CarCare and Medicare: A Fable for Today

Published July 1, 2001

“Cars are just too expensive for seniors,” thundered the politician as he unveiled his new plan. Not daring to anger the AARP lobbyists nearby, his colleagues bobbed their heads in agreement. When the vote came up, the bill passed with nary a nay vote.

A new payroll tax was imposed on anyone who did not work for the government. Acting as agents of the Department of Treasury, employers collected the tax from their employees’ paychecks. The feds used the money to buy the cars, then paid the auto dealers about 20 percent of the market prices.

Soon, every senior had a car through the government program cleverly called “CarCare.”

And then came the unintended consequences.

The showrooms of some dealers were cleaned out as seniors clamored for luxury cars at the government’s bargain-basement price. Some dealers went out of business, facing bankruptcy because they had to sell so many pricey cars at a loss. Other dealers stayed afloat, at least for a while, by raising the prices on all their cars.

When a shortage of cars developed, seniors tried to buy cars outside the program, with their own money. But the government said that was illegal, and threw the dealers in jail.

Not So Far-Fetched

Does the CarCare story strike you as far-fetched? Just substitute Medicare for CarCare, and doctors for dealers.

When Medicare was launched in 1967, many Americans supported it. The federal government had, in essence, obligated itself to pay for most medical spending for most Americans over age 65. Who could refuse?

But the country responded to Medicare in the same way as our mythical senior citizens did to CarCare. Many Medicare patients sought out highly trained specialists, better hospitals, and more expensive treatments. Demand for health care escalated . . . because patients used the system as it was designed to be used.

The grandmother of a friend of ours was a very frugal woman who rarely saw the doctor—until Medicare was established. Then, because Medicare would pay for one doctor visit every month, she saw her doctor every month.

Soon Medicare spending projections were off by 1,000 percent. The planners had not adequately planned for the unintended consequences. The unexpectedly dramatic increase in demand for more and higher quality services put serious inflationary pressure on medical prices. If the CarCare program had been launched in 1967 and followed Medicare’s lead, the average automobile would now have a list price of roughly $100,000.

When the politicians were called on to come up with more money for Medicare, they cried foul and sought a scapegoat to blame for their budgeting folly. As there aren’t as many physician-voters as there are Medicare-voters or even government-bureaucrat-voters, the politicians turned up the heat on doctors.

Fraud Net Catches the Innocent

In 1996, Congress made it a crime to make a mistake, criminalizing clerical billing errors made by Medicare providers. As a result, many capable and honest doctors have been victimized by government prosecutors. Yes, criminals have been caught, but at least as many honest doctors have been driven from practice, forced into early retirement, financially ruined or even jailed because of “overzealous” prosecution.

Yet, Medicare invites fraud. Unlike credit card statements or other bills, Medicare billings are often never even seen by the patient. On the rare occasion a patient receives a hospital billing copy, it’s so riddled with uninterpretable codes and acronyms and abbreviations the patient needs another consultation with the doctor just to understand it all. And in the end, since the government pays most of the charges anyway, what’s the point of trying to figure it out?

The effort to ferret out Medicare fraud and abuse has had unintended consequences. According to a survey conducted by the Association of American Physicians and Surgeons, published in February 2000, roughly one-fourth of the nation’s doctors are refusing to accept new Medicare patients. The top reason survey respondents gave was “hassles or threats” from the government. The amount of the fees paid to physicians providing care to Medicare patients was a distant fourth.

If the real aim of the government’s anti-fraud effort is not to persecute doctors, but to cut waste, and thereby costs, in the Medicare program, there are better ways. If patients were to pay their doctors directly, fraud would be significantly curtailed. The Medicare check and a comprehensible explanation of services should be sent directly to the patients, who in turn should pay their providers.

Yet government is so intent on controlling the Medicare program they make it nearly impossible for doctors to provide additional care to patients willing to pay for it, or even free medical care to those who cannot. Doctors offering those services face criminal prosecution and jail time.

In 1995, the Association of American Physicians and Surgeons marked the first “Medicare Patient Freedom Day” by treating patients for $1 cash, while refusing to file claims for reimbursement from taxpayers. The government responded by saying it was illegal not to file a claim for payment. AAPS President Jane Orient, M.D., declared, “Doctors should refuse to be willing participants in this game of regulatory Russian roulette.”

It would seem fair to call the Medicare system “dysfunctional” when it allocates one billion dollars to lawyers and investigators to search out and destroy fraud, while paying dimes on the dollar to the providers of medical care.

Rethinking the Entitlement

When asked why he robbed banks, Willie Sutton answered, “because that’s where the money is.” While no one would accuse Medicare patients of robbery—they’re merely behaving as the program was designed to have them behave—the fact remains Medicare is where the money is. As long as we think of Medicare as an unlimited entitlement, the question may not be how to fix Medicare, but can it be fixed at all?

We hope legislators with a flair for fairness will reassert themselves and come to understand it is unfair to ask lower-paid, young workers supporting a growing family (and perhaps even their own parents) to subsidize the medical care of those senior citizens who can afford to pay their own way. Baby boomers are fast approaching Medicare age; it may well be time to reinvent Medicare to fit the demographics of the twenty-first century.

Doctors are Healers, not Bureaucrats

Most observers would agree that Medicare patients should have greater freedom to choose their doctor. But the program today discourages many fine physicians who would rather be taking care of patients than pushing paper. Attempting compliance with the enormously complicated and often poorly defined Medicare regulations is time-consuming at best . . . and dangerous at worst. The penalties for incorrect paperwork—fraud, the government calls it—are stiff.

According to the AAPS survey referred to earlier, doctors spend an average of 500 hours a year—more than two months of eight-hour workdays—dealing with the Medicare maze. Who could disagree that time would be better spent treating Medicare patients?

Michael Arnold Glueck, M.D., of Newport Beach, California, writes extensively on medical, legal, disability, and mental health reform issues. Robert J. Cihak, M.D., of Aberdeen, Washington, is currently president of the Association of American Physicians and Surgeons.