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"My" Medicare

One of the best-known ironies of the health care reform debate is that beneficiaries of the government-run Medicare program are perhaps the least likely category of Americans to support universal health reform. There are many jokes and anecdotes about Medicare beneficiaries angrily telling Members of Congress to "keep the government out of my Medicare." And unsurprisingly, some reform proponents suspect that folks on Medicare have an "I've got mine" attitude about health insurance based on indifference to the plight of the uninsured or a general antipathy towards Obama or "liberals."

But I'm guessing there's something more than sheer ignorance or selfishness at play here: a sense that Medicare, unlike the insurance that would be offered along with subsidies under the proposed reforms, is an earned benefit, while government-provided or -financed health insurance for non-retirees is welfare.

That's at best partially true. Current payroll taxes and premiums cover a little over half of Medicare expenditures (though even there, it's important to understand that it's current workers' payroll taxes, not "banked" payroll taxes from retirees, that we are talking about); the rest comes from general federal revenues. Moreover, only the poorer beneficiaries of a new system would get anything like full federal subsidies for their premiums. So Medicare's not fully an earned benefit, and the new benefits won't be fully "welfare."

But these are powerful perceptions, and not the sort of thing that pollsters have been looking at lately, so far as I can tell. And the idea that many of the currently uninsured will be given something that Medicare beneficiaries don't have--not the insurance itself, but the means to pay for it--helps explain why lots of retirees feel no particular solidarity with the uninsured, and are open to right-wing arguments that health reform is an exercise in "socialistic" big-government "redistribution."

Now I do not recommend that reform proponents deal with these perceptions by lecturing Medicare beneficiaries that they are themselves "on welfare," though it remains important to remind them that Medicare is a government program, and that government's role in the new system will be more as a catalyst than as an owner-operator. But the better approach is probably to stress the fundamental idea of universal insurance against medical circumstances beyond anyone's control, and the injustice of losing access to health care because you get sick, your employer drops coverage, or your premiums keep going up. The truth is that most beneficiaries of health reform will be middle-class working folk with bad luck; that reform is the best way and the only way to get costs under control; and that everyone will benefit from a country where everyone has health insurance.