- Email: [email protected]
washington Medicare reform hangs in the balance
WASHINGTON
Medicare reform hangs in the balance
T
he bipartisan commission created by Congress in 1997 to chart a way to solvency for Medicare disbanded in disagreement on March 16, thus assuring continuation of the political conflict over the financially-threatened health-care programme for the elderly and disabled. As the elderly insist on the preservation, and even the expansion of their benefits, there are clear political advantages in championing the Medicare cause. The problem is that Medicare is going broke. To save Medicare, ten of the 17 commission members favoured a transition to a competitive healthcare market for the elderly, inevitably raising concerns about a bonanza for the insurance industry and commercial exploitation of those in need of medical care. Under the commission’s draft proposal to bring in competition, with its presumed cost savings, Medicare would provide its beneficiaries with money to buy services from health-maintenance organisations or from fee-forservice providers, in place of the present system of setting prices and reimbursing for care. The vote for the proposal, which would have been purely advisory, fell one vote short of the required number for a formal recommendation. Even so, President Clinton denounced the proposal, and called for the introduction of broad insurance coverage for prescription drugs. But the commission, appointed by the President and leaders of Congress, then went MALAYASIA
out of business. Medicare provides funds for the health care of about 39 million people, but the actual number of benefits provided is quite low, lacking, for example, reimbursement for drug prescriptions, and requiring supplementary insurance payments for physician services and other assistance. Forecasts of growth in the population eligible for Medicare, which now accounts for about 25% of all US health-care spending, indicates that Medicare will overrun its income early in the new millennium, just as large numbers of baby
“The preservation of Medicare . . . is enshrined in politics” boomers reach 65 years of age, the current age of eligibility. Despite its deficiencies, Medicare has taken much of the financial worry out of health care in old age. And support extends to the children of its elderly beneficiaries to help them with the health-care costs and problems posed by aged parents. 2 years after the Republican Congressional triumph in the 1994 election, Clinton achieved a great comeback with allegations of Republican plans to reduce Medicare benefits. The preservation of Medicare, at no additional expense or reduction of benefits for the elderly, is enshrined in politics. In 1987, Congress passed a Medicare amendment to provide
generous catastrophic-care coverage—insurance cover for serious illnesses—at no cost for the very poor and modest additional cost for the better-off elderly. The measure soon after became a cause célèbre when it was depicted as a surcharge on benefits that already belonged to retired people. In a hurried bow to the popularity of Medicare, Congress repealed the measure. Popularity does not extend, however, to the few feasible remedies for keeping Medicare financially afloat. These solutions call for: higher taxes; larger cost-sharing by recipients; reducing expenditures by encouraging or forcing beneficiaries into managed care, rather than the fee-for-service system that now prevails; gradually raising the age of eligibility from 65 to 67; and continuing the cost-paring tactics of recent years, with further reductions in payments to health-care providers. Clinton has proposed setting aside some of the surpluses now accumulating in federal revenues for Medicare, whereas the Republicans are less clear about using the surpluses for such a purpose. As the year 2000 presidential campaign looms chances for bipartisan Medicare reform have disappeared. The fundamental problem is the absence of a coherent health-care system for the population and Medicare is just part of a problem that eludes political solution. Daniel S Greenberg
Japanese encephalitis outbreak leads to military intervention
M
alaysian soldiers began a slaughter of more than 3 0 0 000 pigs on March 20 in an attempt to halt a Japanese encephalitis outbreak that has reportedly killed 53 people. About 1400 troops wearing surgical masks, hoods, and gloves entered three vil lages in the Negri Sembilan state, 100 km south of Kuala Lumpur, where they will kill about 35 000 pigs, every day, for 10 days. Since the outbreak started in October 1998, Negri Sembilan has been the worst affected region with 33 deaths. Almost all of the cases involved pig-farm workers. Local villagers have fled the area to escape the virus, which is passed from infected pigs to humans by Culex mosquitoes. To try to sup -
THE LANCET • Vol 353 • March 27, 1999
press the population of mosquito carriers, the government has dis patched helicopters to spray the affected areas with insecticide. It has also launched a Japanese encephalitis vaccination initiative for 500 000 pigs and 300 000 people living close to or on pig farms. It remains unclear, however, whether Japanese encephalitis is behind all the fatalities. Experts from the US Centers for Disease Control and Prevention, which has been called in to help, said the pathogen has not been properly identified. Of the 98 recently diag nosed cases of encephalitis, 12 have been identified as the variant Hendra virus. Although these viruses cannot be contracted by eating meat, pork sales are down by
up to 70%, threatening to devastate Malaysia’s UK£ 50 million per year pig industry. The outbreak has also stirred up ethnic tensions because the Chinese minority, which includes most of the pig farmers, has accused the government, which is led by the Muslim prime minis ter, Mahathir Mohamed, of being slow to act. Most Malays are Muslim and consider pigs unclean. Meanwhile, neighbouring countries have closed their borders to pigs from Malaysia, but one suspected Japanese encephalitis fatality was reported in Singapore on March 20. The dead man worked in a slaugh terhouse that imported pigs from Malaysia. Jonathan Watts
