An Unhealthy System

...It also "does nothing to encourage proactive attention to progressive impairments" by assigning social workers to check homes for hazards that could lead to falls, or by fostering good hygiene and physical activity to reduce the risk of pneumonia...

...In their own self-interest, employers like GM ought to get on the single-payer bandwagon...

...The one bright spot in recent reforms is the Program of All-inclusive Care for the Elderly (PACE), funded by Medicare and Medicaid as a permanent program since 1997...

...Reviewed by Sanford Lakoff Professor emeritus of political science, University of California, San Diego...

...Thus they tend to treat complaints in isolation without considering complex factors that can turn a therapy for one problem into the cause of others, sometimes prescribing remedies appropriate for younger patients but not the aged...

...High doses of anti-inflammatory medications, for example, need careful monitoring to avoid effects like internal bleeding, renal failure, or heart problems—not ordinary concerns in younger patients...

...Medicare administers one of the most efficient [government-run] payment systems for health insurance in the world," Cassel says, "and may be reasonably viewed as a model for a universal system...

...That, she shows, is one of the chief defects of modem health care...

...Rather, "the fee-for-service arrangement provides treatment only when the patient gets sick or injured and arrives at the clinic or emergency room...

...In 1935 Harry Hopkins, then head of the Works Progress Administration, spoke for those who wanted more: "With one bold stroke we could carry the American people with us, not only for unemployment insurance, but for sickness and health insurance...

...Indeed, corporate executives, politicians and the rest of us would do well to pay attention to the findings and recommendations of Cassel's excellent study and finish the job the New Deal started...

...Although the United States remains the only advanced industrial nation without universal health insurance, Medicare today covers 40 million mostly elderly beneficiaries—a figure that is bound to rise...

...Health care for the elderly—and everyone else—further suffers because the U.S...

...by 2030 their number is expected to reach 20 per cent...

...Adding to the elderly's problems is the madcap conservative push to save money and promote self-reliance by leaving it to individuals to obtain the information they need to decide on the best choices among various medical providers and prescription options...

...An Institute of Medicine study found that 46 per cent of Americans are "functionally illiterate with respect to health care...

...enrollment dropped from a 1999 peak of 17 per cent of those eligible to 10 per cent in 2004...

...Even the most sophisticated are hardly likely to have the ability to investigate every possible alternative...

...Improved care for the elderly therefore entails medical education reform so that more primary care doctors receive geriatric training...

...Though the elderly require coordinated care, traditional Medicare pays for "episodic treatments and not comprehensive management...

...What has emerged instead, as Christine K. Cassel demonstrates in her new book, is a mostly private hodgepodge vexed by fragmentation, the profit motive, disregard or ignorance of patients' needs, and a misplaced emphasis on self-reliance...

...A staggering 88 per cent of Medicare patients live with one chronic condition— like diabetes—or more, and coordinated management can drastically reduce complications and hospitalization...

...Cassel praises PACE for helping patients maintain greater control over their care and enabling them to remain in their communities for as long as possible...

...Nevertheless, as she points out at length, it has serious flaws that are being ignored in the George W. Bush Administration's efforts to "fix Medicare" by cutting reimbursement rates (driving more providers to refuse Medicare patients) and subsidies to medical education...

...The addition of Medicare and Medicaid in 1965 went some way toward correcting a deficiency champions of the welfare state accepted 30 years earlier to gain minimal guarantees of income security...

...With many diseases, of course, it is impossible to predict death within six months...

...Unlike health plans for the elderly in other countries, too, Medicare offers only restricted long-term care...

...author, "Democracy: History, Theory, Practice" The Social Security Act, along with unemployment insurance, formed the "safety net" that has proven the most politically unassailable legacy of the New Deal...

...Medicaid underwrites care for another 40 million who qualify as living in poverty (a category that includes 6.5 million elderly citizens without the resources to pay for longterm care and other services Medicare does not cover...

...medical schools have departments of geriatrics, and only a few thousand board-certified geriatricians are now practicing...

...With over 40 million lacking any coverage, and everyone else facing cutbacks in coverage and rising premiums and copayments, surely the time has come for fundamental change...

...Medicare does cover hospice costs (either in a facility or at home) if a physician certifies that a patient has six months or less to live, and the patient agrees to receive only palliative care...

...Apart FROM reforming Medicare, the larger question raised by studies like Medicare Matters is whether it makes sense to perpetuate a wasteful and inefficient health insurance patchwork relying mainly on tax-subsidized, employer-funded coverage, supplemented by Medicare and Medicaid...

...It promises to be "both expensive and ineffective," because it does not curb the pharmaceutical industry's exorbitant marketing expenditures or assure lower-income patients affordable medications...

...Yet while spending on drugs is increasing two to five times faster than spending on hospitalization or physician services, the new drug benefit law bars Medicare administrators from using the system's potential market power to negotiate price discounts...

...In 2003, 8,000 physicians fed up with increasing corporate control of health care endorsed single-payer universal health insurance...

...The President's most flaunted initiative, the perplexing "Part D" prescription drug benefit, gives little if any real help to the neediest...

...The original legislation and recent piecemeal efforts to amend it have focused on financing and the details of insurance coverage, not the human beings involved...

...Under the 2002 Health Insurance Portability and Accountability Act, all providers who bill Medicare or Medicaid must do so electronically, but since it does not stipulate a single format, medical records are not always transferable from one provider to another...

...The specialty emerged in the early 20th century yet has still not been widely adopted in medical curricula: A mere three U.S...

...In 2000,12.7 per cent of Americans were over 65...

...The prudent who can afford it buy long-term care insurance...

...system's fragmentation inhibits adoption of universally accessible electronic record keeping...

...Designedto keep older adults out of nursing homes, it allows for day care and multidisciplinary teams of physicians, nurses, social workers, and physical therapists...

...But its reach is limited: There are now 25 sites in the U.S., each covering about 200 people whose average age is 80...

...Managed care plans, initiated in 1997 to boost the preventive and coordinated approach, accept responsibility for beneficiaries' care in exchange for a fixed monthly payment from Medicare...

...Rising drug costs pose an acute problem for all patients, but especially the elderly...

...IN fact, Medicare's obsolete approach to treating the elderly is one of its major weaknesses...

...Its incentives encourage the overuse of expensive technology to handle discrete conditions...

...But these insurers frequently contrive to avoid accepting the sickest applicants...

...the rest are forced into the lowcost warehouse facilities that accept what Medicaid pays...

...Cassel's diagnosis of Medicare draws on her 25 years of practicing geriatric medicine...

...Physicians are often unprepared to deal with the age-specific vulnerabilities of the elderly (including weakened immune systems and musculoskeletal disorders, such as arthritis and osteoporosis...

...General Motors, complaining that it must spend as much as $ 1,500 a car more for health care than its foreign competitors, has compelled its employees to accept scaled-back coverage...

...She laments, however, that "no one on the financing end is making .. [PACE] worth replicating on a larger scale...