5% of GDP to 4.8% in that time frame. Total Medicare expenditures are expected to rise from 3.2% of GDP to almost 11%. Just under the 15% for all current health care consumption.

How can we sustain this? We cannot. Unless the rules change, actuary expectations project that by 2070, 100% of our federal budget will go to Medicare, Medicaid and Social Security. That means no roads, no bridges, no FBI, no CIA, no military. No nothin’.

So what do we do about it? Raise taxes or decrease spending. We cannot grow our economy out of this mess. Europe is in the flat tax revolution of a lifetime; While each country is fighting to lure healthy businesses and wealthy business people, America is talking about raising taxes on the top 20% that already pay 80% off all income taxes. Based on current tax laws, the effective tax rate of the bottom 20% of households is 1.1% (income and payroll included) rising to an average of 26.2% in the top 20% of income earners. We have put the burden of taxation entirely on the shoulders of the successful, educated and capitalistic minds of our society. Simultaneously, we have created a federal entitlement economy that cannot be sustained on the shoulders of the few. Something has to break.

The appropriate course of action should be a radically new approach to the Medicare entitlement program. We do not have a choice. The political suicide of such an action is however glaring. Our Congress is bogged down in billions of dollars of free cash flow coming from the coffers of big business looking to keep their gravy train flowing. It will take enormous servitude by our government officials to declare an end to the automatic money train known as Medicare. A restructuring of the program towards a transparent means based qualification system is necessary. Having Uncle Sam pay for an elective cataract surgery so grandma can go on an African safari is inexcusable in a time of financial collapse. The war in Iraq is peanuts compared to the financial destruction extolled by our entitlement programs.

Of course the sickest Americans cost the most. Fifty percent of our population is responsible for just 5% of total health care expenses, while 5% of our population is responsible for 49% of our 2 trillion dollar health care tab. And those with 7 chronic conditions are seven times more costly than those with one medical condition. These numbers are staggering. Because older people are generally sicker, these numbers place a large undue burden on the federal health care entitlement programs, programs that will no longer be financially viable in a few short years to come.

We will have to say no. No to dialysis. No to life support. No to elective procedures. No to brand name drugs. No to the latest expensive technology. We will have to place greater weight on quality of life over quantity of life. We will have to demand hospice care in futile situations. We will have to demand palliative comfort over slice and dice. We will have to reject marginally effective proceduralization and imaging of our elderly. We have to. We don’t have a choice. There is no other way.

The current modus operandi of Uncle Sam is to promise everything at ½ price rather than pay the right price for the right care. Medicare killed primary care by playing along with the house of RVU cards that RUC built. A saving grace for Medicare will need to be a fully funded primary care program which has the ability to put the brakes on unnecessary, expensive and marginally effective care that comes from all corners of the health care universe. Right now, Medicare promises all for one. Unless something changes we will eventually have none for all.

And that is simply not acceptable.

The Happy Hospitalist is an internal medicine physician and blogs at The Happy Hospitalist.

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