President Bush’s State of the Union address highlighted his focus on the predicted bankruptcy in Social Security. The media blitz from proponents and opponents of his plan has been substantial. The good news in this bad news is that most pundits accept that there is a solution to ensure the solvency of Social Security. The bad news, perhaps, is that there is widespread disagreement on which fix: raising the age of eligibility for benefits, changing the amount that workers pay into Social Security, modifying the formula to index cost of living increases, and so forth. But, there is at least a solution; the only question is, Which elixir has the best taste and fewest side effects? Upon reflection, maybe Social Security is not really a crisis after all.
Medicare, on the other hand, is a looming crisis of tsunamic proportions. Medicare costs are directly correlated with the graying of our population, and we know that the number of Medicare-eligible recipients is going to skyrocket, at the same time that the unit cost of health care is also rising faster than inflation. The result: a recipe for economic disaster that, if unabated, will swamp other components of our national budget. Parenthetically, the growth of Medicaid is doing to state budgets what Medicare will be doing to the federal budget.
Put another way, if, as projected, the number of workers approaches the number of Medicare recipients, and the average age of Medicare recipients rises, the number of workers who will be needed to provide health care and nursing services to seniors will consume a significant fraction of our working population. Currently, nursing home costs for seniors are the most rapidly growing segment of the Medicare dollar. And there is nothing on the horizon that is likely to reduce our nursing home population. Regardless of whether you think Medicare is doing a good job now or not, the demographics are too powerful a force to continue this health care “business as usual.”
So, what, you might ask, is the solution? Raising the age of Medicare eligibility? Rationing? Electronic patient records? Changing the model for delivery of services? How about shipping retirees off to Guam or Fiji where the weather is good and the cost of living low?
Here’s the correct answer: I don’t know. And I suspect no one else does, though I hope someone at the Bloomberg School of Public Health knows but isn’t being heard. I am pretty convinced that we can’t modify our fractionated, stove-pipe medical delivery system enough to solve the problem. It is more likely going to require an integrated approach, combining primary care doctors with all elements required for delivery of services. A necessary step, I believe, in bringing costs for elderly care down and increasing quality would be properly organized delivery networks that encourage primary care physicians to deliver efficient care management.
Now for the really bad news: We can’t do this because nationally we are only training about 200 geriatricians annually. Not only do we have a nursing shortage, but now a doctor shortage as well. Unless Hopkins minds come together to craft an innovative solution, I’m buying suntan lotion and a grass skirt in preparation for retirement in Fiji.
