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The Medicare Referendum

What the 2012 Congressional election is really about—in Kathy Hochul’s district and everywhere else

The 60-somethings are getting more numerous around here. Those in their seventh decade as of the 2010 Census amount to more than one in five of the residents of Erie County. The oldest among us are very numerous in Tonawanda, Cheektowaga, and West Seneca, where well over one in four of the people living there are over 60. In those towns, almost half of the folks who are over 60 are actually over 75.

Put it another way: More than one in 10 residents of Tonawanda, Cheektowaga and West Seneca are over 75. The numbers for Hamburg, Evans, Alden, and many of the other towns in what has just become Kathy Hochul’s Congressional District aren’t far off.

Everybody knows that it’s the over-60 crowd that receives Social Security and pension income. Those are the folks who also receive Medicare, because after a working lifetime of paying into Social Security and Medicare, one becomes eligible to receive the benefits when one becomes old enough. When the share of the population in any area becomes large, the economic impact becomes large. Nationally, the average for any county is that around 17 percent of all income is in that category known as transfer payments—including Social Security, Medicare, Medicaid, veterans benefits, food stamps, and, for a very few, cash welfare payments. Most of the transfer payment money goes to old folks.

In Erie County overall, the number is not 17 percent of all household income. It’s 22.1 percent. In the other counties that are now in Kathy Hochul’s district, it’s more. Over 26 percent of the income in Niagara County comes from transfer payments. The number reaches almost 27 percent in Orleans County, where registered Republicans outnumber registered Democrats. In reliably Republican Genesee, Wyoming, and Livingston counties, the numbers are 24.1 percent, 24.3 percent, and 23.3 percent, respectively—more than in Erie County, much more than the national average.

Kathy Hochul’s Congressional district now comprises more rural communities where household income isn’t very high, where dependency on government programs is significantly higher than the national average, and where there are, like in Buffalo’s first-ring suburbs, a lot of old white folks. Health data also show that there are a lot of sick old folks: Rates of heart disease and other lifestyle-related illnesses are quite high in some of the small towns.

Nevertheless, given history, one might think that a Democrat might have a hard time winning such a district. And until a Republican Congressman from Janesville, Wisconsin, came forward with a plan to destroy Medicare, no Democrat stood a chance in that district which used to be represented by Chris Lee, Tom Reynolds, and Bill Paxon.

But then came Congressman Paul Ryan’s assault on Medicare in 2010. The Ryan Plan to turn Medicare into a voucher program was a major issue in Hochul’s 2011 victory over Jack Davis and Jane Corwin. The other major issue was income inequality: Recession-pounded suburban and rural voters did not reflexively support a bejeweled resident of Spaulding Lake, instead responding positively to a plainly dressed suburbanite who talked economic fairness—especially to elderly people who had contributed to the Social Security and Medicare systems since 1964, and who didn’t want those systems to end.

Hochul’s political existence in 2012 depends on those elderly white folks understanding today, as they did in sufficient numbers last year, that the Republicans are explicitly, intentionally endeavoring to make this election a referendum on ending Medicare as it exists today. The Republican Party is betting that it can hold the House of Representatives, and win a majority in the US Senate, and also command Mitt Romney, with the Ryan Plan, which they are voting on this week in the US House of Representatives.

Stark contrast

In As You Like It is that famous monologue by Jacques that begins “All the world’s a stage,” a monologue that is mainly about the stages of human existence, from screeching messy babyhood to doddering messy old age. Almost 50 years ago, America decided, with some bullying from President Lyndon Johnson, to enact a national healthcare plan for poor people called Medicaid, and another one for old people called Medicare, so that Shakespeare’s description of the last of the seven “ages of man” wouldn’t be the American way anymore.

“Last scene of all,” Shakespeare wrote, “is second childishness and mere oblivion, sans teeth, sans eyes, sans taste, sans everything.”

