People in their 80s and 90s, when their health starts to deteriorate, tend to have multiple things wrong with them. From a doctors point of view, they are very time consuming to treat. They often tend to be fearful and forgetful.

All of this means that either a family member, or a very conscientious doctor, needs to be carefully coordinating their care, or disastrous mishaps will occur. But middle aged sons and daughters are nearly all in the workforce, without much time to spend with frail and aging parents.

And despite the promise of managed care, they one thing doctors are not paid to do is spend a lot of time with patients or on the phone.

Indeed, managed care has become a parody of its original aspirations. Back in the days when HMOs were nonprofit, prepaid group health plans, the idea was that paying doctors salaries to treat a fixed number of patients would reward prevention and remove any incentive either to undertreat or to overtreat.

In the 1990s, after most HMOs had become for-profit, shareholder owned corporations, they tried to make money signing up Medicare patients. The government encouraged HMOs to serve seniors, on the theory that this would cut costs. HMOs targeted relatively healthy oldsters, in the hope of making a bundle.

But it mostly didn't work. For one thing, old people gradually become older people. Even healthy ones eventually get sick. For another, the Medicare payments to HMOs weren't adequate to the need. So most elderly people, especially the sickest ones, went back to conventional Medicare.

The Medicare program, though reformed to discourage overly long hospital stays, is still basically a fee-for-service program. That means it rewards intensive medical interventions, such as surgery, but doesn't reimburse enough money to compensate doctors for the careful case management that older people require. The more that Congress cuts the Medicare budget, the more money comes out of hands-on care.

One member of my extended family has been shuttled from specialist to specialist, while his case falls between the cracks because his overworked primary care doctor fails to adequately coordinate the whole enterprise. After many months, nobody knows what's wrong with him.

Another, in her mid-80s, was barely spared unnecessary and dangerous open heart surgery, only because her daughter had the wit and the energy to ask impertinent questions and seek a second opinion.

The mother has multiple conditions. The daughter is spending half her time on the phone doing what her mother's primary care doctor should be doing.

The managed-care system is saving money by displacing the burdens of caring back onto families. Those who don't have families available to accept such burdens risk becoming casualties of the medical system. When it comes to people in their 80s and 90s, especially those without close relatives on the case, the system can simply bury its mistakes.

The story is, if anything, worse when it comes to nursing care. Most nursing home care is paid by Medicaid. The reimbursements are inadequate, so nursing homes tend to recruit help from the very bottom of the labor market.

Assisted living is an attractive alternative to nursing care, but is costs far more than most elderly people typically can afford usually $2,500 a month and up. And Medicaid won't pay any of its costs.

Both parties are crowing about the huge and growing budget surplus, as if it were a costless boon to the economy. But the fact is that a big chunk of the surplus came out of cuts in the budget for Medicare and Medicaid.

Our society is demanding that everyone work, but ignoring the cost to the enterprise of caregiving. We are becoming a richer economy, while we impoverish those most dependent on the care of others.

So the wondrous budget surplus is anything but costless. As anyone who has lately helped an elderly friend or relative navigate hospital care can tell you, the costs are coming at the expense of our own parents.

This is a political failure, because these are mostly public dollars. But somehow, the voters aren't connecting the dots and demanding better of our elected officials. If we fail to make this a public issue, our families will suffer the consequences.

Robert Kuttner is co-editor of The American Prospect. His column appears regularly in the Globe.

© Copyright 2001 Globe Newspaper Company

###