Academic journal article Washington and Lee Law Review

Medicare and Political Analysis: Omissions, Understandings, and Misunderstandings

Academic journal article Washington and Lee Law Review

Medicare and Political Analysis: Omissions, Understandings, and Misunderstandings

Article excerpt

I. Introduction

The focus of this Article requires some explanation. It is not a recapitulation of the patterns of Medicare's politics from enactment in 1965 to the present (2003). That is the subject of Jonathan Oberlander's other article in this issue. Nor is the main.focus on projections of Medicare's future politics, a daunting topic addressed only briefly here. Instead, the Article aims to make sense of the scholarly literature on the Medicare program and its politics by distinguishing among (and discussing) three categories of commentary:

(1) Program and policy discussion without political analysis: the literature of straightforward omission.

(2) Program and policy discussion with serious political analysis: the literature of commendable commission.

(3) Program and policy evaluation that purports to incorporate political analysis, but fails to do so credibly: the literature of regrettable misunderstanding.

Why focus on the existing Medicare scholarship and, in particular, the quality of political analysis in that literature? Our fundamental premise is that the Medicare program is regularly misunderstood through ignorance of its political history, confusion about its fundamental values, and distortion of the program's choices by unsubstantiated presumptions about what Medicare's purposes were supposed to be. The future of Medicare is certain to be a matter of political concern in the decade ahead. Prudent reform depends crucially on clarifying what the program does and does not do. That, in turn, requires attention to Medicare's central social aims, actual historical experience, and recognizable political identity. Our literature search revealed serious difficulties on all three counts.

Our survey of the Medicare literature illustrates just how often Medicare is misunderstood and how rare cogent analysis of its politics is. If the public debate on Medicare is to be improved in these respects, we need to identify and understand common misconceptions about the program and explain their apparent staying power. That is the aim of this Article.

II. The Literature of Straightforward Omission: Program and Policy Discussion Without Political Analysis

The dominant literature on Medicare is what many call health services research.1 The great majority of researchers working on Medicare understand the program predominantly from the perspective of systematic policy analysis and consequently view public policy largely as collective problem solving. Often trained in economics, they have produced a vast literature on the impact of Medicare payment policies, the structure of its benefit package, and the economic behavior, demographic characteristics, and financial state of Medicare beneficiaries.2 This line of scholarship suggests that if there were more factual understanding of Medicare's circumstances, the quality of problem solving would improve. And this work presumes that public policy can and should be studied as a matter of objective, technical inquiry.

Health services research rests on the assumption that policy is separable from politics. This is, as we will argue, in most respects an unsustainable division. The technocratic perspective has at least three consequences for understanding Medicare politics that we want to highlight. The first is that the politics of Medicare is willfully ignored. Since the two phenomena of policy and politics are presumed to be distinct, the analysis of policy, as a matter of division of labor, need not explicitly attend to political analysis. Medicare policy in this tradition is discussed independently of American political institutions, interests, and ideologies.

The literature on Medicare's reform of its system for paying physicians is an illuminating case in point. In 1989, the federal government replaced the existing method of paying physicians retrospectively for their costs with a prospectively determined fee schedule. The fee schedule-officially the Resource Based Relative Value Scale or RBRVS-was organized around the relative values assigned to all services that physicians provided. …

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