That sounds like the Paul Ryan plan for Medicare. Ryan proposes that the elderly be encouraged to move off Medicare with the help of a partial government subsidy so they can shop for a private health insurance package. His rationale is that Medicare is too bureaucratized and is heading for bankruptcy.

The rational rejoinder to Ryan is this: Any insurance pool that shrinks is going to be riskier than a bigger one, unless you can toss all the risk over to somebody else. So the way to fix Medicare is not to shrink it, but to make it universal, the way that most of the other advanced countries in the world do it. Healthcare expenditures are smaller and outcomes are equal or, in most cases, better, in Europe, Britain, Canada, and Japan, all of which have all-encompassing public health insurance pools. That doesn’t mean we should adopt a British-style system where every doctor works for the National Health Service, but it’s pure ideology, and bad arithmetic, to say that further fragmenting an already fragmented system is any way to achieve savings.

But this is American politics we’re talking. We don’t get a bold Democratic plan for universal coverage. But we do get a bold Republican plan, laced with subtle racial messages, that may actually become law. The Ryan message on healthcare for old people is part of his neo-Reaganist messaging package, the pitch for which is this: America can have robust economic growth again if only we cut taxes on corporations and investors, and sharply cut government spending, because government spending is bad for America, while the free market is good.

In those rural parts of Western New York that lay beyond east of Cheektowaga, north of Tonawanda and south of Lackawanna, the Republican bet is that antipathy toward Barack Obama is a good political bet, just as it is in rural Wisconsin.

Dependency and healthcare

There are around three million New Yorkers on Medicare. There are about five million New York State citizens who are eligible for Medicaid, which is the federal healthcare program for poor people. Of those five million, the government office called Health NY says that about a million are pretty expensive to care for because they’ve got “multiple chronic illnesses.” That means these folks are either in long-term care or are chronically ill with conditions such as muscular dystrophy, multiple sclerosis, or brain injuries, or are so severely developmentally disabled that they can’t live independently, or are behavioral or mental-health cases. As the government website puts it, “[w]hile the majority of Medicaid enrollees is relatively healthy and only requires access to primary care practitioners to obtain episodic and preventive health care, the Medicaid program also has several population groups who have complex medical, behavioral, and long term care needs that drive a high volume of high cost services including inpatient and long term institutional care.”

When Republicans rant on about Medicaid, what they want voters to believe is that the main cost of this program is incurred by lazy welfare cheats and their innumerable illegitimate children, rather than by elderly white folks in the last six months of life, by psychiatric patients, by the brain-injured, and by those afflicted with wasting diseases that deprive them of mobility and a normal lifespan. But with Medicaid, it’s the old 80-20 rule at work: Most of the cost of the system comes from a small segment of the patient population.

Proposing to do away with government-funded healthcare is a political winner among suburban white folks. Proposing lower taxes is a winner, too, even in places like Allegany County, where almost 30 percent of household income comes from the government.

The economic reality of dependency is not the political reality. But in 2011, briefly, it was, because the message of the Democratic National Committee was sharp and simple, thus: The Republicans are trying to take your hard-earned benefits from you in order to give rich people more. Now that the new numbers on income are in—with 93 percent of all income growth since 2008 having been delivered to only one percent of American households—and now that Congressman Paul Ryan has once again told us that it is the Republican plan to end Medicaid and Medicare and to cut taxes on corporations and investors—the messaging should be simple again.

But it’s a strange thing, dependency. Suburban and rural white folks in all those Red States live in places where the federal government pumps massive transfers, not only in the form of transfer payments to individuals, but for infrastructure, military bases, and defense contracts. Dependency there has the political effect of dependency in Upstate New York. They’re on the tit, but they vote as if they hate it. Cognitive dissonance, to be sure: Let us live free, but keep them checks a-comin’.

Maybe that will change in 2012, as it did for Kathy Hochul in 2011, when it was the Republicans themselves who threatened to stop payment.

Bruce Fisher’s new book is Borderland: Essays from the US-Canada Divide, available at bookstores or at

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