For Bob Byram, almost 81, Medicare has been "a godsend"--and he likes it just the way it is.
In 1991, the retired electrician from Temple Terrace, Fla., had a pacemaker implanted in his chest and suffered a bout of acute pancreatitis, accumulating $72,000 in hospital and doctor bills. Medicare paid almost all of it.
Byram has formed trusting relationships with his doctors over many years, and he wants to keep them. For that reason, he is not the least bit tempted to join cost-conscious health maintenance organizations or explore other forms of managed care.
"I want somebody who knows me when I walk in, not a place where you can't get by the receptionist at the desk," he declares. "The HMOs, you have to take their doctors, and you don't exactly get the best care in the world. I don't want any changes. I'm going to stick with the thing that has done right for me all along."
Byram, who lives alone in a small condominium on a fixed income of $1,200 a month, believes he speaks for many of the nation's 37 million Medicare recipients.
As Congress scrambles for ways to meet its commitment to slash $270 billion from Medicare's projected growth over the next seven years, many of its beneficiaries are anxious about the new system that is likely to emerge.
The congressional debate has already taken a familiar turn: Medicare beneficiaries soon could be squeezed, much as the rest of the country has in recent years, into abandoning traditional fee-for-service health care.
In both the House and the Senate, Republican-drafted reform plans would establish private, lower-cost alternatives, such as HMOs, to fee-for-service coverage. The proposals would lure seniors with incentives, such as additional benefits for drugs and eyeglasses that are not available under the current system. Participation would be voluntary.
Both plans also would require recipients to pay higher premiums for Medicare coverage, with wealthier seniors bearing the brunt, and would reduce payments to doctors and hospitals.
In addition, the Senate proposal would increase the deductible for doctor bills, and gradually raise the age of Medicare eligibility to 67 in the next century.
"They basically are saying: The rest of the country is suffering this, while you guys still have open-ended, unrationed fee-for-service," says Princeton University economist Uwe Reinhardt. "They're saying: In the short run, we'll allow you to keep it, but in the long run, you won't want to stay in it."
Under current rules, Medicare requires participants to pay out-of-pocket costs of $553 in annual premiums; $716 in deductibles for each hospitalization; an annual physician deductible of $100, and co-payments of 20% for outpatient services.
For seniors on fixed incomes, increasing those costs could be risky.
"All older people are scared--unless they've got plenty of money," Byram says.
Although a switch to less expensive HMOs would not be compulsory under the proposals, many seniors are wary that ultimately it will become mandatory.
"Choice is very important for people who have a continuing relationship with their physicians," says Bob Blendon, a Harvard University professor of health policy. "The older you are, the more chronic are your illnesses. If you have a doctor who says: 'Don't worry, we'll just watch this, come back,' and suddenly you can't come back, you're going to be very threatened."
In Blendon's view, the gamble boils down to this: "Are the additional benefits worth the possibility that some things may be limited? If you're relatively healthy, these plans are terrific because they give you a system with a lot more benefits. But if you're really sick, the specialists you want are not always in the same plan, and the best hospitals are not always in the same plan."
To be sure, proponents of HMOs point out that many seniors already opt for the less expensive alternatives, and are content with them. About 10% of the nation's elderly belong to HMOs, and the percentage is even higher in California.
Such plans can work well for members. Some plans even provide services that are geared to the needs of the elderly, offering such extras as vans that take them to doctors' appointments and bring them home, and special nutrition and exercise programs.
"Seniors who are in HMOs and understand what they're about are very satisfied and like them a lot," says Susan Pisano, a spokeswoman for the Group Health Assn. of America. "People who aren't in them may not be as comfortable, because they haven't had first-hand experience with them, or don't have complete information about them."
There is "a large body" of information that shows people are "quite happy" with their HMOs, she says.
A study released by the organization in June showed that only about 4% of the elderly who choose HMOs eventually leave to return to fee-for-service. The same study, based on data collected by the Health Care Financing Administration, showed that 84% remained with their HMOs, 6% switched to another HMO in their area and 6% left for other reasons, such as moving out of the area.
Having one physician in charge is reassuring and even provides a layer of safety, proponents say. For example, having one physician who is aware of all the medications a patient is taking can prevent potentially harmful drug interactions.
"One aspect of HMO care that Medicare patients like in particular is having a personal physician who coordinates care and helps them make their way through the confusing maze of today's health care system," says Lee Newcomer, chief medical officer of United HealthCare Corp.
But many seniors remain wary.
Stephen Pearlman, 75, a retired self-employed efficiency expert who lives in Houston, is convinced that he survived pneumonia because he was treated by physicians who were familiar with his chronic pulmonary problems and could respond quickly.
"If I had not had the freedom to choose my own hospitals and my own doctors, I wouldn't be here to talk to you today," Pearlman says. "If they're going to give you a bunch of rinky-dink doctors on a listing, then you become just a number. It removes the intimacy you have with your doctors. If they know you, you'll get better care. Without them, I'd have been a dead cookie."
The prospect is especially daunting for seniors who are frail, do not drive, or whose hearing or vision is impaired.
"Managed care may be a harder world for the elderly to navigate," says bioethicist Art Caplan, a member of the Clinton Administration's health reform task force.
Some experts warn that shifting millions of seniors into such programs might result in a surfeit of managed-care plans "with no accountability, no oversight and no quality control, except the marketplace, which leaves them much more vulnerable than when they had a federally supervised and sponsored program," Caplan says.
"Saying caveat emptor to someone who can't see well, suffers from memory loss and is institutionalized may not be sufficient advice," he adds.
For many of the elderly, the proposals under debate are generating considerable anxiety.
"I can probably afford [the increases], but that's not the point," Pearlman says. "For some people, these costs will absolutely fracture them.
"They're treating seniors as if they're the enemies. We've worked all our lives, and were looking toward to the rest of our lives to be free from worry. And now they're taking that away from us."