1075
Medicare reform hangs in the balance
T
he bipartisan commission created by Congress in 1997 to chart a way to solvency for Medicare disbanded in disagreement on March 16, thus assuring continuation of the political conflict over the financially-threatened health-care programme for the elderly and disabled. As the elderly insist on the preservation, and even the expansion of their benefits, there are clear political advantages in championing the Medicare cause. The problem is that Medicare is going broke. To save Medicare, ten of the 17 commission members favoured a transition to a competitive healthcare market for the elderly, inevitably raising concerns about a bonanza for the insurance industry and commercial exploitation of those in need of medical care. Under the commission’s draft proposal to bring in competition, with its presumed cost savings, Medicare would provide its beneficiaries with money to buy services from health-maintenance organisations or from fee-forservice providers, in place of the present system of setting prices and reimbursing for care. The vote for the proposal, which would have been purely advisory, fell one vote short of the required number for a formal recommendation. Even so, President Clinton denounced the proposal, and called for the introduction of broad insurance coverage for prescription drugs. But the commission, appointed by the President and leaders of Congress, then went MALAYASIA
out of business. Medicare provides funds for the health care of about 39 million people, but the actual number of benefits provided is quite low, lacking, for example, reimbursement for drug prescriptions, and requiring supplementary insurance payments for physician services and other assistance. Forecasts of growth in the population eligible for Medicare, which now accounts for about 25% of all US health-care spending, indicates that Medicare will overrun its income early in the new millennium, just as large numbers of baby
“The preservation of Medicare . . . is enshrined in politics” boomers reach 65 years of age, the current age of eligibility. Despite its deficiencies, Medicare has taken much of the financial worry out of health care in old age. And support extends to the children of its elderly beneficiaries to help them with the health-care costs and problems posed by aged parents. 2 years after the Republican Congressional triumph in the 1994 election, Clinton achieved a great comeback with allegations of Republican plans to reduce Medicare benefits. The preservation of Medicare, at no additional expense or reduction of benefits for the elderly, is enshrined in politics. In 1987, Congress passed a Medicare amendment to provide
generous catastrophic-care coverage—insurance cover for serious illnesses—at no cost for the very poor and modest additional cost for the better-off elderly. The measure soon after became a cause célèbre when it was depicted as a surcharge on benefits that already belonged to retired people. In a hurried bow to the popularity of Medicare, Congress repealed the measure. Popularity does not extend, however, to the few feasible remedies for keeping Medicare financially afloat. These solutions call for: higher taxes; larger cost-sharing by recipients; reducing expenditures by encouraging or forcing beneficiaries into managed care, rather than the fee-for-service system that now prevails; gradually raising the age of eligibility from 65 to 67; and continuing the cost-paring tactics of recent years, with further reductions in payments to health-care providers. Clinton has proposed setting aside some of the surpluses now accumulating in federal revenues for Medicare, whereas the Republicans are less clear about using the surpluses for such a purpose. As the year 2000 presidential campaign looms chances for bipartisan Medicare reform have disappeared. The fundamental problem is the absence of a coherent health-care system for the population and Medicare is just part of a problem that eludes political solution. Daniel S Greenberg
Japanese encephalitis outbreak leads to military intervention
M
alaysian soldiers began a slaughter of more than 3 0 0 000 pigs on March 20 in an attempt to halt a Japanese encephalitis outbreak that has reportedly killed 53 people. About 1400 troops wearing surgical masks, hoods, and gloves entered three vil lages in the Negri Sembilan state, 100 km south of Kuala Lumpur, where they will kill about 35 000 pigs, every day, for 10 days. Since the outbreak started in October 1998, Negri Sembilan has been the worst affected region with 33 deaths. Almost all of the cases involved pig-farm workers. Local villagers have fled the area to escape the virus, which is passed from infected pigs to humans by Culex mosquitoes. To try to sup -
THE LANCET • Vol 353 • March 27, 1999
press the population of mosquito carriers, the government has dis patched helicopters to spray the affected areas with insecticide. It has also launched a Japanese encephalitis vaccination initiative for 500 000 pigs and 300 000 people living close to or on pig farms. It remains unclear, however, whether Japanese encephalitis is behind all the fatalities. Experts from the US Centers for Disease Control and Prevention, which has been called in to help, said the pathogen has not been properly identified. Of the 98 recently diag nosed cases of encephalitis, 12 have been identified as the variant Hendra virus. Although these viruses cannot be contracted by eating meat, pork sales are down by
up to 70%, threatening to devastate Malaysia’s UK£ 50 million per year pig industry. The outbreak has also stirred up ethnic tensions because the Chinese minority, which includes most of the pig farmers, has accused the government, which is led by the Muslim prime minis ter, Mahathir Mohamed, of being slow to act. Most Malays are Muslim and consider pigs unclean. Meanwhile, neighbouring countries have closed their borders to pigs from Malaysia, but one suspected Japanese encephalitis fatality was reported in Singapore on March 20. The dead man worked in a slaugh terhouse that imported pigs from Malaysia. Jonathan Watts
1075