June 15,2016

Wyden Statement at Brookings Institution on Chronic Care and Updating the Medicare Guarantee

As Prepared for Delivery

What drove me to come speak before you all today is a sense that the national debate on health care is starkly out of whack. It’s out of whack for a variety of reasons, and I want to focus today on the one I find particularly offensive, which is the lack of attention paid to chronic illness in America and what it means for Medicare.

For the last few years -- and certainly throughout this election season -- the health care debate in this country has been stuck on one question: are you for or against the Affordable Care Act? Obviously there are ways the law could be strengthened through bipartisan work. But what’s not on offer is taking the country back to the dark days when health care was reserved for the healthy and the wealthy.

So after trading the same blows over the same law for six whole years, it’s time for the health care debate in America to mature and turn to an issue of serious consequence for older people nationwide.

The next major undertaking, in my judgement, is updating the fundamental guarantee of Medicare for an era when chronic illnesses -- heart disease, cancer, diabetes, stroke -- are the greatest burden on the program. Older Americans afflicted by these persistent illnesses now account for an astounding 93 percent of Medicare spending. Broken ankles and nasty bouts of the flu, in terms of their impact on the program, are a memory.

Ever since 1965, Medicare has stood on a guarantee of defined, secure, and high-quality health benefits for American seniors. Now, in 2016, 10,000 people become eligible for the program every day, and many of them have at least one chronic illness. For this new age of Medicare beneficiaries, the guarantee is falling short. So in my view, seniors have a right to know how the Presidential nominees and lawmakers in Congress plan to update the Medicare guarantee in light of that fact.

Americans have a right to know that sacred guarantee will mean as much in the years and decades ahead as it did half a century ago when Lyndon Johnson put pen to paper and signed the program into law. I think you’re kidding yourself if you don’t believe managing the demands of chronic illness is a major part of that equation.

I have no doubt that each and every person in this room has at least one family member or a friend who suffers from a chronic illness. And I’d be willing to bet that some of you have seen firsthand a few of the ways Medicare’s shortcomings leave some of the most vulnerable seniors struggling to manage their conditions.

Leaving seniors on their own when it comes to coordinating care, even after preventive visits. Uprooting the elderly as a rule and sending them to hospitals when getting treatment at home can be as effective, more comfortable, and less expensive. Charging an inexplicable co-pay for coordination. A menu of plans in Medicare Advantage that can be insufficient for a person with complicated medical needs. Policies that keep doctors from helping stroke patients at the very moment help is needed most. These are some of the most glaring ways Medicare fails seniors with chronic illness.

Let’s start by taking stock of how Medicare fails to coordinate care – to bring together the small army of doctors, specialists and pharmacies that a lot of seniors visit on a regular basis. John is 65 years old and a new enrollee in Medicare Part B. Thanks to the Affordable Care Act, he gets a free wellness visit as a “welcome to Medicare.” Maybe a symptom raises flags during his appointment, or an odd result of a test prompts a referral to an oncologist. John is better off as a result of having had that free visit. But after it wraps, seniors like him are largely on their own when it comes to managing their care. It’s as if seniors are told, “here’s what’s wrong with your health, now go figure out what to do about it.”

The burden of managing your care and keeping all your information straight is a lot to ask of someone in relatively good health. For the millions of seniors with multiple chronic illnesses – two thirds of Medicare beneficiaries – it can be a full-time job. Cross-town appointments to make in various offices. Batteries of pills to take on precise schedules. Stacks of bills to pay. There are far too many chances for dangerous errors and missteps.

Next, let’s look at the coordination co-pay, which in my judgement is an absolute head-scratcher. Phillip is a 77 year old grandfather of limited means. He’s diabetic and a cancer survivor. He’s on a fixed income – Social Security and a small pension from a career on the factory line are all he has to get by. Phillip spends a lot of time in a lot of providers’ offices – his general practitioner, his oncologist, a renal specialist, a physical therapist to help him maintain his mobility. Those offices need to talk to each other. They have to share information to make sure Phillip’s treatment is in order.

