Bush Administration Plays Politics with Obesity

By Theodore R. Marmor

Originally published in Newsday, August 17, 2004

Extending Medicare insurance coverage for obesity is just the latest of efforts by the Bush administration to shift attention away from its domestic disaster, the so- called Medicare Modernization Act of 2003.

Obesity is a big health problem in the United States - and growing elsewhere. But it is neither a priority for Medicare reform nor an appropriate preoccupation for medical care. Medicare's older and disabled clients have many more pressing insurance needs than financing for obesity interventions.

And doctors have no monopoly in any case for dealing with obesity, a problem most significant in younger populations and hard to address with the tool kit of modern medicine. A bicycle in every garage might be a much better slogan for obesity prevention than after-the-fact gastric bypasses.

In any case, medical problems associated with obesity already are covered by Medicare. So why the concern to give Medicare beneficiaries this "benefit" now?

The simplest - and most convincing - answer is that the Bush administration wants to change the way Medicare is now discussed. As it is, what was orginally touted as the great reform project of 2003 - adding prescription drug coverage to Medicare - became in 2004 a political disaster. Both The Washington Post and The New York Times editors have apologized for naively treating the Bush administration's war policy in Iraq. And recently The Times extended this apology to its overly optimistic endorsement of the Medicare reform effort.

In fact, President George W. Bush's Medicare reform was an exercise in legislative chicanery and rhetorical misrepresentation of its purposes. While including a modest, convoluted drug benefit, the bill's main purpose was to try to transform Medicare. It was, and is, a stealth attack on the program's fundamental character.

As it turned out, neither the press nor the public has remained naive. The press discovered apparent bribes in the legislative process. They also exposed the story of how the then-head of Medicare, Tom Scully, allegedly threatened to fire the program's actuary if he sent Congress his cost estimates.

Attention has shifted to three topics: investigations of misleading fiscal estimates, reports that elderly majorities are critical of the law, and evidence that the nation's drug firms had a lot to do with the provision preventing Medicare from using its market power to bargain with pharmaceutical firms on price. As every student of the industry knows, the United States is the only industrial democracy in the world to regulate drugs without using governmental legal or purchasing power to moderate prices.

The connection to the obesity issue is simple, but indirect. No one reading a newspaper or magazine in the last year could miss the attention to how fat Americans have become and how dangerous that is to their health. Obesity, in short, has become an obvious public health concern. Alas, unlike tuberculosis or hypertension, medicine has few obvious ways to prevent or to treat obesity effectively. Medicare's financing obesity treatment has less to do with public health than public relations.

The administration presumably believes that obesity coverage will cause us to forget that the real purpose of last year's "reform" was to lure Medicare beneficiaries out of the traditional program with generous subsidies. Reformers like Scully are, at least now, candid about this. In a recent speech, Scully emphasized that these subsidies were designed to induce exit to private health insurance plans.

The irony of all this is how much the current ideological fight over Medicare resembles the battle over the original legislation in l965. Then, as now, there was an obvious divergence between the Democrats and Republicans about the core principles of Medicare. On the one side, Democratic leaders were committed to taking hospital and physician insurance out of ordinary market dynamics. Medical services for the elderly should vary with their illnesses, not the size of their wallets, they argued. The Republican response, then as now, is that the market works better than governments and that the proper role of government in medical care is helping those who could not fend for themselves.

Forty years later, no one other than a retired administrator can say publicly what Republican conservatives have long felt. So subterfuge is necessary. One kind is simply to mislead the public about what is being done: the false advertising of this past year's promotion of Medicare reform. The other is to try to change the subject: Make obesity coverage a news item to divert attention away from what has become a political disaster.