What an interesting premise, albeit somewhat extreme, and fascinating method of presenting one man’s dim view of Medicare.  Written by David Hyman, Adjunct Professor at the Cato Institute—which should automatically tell the reader how he feels about his subject—and Professor of both Law and Medicine at the University of Illinois, Medicare Meets Mephistopheles compares the basic tenets of the Medicare system to the seven deadly sins, avarice, gluttony, envy, sloth, lust, anger and vanity.  Dr. Hyman goes on to describe how Medicare differs, quite significantly, from such American virtues as thrift and truthfulness.

So how does Hyman do this?  For those who are familiar with CS Lewis’s Screwtape Letters, the correspondence between Underling Demon 666 and His Most Exalted Satatnic Majesty, Lucifer, the Prince of Darkness, should seem at the same time comfortable and, like the Screwtape Letters, a bit scary.  The Screwtape Letters was written, not surprisingly, as a series of letters between Screwtape (a kind of middle manager in Hell) and his nephew, still learning the ropes, Wormwood.  Essentially, Screwtape offers Wormwood advice on methods to destabilize faith and promote sin both in general and as it concerns one individual in particular, the Patient (ironic for this book review).  After converting to Christianity early on and eventually going to Heaven after dying in a war, Wormwood is punished severely.

One last bit of background before diving into the relationship between the seven deadly sins and Medicare, just who is Mephistopheles?  It would take page upon page to accurately characterize Mephistopheles; for the purposes of this review, and I believe Hyman’s book, Mephistopheles should be viewed as a devil, one of Satan’s workers.  He is portrayed in countless books, plays, etc. as someone to whom Doctor Faustus sells his soul for power, knowledge and fame.

Given that introduction and given where Hyman works, it should not be surprising to have him, with tongue firmly planted in cheek, compare our current Medicare system as a tool of Satan to destroy the United States, corrupting all who come in contact with it.  Satan accomplishes this by involving all of the seven aforementioned deadly sins.  Like Screwtape, Underling Demon 666 does this by convincing, not with argument, but with propaganda.

Before going on, there are so many fun sayings included in Hyman’s book.  Sayings, quotes, anecdotes that satirically, as Juvenal would no doubt agree with,

  • Reverse-Robin Hood
  • Is a pyramid or Ponzi scheme?
  • If something cannot go on forever, it will stop
  • A great deal of intelligence can be invested in ignorance when the need for illusion is deep.
  • Federal government is simply a giant insurance company with side job as defender of homeland security
  • “Switching” sins mid-stream

Before addressing some of those fun quotes and before jumping into the seven deadly sins of Medicare, it is important to point out the background that Hyman provides the reader at the outset of the book.  He describes the beginnings in the Johnson administration, how it was hoped to be the proverbial foot in the door to universal coverage.  He describes the origins of Medicare Parts A-D and their funding sources (same as provided in class by Dr. Mueller).  And he provides a case for the future (or lack thereof) of Medicare secondary to poor finances by inserting a CMS table from 2003 indicating that in 1970, there were approximately 20 million recipients of Medicare, each of whom had approximately 4.5 workers supporting him or her.  Whereas in 2030, as imprecise as predictions are, it is projected that approximately 78 million US persons will receive Medicare with only 2.4 workers per beneficiary.  So, again, his history and background was a simultaneously enlightening and insightful introduction to the topic.

Without further ado, the seven deadly sins!

Avarice, an “insatiable greed for riches.”  According to Hyman, by constantly trying to get more money from government, providers are guilty of this first deadly sin.  Not only is it their desire to get paid more, they desire to do so based not on what is accomplished, rather, it is his contention that providers are paid even if lower quality care is provided.  This has not been my experience at all.  As a provider with a stake in the business operations, this is not my feeling.  While it has always been my goal to help all who came to me, if I had a choice, I would not choose to accept Medicare (or Medicaid, for that matter).  Not only do they not pay well (will be discussed in the forthcoming Envy section), there are countless hopes providers (and beneficiaries too) must jump through to receive payment and to avoid fraud, intentional or otherwise.  I have heard discussion that many physicians are opting out of Medicare for exactly that reason, fear of prosecution for actions, intentional or otherwise deemed to fraudulent.

Gluttony—the Reverse-Robin Hood. As is the case with all so-called entitlements, once citizens receive them, they do all they can to hold on to them, to never let them go.  Robin Hood robbed from the rich and gave to the poor; the reverse-Robin Hood allows the government (in this case) to steal from the poor for the benefit of the rich.  Example, one of the first beneficiaries of Medicare was President Truman.  Now, honestly, how many former presidents need working Americans (or anyone else, really) to pay for their health care?  Really?  But that’s what happens now, very Bernie Madoff-like.  New workers pay into Medicare for the benefite of older beneficiaries.  OK, maybe that’s not technically a Ponzi scheme, but can someone explain how it’s not a pyramid?

