Let’s say you’re the devil, and you want to corrupt the American republic. How would you go about it? According to David Hyman, you might create something like Medicare, the federal health care program for the elderly. Hyman submits that Medicare may be the greatest trick the devil ever played. Medicare feeds on the avarice of doctors and other providers, turns seniors into health care gluttons, and makes regions of the United States green with envy over the dollars showered on other regions. The program exploits the sloth of government officials to increase the tax burden on workers and drag down the quality of care for seniors. Medicare makes Democrats lust for socialized medicine, while its imperviousness to reform makes Republicans angrier and angrier. Most of all, Medicare allows its ideological supporters to bleat and preen their way to the heights of moral vanity. In the style of C.S. Lewis’ The Screwtape Letters, Hyman writes that Medicare has “freed the self-interest of these mortals from its natural restraints. As a result, the seven deadly sins have blossomed.” With epic political battles over Medicare and the future of limited government looming just over the horizon, Hyman uses satire to cast a critical eye on this mediocre government program.

In his deliciously funny book, Medicare Meets Mephistopheles (Cato 2006), Professor David Hyman argues that Medicare corrupts our most base impulses - urging us to grab for more than our fair share of benefits while offering providers "the prospect of staggering amounts of money - even as ... actuaries were promising Congress that the Medicare program would be easily affordable." Modeled on C.S. Lewis' The Screwtape Letters, Professor Hyman's satirical examination of Medicare is sprinkled with political cartoons, absurd (but true) stories of Medicare's over-the-top fraud enforcement efforts, and a historical account of Medicare's genesis replete with Congressmen and strippers. Medicare Meets Mephistopheles gives us a well-researched and easy-to-read primer on the biggest pot of gold in medicine. While we are not as certain as Professor Hyman is that Medicare's limitations rise to the level of mortal sins, Medicare's tendency to encourage over-consumption, its thousands of pages of "guidance," miles of red tape, and insane enforcement scheme are not serving the American public well. It just doesn't make any sense. Medicare Meets Mephistopheles should be required reading for students in courses ranging from health law to nursing.

This essay is an edited version of my remarks during the first panel of the Mississippi College Law Review's symposium on health care reform, which was held on February 26, 2010, in Jackson, Mississippi. The essay integrates my prepared comments with my responses to comments and questions during the discussion period. I have also added some further thoughts on several of the issues that are relevant to the subject matter, especially in light of the subsequent passage of a major federal health reform bill. These remarks are necessarily brief, and they therefore can include only a hint of the issues that arise with respect to a subject as important as health care reform. These remarks do, however, provide an opportunity to describe some of the most important issues at stake in our continuing efforts to improve our health care system: the quality of care available, the number of people to whom care is provided, and the cost of providing that care. In future work, I will expand upon the ideas raised in this essay, focusing in particular on whether the 2010 health care law appears to be succeeding in reducing health care costs.

Why health care reform must tackle the escalating cost of medical technology Technological innovation is deeply woven into the fabric of American culture, and is no less a basic feature of American health care. Medical technology saves lives and relieves suffering, and is enormously popular with the public, profitable for doctors, and a source of great wealth for industry. Yet its costs are rising at a dangerously unsustainable rate. The control of technology costs poses a terrible ethical and policy dilemma. How can we deny people what they may need to live and flourish? Yet is it not also harmful to let rising costs strangle our health care system, eventually harming everyone? In Taming the Beloved Beast, esteemed medical ethicist Daniel Callahan confronts this dilemma head-on. He argues that we can't escape it by organizational changes alone. Nothing less than a fundamental transformation of our thinking about health care is needed to achieve lasting and economically sustainable reform. The technology bubble, he contends, is beginning to burst. Callahan weighs the ethical arguments for and against limiting the use of medical technologies, and he argues that reining in health care costs requires us to change entrenched values about progress and technological innovation. Taming the Beloved Beast shows that the cost crisis is as great as that of the uninsured. Only a government-regulated universal health care system can offer the hope of managing technology and making it affordable for all.

This book provides a comprehensive and approachable overview of Medicare under the Affordable Care Act. The author illustrates how the ACA addresses the long-term fiscal and demographic challenges facing Medicare, as well as the potential for Medicare to become a single-payer system.

Everyone agrees on the need to reform Medicare but not on how to do it. Some argue the program is too comprehensive, others that it is not comprehensive enough. Some suggest it pays too much for health care, others, too little. Meanwhile, the financial stakes continue to mount. Medicare spending exceeded $400 billion in 2007, making it more expensive than the entire health systems of most other nations, as well as the largest national public program other than Social Security and national defense. In R eforming Medicare, Henry J. Aaron and Jeanne M. Lambrew deftly guide readers through this complex debate. They identify and analyze the three leading approaches to reform. Updated social insurance would retain the current system while rationalizing coverage and reducing bureaucracy. Premium support would replace the current system with a capped, per-person payment that beneficiaries could use to buy health insurance. Consumer-directed Medicare would have beneficiaries pay for care up to a high deductible from government- supported savings accounts and offer premium-support coverage above the deductible. In addition to rating each option on its ability to promote access to health care, improve the quality of care, and control costs, the authors evaluate each reform's political strengths and weaknesses. Given the heat generated by the Medicare debate, it is unlikely that any single approach will be implemented in full. Consequently, Aaron and Lambrew describe incremental strategies that blend elements of each plan. Their analysis provides essential insight into the types of hybrid policies that Congress will consider in coming years.

After the Constitutional Convention, Benjamin Franklin was asked, “Well, Doctor, what have we got—a Republic or a Monarchy?” Franklin’s response: “A Republic—if you can keep it.” This book argues: we couldn’t keep it. A true republic privileges the common interest above the special interests. To do this, our Constitution established an elaborate system of checks and balances that disperses power among the branches of government, which it places in conflict with one another. The Framers believed that this would keep grasping, covetous factions from acquiring enough power to dominate government. Instead, only the people would rule. Proper institutional design is essential to this system. Each branch must manage responsibly the powers it is granted, as well as rebuke the other branches when they go astray. This is where subsequent generations have run into trouble: we have overloaded our government with more power than it can handle. The Constitution’s checks and balances have broken down because the institutions created in 1787 cannot exercise responsibly the powers of our sprawling, immense twenty-first-century government. The result is the triumph of special interests over the common interest. James Madison called this factionalism. We know it as political corruption. Corruption today is so widespread that our government is not really a republic, but rather a special interest democracy. Everybody may participate, yes, but the contours of public policy depend not so much on the common good, as on the push-and-pull of the various interest groups encamped in Washington, DC.