BEYOND MEDICARE

...And old people have little savings on which to call to make up the difference...

...A 1963 report by the President's Council on Aging estimated that one out of seven elderly persons with a heart condition is going without medical attention, and that the same holds true of nearly half of those with arthritis, rheumatism, hernias, and eye and hearing difficulties...

...BEYOND MEDICARE by SELIG GREENBERG A fter years of controversy and frus-tration, backers of the long-stalled program for medical care for the aged financed through the Social Security system finally appear to be on the threshold of victory...

...But these difficulties are primarily quantitative...

...Assumption of responsibility for the aged by the Social Security system would relieve voluntary health insurance of the poorest risks and make its problems considerably less onerous...

...It also inserted a cost-sharing provision (in addition to the other deductibles provided in the King-Anderson measure) requiring hospital patients to pay a share of their bills if the costs of hospital care increased more than the contributions to the Social Security fund...

...At its semi-annual meeting in Miami Beach late last year, the AMA House of Delegates cast aside all thought of compromise...

...The benefits were further watered down in the amendments to the Social Security bill which were passed by the Senate last September but later died in conference committee...

...In the first place, it is reasonable to expect that the use of Federal tax funds on a large scale for hospital and nursing home care may eventually lead to some Federal intervention to obtain greater managerial economy in the operation of such facilities and to tighten up the safeguards against using them excessively...

...The Forand bill would have provided the aged not only with hospital and nursing home services but also with free surgical care, the costliest of all medical procedures...

...Donovan F. Ward, the AMA president, conceded that "the hurricane that is about to hit us will be more furious than any we have weathered in the past...

...The Senate version reduced the days of nursing home care to 60 from 180 in the King-Anderson bill...

...All indications thus point to passage of some sort of Medicare legislation this year...

...Benefits under the Kerr-Mills program can include inpatient and outpatient hospital services, physicians' services, dental care, nursing home care, prescribed drugs and eyeglasses, and even private duty nursing services...

...Premium costs for the lower age groups could be reduced by the private insurers, or wider benefits provided at the same rates...

...The deeply disconcerting fact is that despite the warnings of doom it has elicited from the AM A, the formula proposed by Presidents Kennedy and Johnson fails to come to grips with the full dimensions of the grave health problems of the nearly 18,000,000 Americans who are sixty-five years of age or older...

...Only 3,500,000 aged persons have enough income to be liable to income tax...

...Still others must resort to public assistance or private charity...

...On the other hand, despite its frequent denunciation by the AMA as the vanguard of "socialized medicine," the Medicare plan is largely confined to hospital and nursing home care...

...Actually, there is nothing in the proposed legislation that would interfere in any way with the doctor-patient relationship...

...On the eve of what may be one of the most significant breakthroughs in the financing of medical services since President Truman's proposal for universal compulsory health insurance twenty years ago, it is therefore timely to take another sober look at the situation...

...It is intended to be a basic program, such as Blue Cross and Blue Shield are, for helping older people pay the costs of serious illness, with complementary roles for both private insurance and public assistance...

...By relieving the states of some of their health care responsibilities, the Social Security plan would permit them to expand their Kerr-Mills services and relax the eligibility requirements for that program...

...Others are forced to borrow money or to seek help from^relatives...

...That there is considerable substance to this contention is evident from the amendments approved by the Senate in September...

...It is idle to try to pretend that the coverage of surgery and other services by physicians, and possibly also of out-of-hospital drug costs, can be excluded for long from any meaningful medical care program...

...Another serious flaw in the Medicare plan is that it would push into hospitals some patients who ought to be able to get along with ambulatory care...

...Only nursing home care and home health services, up to a maximum of 240 nursing visits a year, would be provided without any deductibles...

...The use of doctors' services by the aged, outside of the hospital, also is much higher than that of the population as a whole, and their average expenditure for drugs is more than double that of persons under sixty-five...

...Not only is the Democratic majority in the new Congress the biggest in more than a quarter of a century but, most important, SELIG GREENBERG is a prize-winning writer on medical and related problems for The Providence Journal and Evening Bulletin...

...But only about fifty-five per cent of those sixty-five and over, as compared with nearly eighty per cent for those who are younger, have some type of health insurance coverage...

...Although forty states are now participating in the program, many of the plans are extremely limited, and only about 200,000 persons, or little more than one per cent of the nation's older citizens, are covered so far...

...The basic trouble with the Kerr-Mills Act is that it leaves it up to the states to determine the level of benefits and the standards to be applied in determining medical indigence...

...Not a word in the Administration bill indicates the possibility of any interference with the doctor's freedom to treat or of any bureaucratic intrusion into the treatment process...

...The result is that each year a considerable number of the aged are added to the large group left without any insurance protection at all—at the very time when their income shrivels and their bouts of ill health begin to multiply...

