Medicare and Medicaid at 50 and Beyond

When did M and M design change from support for health access to against health access and why?

Government and Foundations are currently celebrating the accomplishments of Medicare at Age 50 - but which Medicare? Claims of improving the cost of care are merely cover-ups of cost cutting designs - cuts that shrink care. The consistency of Medicare and Medicaid design is best seen from 1980 to 2020 - and not the initial years. The initial years were focused upon rebuilding the US health care system with emphasis on restoring access to populations left behind for decades before (and decades since 1980). As it turns out this was also a good idea for rural health and for care across zip codes and counties with higher concentrations of poor and elderly and increased support for health care where health care was less - by design or lack thereof.

What we have seen in recent years is a continuation of the process begun in the 1980s. Cost cutting, accelerated cost of delivery, increased administrative costs, and other changes that close small practices and small hospitals are not improvements of Medicare or Medicaid - they represent the opposite. The initial design of M and M from1965 to 1980 built up these vehicles of health access and supported the generalists and general specialties and teams to deliver the needed care. M and M design 1980 to 2020 has clearly had the opposite effect on health access. M and M once focused on those left behind. Via DRGs, RUC, SGR, and ACA it institutes payment policies that discriminate against those providing care where needed.

Health access progress is most easily assessed by changes in permanent broadest generalists - Family Medicine. Neglect of health access almost eliminated family medicine across the 1950s and the 1960s. Finally the late 1960s created traction to recovery. FM was returned to formal training in 1970 and rapidly expanded to 3000 annual graduates - graduates most specific to health access. Since 1980, family medicine has remained at 3000 annual graduates - more evidence that the Medicare designs before and after 1980 were quite different.

Talk about improving population health is quite ironic when designers and promoters actually have little awareness of the populations that they should be serving - and supporting with health care payments. When you track the changes in Medicare and Medicaid payments, the payments are sent to locations with top concentrations of health care workforces and away from concentrations of Medicare and Medicaid patients. About 42 - 45% of M and M patients are found in counties with 40% of the US population - 2621 rapidly growing counties with lowest concentrations of clinicians.

When you understand the demographics and distributions of payment, then you understand the magnitude of design failure. These 2621 counties are growing faster and their health care workforce is not growing. In fact their generalists and general surgical specialties that are over 75% of their workforce are shrinking - the impact of the designs of training and the designs of payment. These 2621 counties chock full of Medicare and Medicaid patients are growing faster or fastest in population, in elderly, in poor, in health care demand, in complex patients, in less healthy patients, and in low resource situations.

Closures of hospitals will increase this gap as even lower concentrations of clinicians will be the result. Closures of hospitals and practices on the front lines of care where needed are by design - by intention or by neglect. Lesser payment for primary care and for basic hospital and physician services plus "innovative" new costs and new penalties results in additional deterioration. This deteriorations also result in steady declines in the social determinants and situations that shape health outcomes and population health. As these counties lose dollars and lose support for facilities and workforce, they also lose people who help organize and lead local health care.

With reflective examination, the proper term that should be used instead of "improving the cost of care" is the term cost cutting. In recent decades we have become very good and naming programs in ways that reflect just the opposite of what they should do (No Child Left Behind when so many millions are left behind, Pay for Performance, Meaningful Use, etc.). Indiscriminate cuts have the most consequences on those most left behind. The national and global focus has distracted us from a focus the local battles for health access and for care where needed.

The contrast before and after 1980 could hardly be greater. People who understood care delivery needs designed and built Medicare and Medicaid. People who do not understand what matters have ruled Medicare and Medicaid since that time. They fail to understand health care delivery, care where needed, poor populations, elderly populations, and health care for the poor and the elderly. For a brief period of time we invested in health care delivery and care where needed. Now we attempt to get by with as little cost as possible - which translates to as little care as possible, particularly for those remaining behind from 1950 to 2020 and beyond.


From my last post - At a recent panel discussion to discuss the great benefits of ACA:

"We need to be sure that the delivery system provides enough capacity in primary care, especially in rural and targeted urban areas," said Slavitt (acting administrator for CMS).  

This appears to be good awareness, unfortunately CMS has done much to destroy capacity in primary care, specifically to the rural and targeted urban areas of need. 

Learned panelists continue to make the mistake that access is about insurance - when access is really about available and accessible workforce. Payment too low for decades has shaped poor access, and payment too low continues by design along with higher cost of delivery.

Recent Works

Starting to Solve Societal Inequities - Support for a SMART Start from the Very Beginning of Life

Best Beginnings for Health Access Clinicians - Shared Origins and Optimal Health Access Focus During Trainings

Family Medicine Needs a New Beginning - Current Preparation, Admission, and Medical School Plus Health Policy Interact To Prevent Family Medicine Choice - and Health Access Result

Too Many and the Wrong Clinicians for graphic - Additional consequences result from designs not specific to primary care or care where needed.   

And the Next Victims of Cost Cutting: Dual Eligibles - Those Most Vulnerable and Least Able to Defend Themselves Are Next

ALS Disease Focus Is Not a Top Priority - Have fun, but Minor Incidence Diseases Are Below the Major Diseases, and Far Below Health Care Caused Disease, and Causes of Early Death, and the top 10 priorities for most Americans - and America as a Nation  

Hotspotting Has Many Spots To Consider - Simple Interpretations Are Inaccurate, Many Different Characteristics Shape the Outcomes, Not Just Geographic Location

Retail Clinic Recoil - Many Side Effects Can Be Anticipated, And More to Come

Global Fails Local But Local Focus Succeeds Globally

What Veterans Need Is Family Practice - No Other Type of Clinician Comes Close to the Location or the Scope

Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand

Health Care Delivery Is No Laughing Matter - Political Cartoons are Nice, but...

Blogs indicate that primary care can be recovered and should be recovered.

Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and the long term chair of the STFM Group on Rural Health.


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