In the long run, coordination is supposed to bring costs down. But Medicare policy says coordination is a service like any other, and services come with co-pays. Some doctors say it’s not worth adding a new item to a patient’s tab, and coordination falls by the wayside. But Phillip, already walking an economic tightrope, has to pay for a coordination service that I believe should come free of charge and begin just after the new wellness visit.

Now let’s consider how little sense it makes to pull seniors out of their homes by rule when they need treatment. Sharon is a 72-year old suffering from arthritis and showing the early signs of Alzheimer’s disease.

Sharon’s physician ought to be allowed to provide her care where she’s most comfortable – at home – rather than in an unfamiliar, antiseptic hospital room. There’s a pilot program up and running called Independence at Home, which makes that possible for a limited number of Americans. Early results from this pilot show it bringing costs down by $3,000 per beneficiary. I think that ought to be the norm.

Now let’s look at how Medicare Advantage falls short for older Americans who need the most specialized care. Janet is 66 – recently forced to retire because of a minor heart attack. She’s dealt with C.O.P.D. for years, and type-2 diabetes is common in her family. She’s a lifelong resident of Florida who grew up soaking in the sun, so she worries about skin cancer. The health insurance coverage Janet needs is not your run-of-the-mill plan. She needs insurance that’s tailored to her, but the rules on the books today don’t encourage Medicare Advantage plans to offer that level of personalization. So when Janet looks at the options available to her, she’s probably underwhelmed. In my view, a lot more can be done to give Medicare Advantage plans the flexibility to design innovative coverage options that work for somebody with a very particular set of needs.

Finally, let’s examine how Medicare rules slow down treatment for certain victims of stroke. Harvey is 70 years old. He’s a lifelong athlete in seemingly good health – he starts every day with a three mile run. But one morning, a blood clot travels upward into his brain, and Harvey suffers a stroke. In that moment, every second counts. Getting to a neurologist as quickly as possible can save Harvey’s ability to communicate, his mobility, even basic cognitive functions like reading and recognizing friends and family. However, some hospitals may not have immediate access to a neurologist, and against all logic, Medicare rules today sometimes block the use of telemedicine when it could be life-saving. Those rules ought to be thrown in the dustbin. An outdated Medicare policy cannot be the reason a stroke victim is left unable to speak with loved ones or live a productive life.

Cases like these are too common across the country. And although chronic illnesses are so frequent in America – seemingly a fact of life for people in old age – policymakers cannot be lulled into ignoring the challenge they represent. Patients should not have to go it alone, navigating an overwhelming health care system, fighting against outdated rules, and being forced to receive treatment away from home when it isn’t necessary. That is not the true promise of the Medicare guarantee.

The good news is there is growing, bipartisan interest in Congress in tackling chronic diseases in Medicare. In the Senate, Finance Committee Chairman Orrin Hatch and I, along with Senators Mark Warner and Johnny Isakson, are working on bipartisan chronic care reform. This has been a long process, now almost 13 months, and even longer if you consider the hearing I held as Chairman in 2014. But it seems noteworthy to me when members of the two parties can come together to work on reforms to Medicare, which so often gets reduced to a political football in today’s politics.

It’s important to recognize that updating the guarantee goes beyond chronic care as well. The Medicare guarantee is also a promise that older Americans will have access to the lifesaving drugs of the future. If the trend of high drug prices continues without a more thoughtful approach, too many seniors will be left holding the bag, and Medicare could see a financial crunch that threatens access to medicines that amount to miracle cures in some instances.

The Medicare guarantee is a promise of sensible pain management that doesn’t simply consist of prescribing hundreds of powerful opioid pills with minimal planning, guidance, or warnings.

The opioid epidemic, which has already torn apart thousands of American families, has made it tragically clear in recent years that this country needs a top-to-bottom update when it comes to thinking about managing pain.

And the guarantee promises that Medicare’s benefits will be comprehensive and accessible for all, no matter their station, especially lower-income seniors. That’s why I put forward a proposal to cap out-of-pocket costs for seniors in Medicare Part D. And there is a lot more work to be done bringing out-of-pocket costs down throughout the program.

The bottom line is that it’s time for our debate over health care to mature past the same old ACA fight, and on a bipartisan basis, take on the next set of challenges. In my view, that begins with updating the Medicare guarantee in an era when health care in America is dominated by chronic illnesses.

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