We appreciate Dr. Noel's interest in our commentary; however, we disagree with his assertion that Medicare has become a mandatory welfare program—because no means test exists for Medicare coverage. Clearly, the decrease in reimbursement for patients receiving Medicare is related to the increasing cost of Medicare to taxpayers. In addition, one of the major causes of the inflation of medical-care costs in the United States is cost shifting from patients who receive Medicare benefits to other payers. If Medicare were an actual welfare program, a means test would be available to determine eligibility for benefits. A means test would have the positive effect of providing a benefit to patients who are actually in need while helping to decrease government outlays and eliminating the cost shifting necessitated by the ban on balance billing. Dr. Noel is correct in his comment that patients who are indeed capable of paying the entire physician's fee are essentially subsidized by all other payers. Federal and other state requirements to accept mandatory assignment must be recognized for what they contribute to the inflation of health-care costs—an unnecessary supplement for persons completely capable of fulfilling their obligations. We recognize the political sensitivities faced by elected representatives in Washington. Nonetheless, until Congress recognizes that the limitation of resources will necessitate fundamental changes in the administration of the Medicare program, including a means test and more reasonable deductible and copayment levels, achieving control of spiraling medical costs will be impossible. Problems Associated With MedicareMayo Clinic ProceedingsVol. 67Issue 9PreviewIn the April 1992 issue of the Mayo Clinic Proceedings (pages 385 to 388), Drs. Gracey and Wood discuss the resource-based relative value scale in the commentary entitled “Physician Payment Reform: A Survival Manual for Physicians.” They failed, however, to indicate what is probably the most important aspect of the enabling legislation, the Omnibus Budget Reconciliation Act of 1989. With the passage of this law, Congress changed Medicare from a funding mechanism for insurance to a mandatory welfare program for elderly persons. Full-Text PDF