1. Mason, Diana J. PhD, RN, FAAN, AJN Editor-in-Chief

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It's mid-December, and I'd planned to write an editorial about what's new in AJN for 2004. But President Bush just signed into law the compromise Medicare bill that, while providing a prescription drug benefit, will also privatize coverage in a way that could jeopardize care for many older Americans. Some have criticized the prescription drug benefit, but I'm concerned about other features that could mean Medicare's eventual demise.


Consider the words of Newt Gingrich. In a widely excerpted and debated 1995 speech he delivered to a Blue Cross/Blue Shield conference while then Republican speaker of the House of Representatives, Gingrich said the following about Medicare and the federal agency that administers it: "We don't get rid of it in round one because we don't think that would be politically smart, and we don't think that is the right way to go through a transition. But we believe it's going to wither on the vine because we think people are going to voluntarily leave it."


Just days before the House vote in November, Gingrich championed the bill to House Republicans in closed-door sessions, calling on conservative members of Congress for support. He then called the bill's passage a "huge accomplishment," claiming its critics are "misguided and misinformed."


Consider also the words of another Republican, Senator Don Nickles of Oklahoma. On November 24, 2003, Nickles voted against the bill, saying to his fellow senators, "I don't want to be adding new benefits that will just accelerate the day to where it collapses, where it's not sustainable."


Along with Nickles and many others, I'm concerned about the new law for several reasons. First, the privatization of benefits may undermine a crucial feature of traditional Medicare: the sharing of financial risk among beneficiaries. The high cost of caring for very ill older adults through Medicare has been offset by healthier beneficiaries who require less care, but the new legislation offers older adults the choice between the traditional program or a private plan paid by Medicare. Private insurance companies will receive billions of dollars as incentives to offer older adults an alternative to the traditional, fee-for-service Medicare program. If private insurance companies lure healthier older adults away from traditional Medicare, the financial risk sharing critical to an affordable Medicare program will be lost. (Private insurance companies participated in Medicare+Choice, a competitive HMO alternative to traditional Medicare that was started in the late 1990s and that in 2002 cost Medicare 5% more per capita than the traditional Medicare program did. These private plans enrolled mostly healthy older adults who got sicker over time. Thus, the companies' costs rose as well, and more than half of the companies quit the program between 1998 and 2003, disrupting care for thousands.) Those remaining in the traditional Medicare program will be the oldest and sickest, and Medicare will become unaffordable for many.


Second, the law prohibits the federal government-but not private insurers-from negotiating lower drug prices with manufacturers. This feature has received much criticism and raised suspicions about the motives behind the bill.


Third, individual beneficiaries will bear the onus of "cost containment" through increases in premiums, deductibles, and copayments, as well as through payroll taxes-making Medicare increasingly unaffordable for many beneficiaries.


Nurses should stay informed and communicate the importance of Medicare to policymakers, sharing data and stories that illustrate the impact of the new law once implemented, and advise patients about their rights under Medicare. A recent AJN reader survey indicated that some nurses lack basic knowledge of Medicare. In this issue, we're launching a series on Medicare benefits, produced by the Center for Medicare Education with support from the Robert Wood Johnson Foundation.


Look for other new columns in the coming months on wound management, nutritional support, patient safety, and forensic nursing. This month, we debut two others, one on cardiac and respiratory health (Beats and Breaths) and one produced by the ANA (The Politics of Caring). Happy New Year.


Medicare may become unaffordable for the sickest people.