The spending plan put forward this fall by congressional Republicans starkly illustrated that a government budget is not just a fiscal device, but a slate on which moral choices are written.
Take Medicare and Medicaid as prime examples-two programs slated for a combined $440 billion in cutbacks over the next seven years. Medicare and Medicaid are much more than line items on a budget. Medicare provides health care for 37 million elderly and disabled Americans, spreading costs across the whole of society. Medicaid pays the medical bills of one out of every 10 Americans who is poor, disabled, or elderly. The two programs directly affect millions of people in this country: The child whose parents lost private health insurance coverage when they were laid off, the retiree who is hospitalized with a broken hip, the young woman who is left with physical disabilities after an auto accident.
The programs are essential elements of the U.S. health care system. Medicare provides more than half the revenue at many hospitals and at least a third of the revenue of doctors other than obstetricians and pediatricians. The programs are far from perfect-waste, fraud, and inefficiencies occur in both. Nonetheless, changes in these programs will have both immediate and long-term effects on health care availability and cost for all citizens.
For example, the Journal of the American Medical Association reported that Medicaid caps approved by Congress would eventually prevent states from picking up coverage for the growing percentage of children who have lost employer-based coverage. The Senate's spending bill would strip 12 million Americans of health coverage once federal money and state matching funds are exhausted, according to Consumers Union. The group projects that many emergency rooms and trauma centers will close so that hospitals can avoid the costs of increased numbers of uninsured patients, since federal law forbids denying emergency care to the uninsured.
But it is not just partisan rhetoric to say that health costs and spending must be reduced. Every level of government is affected as the costs increase to provide health coverage for public employees. Local officials are forced to cut spending on services such as road repair, mass transit, and schools just to pay the growing health care bills.
CURBING THE GROWTH of Medicare and Medicaid is vital. But such changes need to be made as part of a much broader discussion on health coverage, costs, and how to share those costs in a way that doesn't abandon those without private coverage. Comprehensive health care reform is the only way to address the crisis of rising costs and at the same time improve access to quality care.
The Republican plan has little to do with either this broader discussion or their narrower, stated goal of "saving Medicare" and increasing the "choice" of Medicare recipients.
When Senate Republicans first issued their proposal in September, Senate Majority Leader Robert Dole said, "Medicare is in critical condition and we're committed to saving its life." By late October, Dole had changed his tune, proudly proclaiming, "I was there, fighting the fight, voting against Medicare because we knew it wouldn't work in 1965."
The Republican plan allows Medicare beneficiaries either to buy into private managed-care systems, set up medical savings accounts, or remain in the traditional program. The sicker and older are the ones most likely to take the latter option, while the healthier and wealthier are drawn out by the first two. The loss of funds from healthier participants and the expense of caring for the very sickest threaten to destroy what they seek to save.
Most Medicaid expenditures are for the poorest of the elderly and disabled, so the proposed Medicaid cuts complete a very grim picture indeed: Medicare effectively destroyed, and Medicaid hobbled to the point that it can't begin to cover the gap. The picture is even worse when you add cuts to hospitals, doctors, and other providers.
Those who opt for the voucher and medical savings plans may end up with coverage, but at a much higher price. As Sen. Paul Wellstone wrote, "The ultimate irony is that changes to Medicare based only on budgetary concerns and not on the needs of real people could end up costing employers, seniors, and families-the people who ultimately pay all the bills-more than our current system."
We're not helped as a society by ignoring budget realities and addressing human needs only by increasing the bureaucracy. But cynical budget slashing to fund tax cuts won't contribute to the public good either. All of us must take seriously that the health of a nation is not only measured economically, but physically and ethically as well.