Book Review

Medicare Meets Mephistopheles

N Engl J Med 2007; 356:314-315January 18, 2007

Article

Medicare Meets Mephistopheles
By David A. Hyman. 138 pp., illustrated. Washington, DC, Cato Institute, 2006. $14.95 (cloth); $9.95 (paper). ISBN: 978-1-930865-90-7 (cloth); 978-1-930865-92-1 (paper).

Toward the end of Goethe's Faust (Part 1), Mephistopheles rejects Faust's demand that the devil rescue Gretchen, saying, “Who was it that plunged her into ruin? I or you?” In a provocative and penetrating satire, Medicare Meets Mephistopheles, David Hyman trenchantly argues that Medicare was flawed from its inception in a devilish plot to “corrupt the American Republic” and plunge the country into ruin.

Though bathed in satire, the issues Hyman raises are serious and command our attention. He challenges Medicare's proponents to consider whether the structural flaws that he so gleefully exposes are, dare I say it, beyond redemption. In that sense, the book should be subtitled “The Devil Is NOT in the Details — It's in the Design.”

Readers looking for an evenhanded assessment of Medicare's strengths and weaknesses will not find it in this polemic. Instead, Hyman raises legitimate problems with Medicare and offers a cursory description of proposed policy alternatives that consist largely of current market-based strategies. The book's strength is its concise and insightful depiction of Medicare's structural and political deficiencies.

After an incisive explanation of the Medicare program, Hyman sets forth his vision of Medicare as a diabolically inspired program that should be terminated. Using the seven deadly sins as his framework, Hyman begins his analysis with avarice, in particular the “staggering amounts of money” spent on Medicare. Closely related is the sin of gluttony, the medical largesse available to beneficiaries, paid for by future beneficiaries. Next comes envy of the elderly by the younger members of the population, a phenomenon that Hyman admits has not been a problem.

Sloth is crucial to the devil's success because it effectively paralyzes legislators and administrators who, Hyman maintains, reinforce one another's tendencies to ignore Medicare's serious financial crisis and spotty quality of care. In Hyman's telling, lust is found in legislators' desire to expand the program to achieve greater bureaucratic and political power. From there, Hyman moves to the politics of anger, noting that Democrats become angry when changes to Medicare are suggested, while Republicans are angry that Medicare even exists. Hyman saves the devil's favorite sin, vanity, for a broadside attack against health policy analysts for defending Medicare.

At the core of Hyman's polemic is the idea that Medicare offers “a rotten benefit package and mediocre health care.” Medicare, he writes, is “a pyramid scheme structured on an intergenerational basis.” Even worse, the program undermines the American virtues of thrift and truthfulness.

Hyman is surely correct that current financial trends in Medicare funding are unsustainable and will eventually erode public support. But in focusing on Medicare's inadequacies and mocking the system as an intergenerational scam (my word, not his), Hyman overlooks the reason why Medicare was enacted in the first place and why it retains considerable public support. At its inception, Medicare addressed the palpable medical needs of the elderly and the failure of the private insurance market to meet those needs. The program reflected a set of values and social commitments that included universalism, government responsibility for social welfare, and public accountability.

More important, Hyman ignores the reality that many of Medicare's flaws are at least rivaled, and perhaps exceeded, in the private sector. It is doubtful that the private sector would match Medicare's considerable strengths in providing access to health care that was unavailable before the program was introduced. Whatever its failures, there is evidence that the program has clearly improved the lives of its intended beneficiaries. As J. Lubitz and colleagues wrote in Health Affairs (“Three Decades of Health Care Use by the Elderly, 1965–1998”) in 2001, “Our findings are consistent with the idea that Medicare-funded services have improved the health of the elderly.” Is there any legitimate nonideological reason to believe that consumer-driven health care will better serve the elderly than Medicare? I am dubious.

Still, Hyman's bracing critique reflects the fact that neither Medicare's problems nor the ascendancy of market-based approaches to solving them can be ignored any longer. In an era of rampant individualism, the attempt to defend Medicare's collective ethos has the aura of a reactionary battle waged to save an old order in the midst of its last throes. Those who support the social obligations underlying Medicare must demonstrate anew why market-based solutions are unappealing and why governmental investment in health care is morally justified.

Anyone interested in provocative (not to mention satanic) commentary will devour Hyman's monograph. Although his gratuitous insults to Medicare's defenders grow tiresome, Hyman has a lively and engaging style that he uses to raise perceptive and important questions about health policy. If we ignore his admonitions, it won't much matter who plunged Medicare into ruin.

Peter D. Jacobson, J.D., M.P.H.
University of Michigan School of Public Health, Ann Arbor, MI 48109
pdj@umich.edu

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   K. Weinger, A. M. Jacobson, G. Musen, I. K. Lyoo, C. M. Ryan, P. F. Renshaw. (2008) Integrity of cerebral white matter in type 1 diabetes. Reply to Wessels AM [letter]. Diabetologia 51:8, 1556-1557
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   Titia M Vriesendorp, J Hans DeVries, Joost BL Hoekstra. (2008) Hypoglycemia and strict glycemic control in critically ill patients. Current Opinion in Critical Care 14:4, 397-402
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