Michael Arnold Glueck and Robert J. Cihak, The Medicine Men
Tuesday, Aug. 14, 2007

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There is yet another relatively silent power grab by the government to limit your freedom of medical choice in the Medicare program.

To retell an old anecdote, the bureaucrat was asked why the driver's licensing offices couldn't be opened on Saturdays. He replied that they'd tried it but had to abandon the idea when they discovered that too many people were using them.

Apocryphal, perhaps. But something very similar is happening in Washington, D.C., as the usual unholy coalition of penny pinchers (for you, not them), ideologues, and bureaucrats try to curtail the growth of the most popular aspects of Medicare:

As originally enacted in 1965, Medicare permits its enrollees to seek care from any approved source that is willing to accept the government's payment rates, put up with its paperwork and run the risk of going to jail for honest errors.

When Medicare was established, everyone (including the bill's backers) understood that their cost estimates were preposterously low. Every few years since, the government has dickered with the program to try to make it more "cost-effective" from their point of view even while expanding benefits.

Herding people into HMOs has long been a favorite and dismally ineffective tactic. But another attempt, originally conceived as a minor corrective, now enrolls 20 percent of Medicare's 43 million-plus beneficiaries.

In 1993, Congress passed the Medicare Modernization Act, which established Medicare Advantage as the successor to the problem-plagued Medicare + Choice program. Under Medicare Advantage, private insurance companies contract with Medicare for the right to sell policies to Medicare beneficiaries; in 2007, there were 602 contracts between Medicare, insurers, and healthcare providers.

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Medicare beneficiaries who buy these policies then deal directly with their insurers and providers, who then are paid by Medicare. Today, about 80 percent of Medicare Advantage beneficiaries are enrolled in HMO or PPO plans.

But the fastest growing segment is the remaining 20 percent who opt for unrestricted private fee-for-service coverage. No managed care, no quality control, just the old-fashioned, "Thank you, I'll make my own decisions consumer approach."

No one expects Medicare Advantage to grow less popular; by some estimates, a third of all Medicare beneficiaries will be enrolled within a few years.

The program is especially popular in rural areas and among the less affluent. It also appears that Medicare Advantage members are, as a group, healthier.

And the Beltway doesn't like it one bit. And they've got good reasons: