A Personal Take on the Medicare Debate

Medicare payments to doctors are currently under threat because the two parties in Congress cannot agree on how to avoid an “automatic” cut in payments even though neither side claims to actually want the cuts to go into effect. The deadlock is usually described as a conflict between the interests of poor sick people, represented by Democrats who want to cut funding for the semi-private Medicare Advantage program, and the interests of insurance companies, represented by Republicans who want to cut benefits to Medicare recipients. If the situation were really that simple, I, a low-income, disabled Medicare beneficiary would have no trouble whatsoever deciding which side to be on: I don't want to lose my benefits! In addition, I am a long-time Democrat and am in favor of a government-managed single-payer system of health care. I have lived in France, which has a national health system, and have friends in England and Canada which each have somewhat different single-payer systems. I have seen the advantages of these systems first-hand.

I offer this account of my own experience choosing a Medicare health plan, complete with the boring and confusing details, in order to show that the decision facing Congress regarding Medicare funding is a complex question requiring analysis of the details of costs and benefits to (different groups of) recipients. It is not, as most commentators seem to think, fundamentally an ideological issue involving a choice between public and privatized models of care, or between serving taxpayers or poor people.

Usually, the mental health community has to kick and scream to get governments to do anything to improve the conditions of the mentally ill. So when an official goes out of his way to help without having to be pushed, it merits great praise. Acting Governor of New Jersey Richard Codey has made unannounced visits to mental hospitals throughout his career in public service, and he did not stop when he became Governor. In a recent interview, Codey said one of the most surprising things about being Governor was that his office allows him to fix things so fast: On a visit in the summer of 2005 to Greystone Hospital, housing over 600 patients, Codey found that there was no working air-conditioning on a 100-degree day. Within two weeks of his visit, air conditioning was installed in all of the patient rooms, hallways, and common areas.

Codey's first official act as Governor was to establish the Governor's Task Force on Mental Health, to recommend improvements to the State's mental health system directly to the Governor. Acting on the Task Force's recommendations, Codey signed executive orders that improves access to services, establishes a fund for housing for the mentally ill, and provides student loans to people who are planning careers in the social services. In addition, Codey and his wife are sponsoring a campaign to educate physicians and women about postpartum depression.

In preparation for the first appointment with a new psychiatrist, I wrote a careful, 8-page summary of my medical/psychiatric history, the treatment I had recieved, and the (mostly catastrophic or useless) results of the treatments. At the end, I told him what I wanted from a psychiatrist, and I said what I would do in return. It is common for psychiatrists to make their patients sign a list of "patient responsibilities" when they begin treatment, but I was doing the reverse. I wanted him to guarantee that he would provide competent care. I almost think all mental patients should get together and agree on a contract which they would insist their psychiatrists sign before receiving their first fee. Patients in public care would never get away with this, of course, but if all the private psychiatric patients even in one small town or city insisted on a basic standard of care without which they would not pay for psychiatric treatment, perhaps we could insist on greater respect and more competent treatment.