Another example of forcing people to pay for the health care of others.  Consider a single mother with two children.   A not insignificant portion of her payroll taxes (2.4%?) go to Medicare to pay for the care of all sorts of retired people.  Hyperbole, perhaps, but Hyman provides the example of this single working mom in effect paying for the care of retired Miami residents . . . “in all honesty, even the devil is embarrassed by that one.”

For yet another example of gluttony, in large part, beneficiaries were in favor of the new benefits proposed (and passed) in 1988 (Catastrophic Coverage Act), they “just don’t want to pay for them.”  I suppose it is human nature to want something for nothing . . . but that doesn’t make it right.

Hyman believes, and I agree, that Medicare has had the side effect of corrupting one of our basic impulses, the need to grab for more than our fair share.

Envy—people (especially providers) are jealous of the monies paid to others based solely upon where they practice.  The current program creates envy along geographic lines as pay is drastically different based on where a provider works.  Perhaps this is why avarice, as Hyman previously suggested applies to providers, is foreign to me.  Mediare simply does not pay all that well.  It’s not the worst out there, but it is far from the best (definitely closer to the bottom than the top).  I wish I didn’t have to worry about that, but as a business owner, it is foolish not to.

Sloth—This was interesting as Hyman points to both legislators and administrators as those guilty of this deadly sin.  In his view, legislators understand the problems of the system, but instead of addressing the larger, longer term needs and problems, these politicians prefer to tinker with day to day operational details.  They don’t want to upset the proverbial apple cart (see glutton above).  Program administrators, on the other hand, simply have little ability to fix quality and little will to leverage Medicare’s purchasing power lest they become hammered by legislators when attempting to do so.

Lust for program expansion AND political power in, primarily (at first) the democratic party.  In Hyman’s view, polling consistently indicates they (democrats) are more trusted to sustain Medicare than republicans. This insatiable lust for power results in program expansion to appease their electorate, thereby helping to re-elect them during the next election.

Anger, on the other hand, tends to affect primarily members of republican party as Medicare is a “command and control program with serious administrative pathologies and Pacman-type appetite for ever increasing share of federal reveneues;” angry because they can’t do anything about it without being savaged by political opponents.  (They might also be a little angry that they are unable to garner the same power as their democrat opponents.)  On the other hand . . .

Hyman also contends that prescription drug coverage (Medicare Modernization Act) resulted in switching of sins.  This time, republicans were lusting after voters and political power via program expansion and democrats were angry about it (probably that they didn’t think of it . . . though I understand few actually like the prescription drug coverage now).

Vanity . . . I will let you decide this one, Dr. Mueller J  According to Professor Hyman, vanity lies with the health policy analysts; he states that these analysts understand the problems but, with few exceptions, “hail the virtues of the program and excuse its dysfunction, reasoning that a program with rotten benefit package, mediocre quality and unsustainable financial commitments is better than no program at all.”  I have actually heard that argument, not from you, but from multiple media pundits.

I was so impressed with this book because it made me not only think, it made me want to research this a little more.  In doing additional research, I learned, from Ted Marmor that Medicare indeed was originally seen as precursor to universal coverage.  It is ironic, then, that per Hyman’s thesis (see gluttony), “those with Medicare don’t want to lose what they have, they prefer a world where they have coverage, but not everybody does.”  Interesting.

In doing this additional research, Hyman, in a different venue, cites the quote from Saul Bellow, “A great deal of intelligence can be invested in ignorance when the need for illusion is deep.” And Stein’s Law, “If something cannot go on forever, it will stop.”  Paul Krugman, no champion of Libertarian policies, used this as the topic of one of his blog postings earlier this year (but I don’t think he was thinking of it this wayJ).  Hyman’s position is that Medicare simply can’t go on forever in its current iteration . . . only question is how and when.

So, how do we address the basic human need to be sure that something will be there for us when we need it . . . when we are critically ill?  I don’t have the answer for that, and I’m not sure Professor Hyman does either.  The answer is not to “take away” Medicare (that just won’t happen), but can it truly be exorcised?  That is a good question that I cannot answer.  Professor Hyman, by way of Underling Demon 666 does describe a threat of exorcism.  Being the philosophical persuasion he is, one of his “cures” (or fears of Underling) is “Demand-side Conservatism;” in other words, an “ownership society.”  I read a snippet from Ezra Klein that describes this view as uncaring and mean (stating we—meaning both sides of the political spectrum—both accurately diagnose the illness, but want different treatments; the conservative side is actually “mean”).

As I said previously, I thoroughly enjoyed Medicare Meets Mephistopheles and would strongly recommend it if not as required reading, as a suggested book that accompanies your Medicare lecture.  It was fun, informative and not just Libertarian in nature (though that certainly was a plus!).

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