A Times Editorial

Revising Medicare reform

Adding drug coverage and tightening rules on insurers are among the changes needed to make managed care work.

© St. Petersburg Times, published June 24, 2000

Medicare reform has revolved around two concepts this election year -- expanding the role of private health insurers and adding coverage for prescription drugs. But the problem with that approach became evident with the recent announcement that the Cigna Corp. would leave the Medicare market. Other health maintenance organizations will follow unless Congress confronts the problems of patient poaching, inadequate reimbursements and the rising cost of prescription drugs.

Cigna's departure puts 104,000 Medicare beneficiaries in 11 states, including 7,500 people in the Tampa Bay area, on the hook to find new doctors or insurance come Jan. 1. More insurers likely will follow suit by July, the deadline for HMOs to notify the government whether they will operate next year.

The debacle is partly the government's fault, having allowed millions of Americans to rush into HMOs without adequate regulatory controls to effect an orderly transition. Now up to 1-million seniors, many who are the sickest in Medicare, face difficult and confusing choices just as Congress considers whether to overhaul the program.

For managed care to work, consumers must have the confidence that choice exists and that insurers will not disrupt access to care to fatten the company's profits. Adding a drug benefit to Medicare clearly would help, for many abandoned by the HMOs were drawn to coverage for drugs not available in the government's traditional program. Making drug coverage universal would level the playing field as competition grows and may drive down the price of some prescriptions.

But drug coverage is only a part of overall reform. The government needs tighter rules on the insurers' enrollment practices, not only to prevent patient dumping but to ensure the sickest have options other than traditional Medicare. Elderly beneficiaries also need the stability of a health care plan that doesn't change dramatically or spiral in price from one year to the next.

Reimbursements under Medicare also lag three times behind the annual increase in costs for medical services. Such paltry rates don't serve Medicare if doctors and insurers end their participation, healthier seniors leave and private coverage becomes a wedge issue that divides Americans in a class debate on the worth of Medicare as an entitlement. Congress also needs a better understanding of why the use and costs of prescription drugs, which have enabled millions to lead more fulfilling lives while reducing the need for costly hospitalization, continues to rise so dramatically. Merely throwing money at the turmoil is not reform.

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