Medicare and Medicaid, two bureaucratic babies of the Great Society, have just celebrated their 25th birthdays -- but the party is bittersweet. The guests -- the elderly and the poor who are eligible for benefits -- are complaining that there's not enough cake and ice cream to go around. Those throwing the party -- government officials and taxpayers -- are complaining that the balloons cost too much. And the party entertainers -- doctors, hospitals -- are complaining that everybody is whining about their performance.
It's fashionable to talk about the crisis in health care. More than 30 million Americans have no health coverage at all. People are afraid that if they get sick -- really sick, with multiple sclerosis or schizophrenia, for example -- they won't be able to pay the escalating costs of the care they need.
Medicare, the federal program for the elderly and disabled, is criticized for costing too much and covering too little -- leaving many Americans without services for chronic illnesses. Another target is Medicaid, the beleaguered federal-state program for the poor that actually covers fewer than half of those living below the poverty line.
But the federal health care czar who presides over both programs bristles at such criticism.
"I think both programs have been successes," said Gail R. Wilensky, administrator of the Health Care Financing Administration. "Medicaid was never intended to be a program to cover all the poor. To judge Medicaid as accomplishing a goal that was clearly not its own is patently unfair."
In fact, Medicaid was aimed from the beginning at a certain kind of poor -- those in welfare programs such as Aid for Families with Dependent Children.
Similarly, as Wilensky notes, Medicare was originally set up to cover acute but not chronic care -- the heart attack patient in the hospital, for example, not the stroke patient in a nursing home.
Both programs have outgrown their origins. But how to correct their shortcomings raises crucial political issues.
The first is the question of fairness: Is medical care -- which often is contingent on public or private health insurance -- a basic right for all Americans? This year's budget has already expanded Medicaid to cover more poor children and has accelerated demands to further broaden public and private coverage to the uninsured and working poor.
The second issue is cost, as medical spending escalates at more than twice the general rate of inflation. The fiscal innocence of 1965 is gone. New government health programs aren't free, as economists warn lawmakers, and Medicare is a perfect example. "It's hardly been a showcase for cost containment," said Wilensky. "It illustrates to those who would have government do it all that government financing does not equate with cost-control pressures."
The third issue is how long-term nursing home care should be covered. Resolving this is much harder than addressing the problems of the poor and uninsured and requires "more soul-searching and more dollars," Wilensky said.
What's at stake are fundamental issues about how important health care is to society -- and whose responsibility it is to pay for it.
"We as a population have changed. Our needs have changed. Our values have changed. Our political philosophy may -- or may not -- have changed. We have to reexamine all these issues."
The question is when. Even in times of peace, the date for putting health care reform on the political front burner has slipped. The government's study of the uninsured, originally due last December, won't be ready until April.
"I'm less hopeful that 1991 will be the year," Wilensky said.
Now, in the shadow of war, everything on the domestic agenda has been put on hold. The "peace dividend" -- anticipated by many Americans with the ending of the Cold War -- has gone the way of the unicorn. "It's too unsettled right now -- the economy, the Middle East," said Wilensky. "These are difficult times for everybody."