...Relatively few of the existing nursing homes provide adequate services...

...they are forced to buy insurance on their own, on an individual basis, which is costlier than group policies are...

...To pay for the Medicare program, as well as for higher Social Security retirement benefits, the Senate voted to hike the present tax of 3-5/8 per cent on both employe and employer to 4.2 per cent this year and 5.2 per cent by 1971...

...The considerations figuring in the health care of the aged cannot be separated from those of the rest of the population...

...Secondly, expansion of the program for the aged beyond its original limited scope would probably be only a matter of years...

...About half of the men and women sixty-five and older who are not in institutions have annual incomes of less than $1,000 each, while the average couple subsists on about $2,500 a year...

...Two things become amply clear in any such examination...

...They maintain that government actuaries have underestimated the anticipated degree of Medicare utilization, and the upward trend in the level of hospital and nursing home costs, and place the expenditure figure at about double the original estimate...

...This is all the more true in the case of those who have no such choice after their years in the plant or office end...

...Such income levels obviously make no allowance for large medical bills...

...And once the principle of the financing of medical services for the aged segment of the population through compulsory payroll deductions has been established by statute, the way might be opened for its ultimate extension to younger categories, if not to everybody...

...Aside from the question of unnecessarily inflating costs, excessive emphasis on hospitalization runs counter to balanced medical programming which should make it possible for physicians to blend the preventive, curative, and rehabilitative aspects of treatment in accordance with each patient's individual needs...

...Estimates based on large-scale surveys conducted by the U. S. Public Health Service indicate that more than 12,000,000 of the elderly have at least one chronic condition such as high blood pressure, heart disease, diabetes, arthritis, or some mental disorder, and that about 1,250,000 of them are invalids who, though not in institutions, are unable to get along without help from others...

...But the AMA, which has already spent more than $5 million in its battle against Medicare, is now mounting another costly campaign of "public education" to drive home the hazards of the Administration plan...

...Basically, the underlying problems of the most equitable organization and financing of medical care are the same, for young and old alike...

...As several studies have shown that the incidence of ill health is highest in the lowest income group, there is reason to believe that the average use of hospitalization is even greater among the aged who have no insurance coverage than it is for those who manage to retain such protection...

...But the health costs of the aged must be met one way or another—if not through regular Social Security contributions, then by private savings, insurance, or some form of welfare...

...To finance the plan, the King-Anderson bill provided for an increase of one-fourth of one per cent in the Social Security tax for both employe and employer, and the raising of the earnings base on which the tax is applied from $4,800 to $5,200...

...The creation overnight of massive new purchasing power for such facilities and trained personnel would have one of two results—the government would be unable to deliver what it has promised, or there would be a further increase in services that fall below minimum standards...

...the House coalition of Republicans and Southern Democrats that has blocked many Administration bills has been largely destroyed by the Johnson landslide...

...He has twice been honored by the Lasker Foundation for his writing...

...Competent opinion is that the costs of medical care will inevitably continue to rise, that the initial increase in the payroll tax will in all likelihood be just a starting point, and that it is inherent in the Social Security concept for the tax to go up with expanding need...

...The King-Anderson bill required a patient to pay $20 toward the cost of hospital outpatient diagnostic services during each 30-day period...

...The Social Security approach provides the best means of spreading the costs of health services in old age throughout the working years...

...President Johnson has made it clear that Medicare is not designed to replace the Kerr-Mills program but rather to supplement it...

...Although the revisions cut the 180-day maximum for nursing home care to 60 days, it raised the wage base on which the tax is computed to a $5,600 maximum...

...By focusing on institutional services, it accentuates the most expensive care, and the one which is best covered by available insurance protection, while leaving untouched the least well-covered segments of medical expenses...

...The plain fact is that they cannot afford the premiums for comprehensive protection...

...It is precisely the poorer states, where need among the aged is most desperate, that have the stiffest eligibility requirements and the most meager benefits...

...There are special difficulties in providing the medical services older people need...

...Like King Canute, organized medicine will spare no effort to roll back the tide...

...Surgical care was dropped from the measure introduced in 1961, and again in 1963, by Senator Clinton P. Anderson of New Mexico and Representative Cecil R. King of California...

...In all fairness to organized medicine, it must nevertheless be conceded that the Medicare legislation is a key test of power and that its adoption would provide the proponents of broader government involvement in medical care with a formidable foot in the door...

...The Medicare proposal has undergone a number of significant modifications since its introduction in 1957 by former Representative Aime J. For-and of Rhode Island...

...Actually, this law is much broader and potentially far costlier than the Administration plan since it puts no statutory limit on the services which may be furnished if a state agrees to share the costs...

...In five states such overhead is reported to range from twenty-five to fifty-nine cents for each dollar paid out in benefits...

...The first-year cost of the Medicare program to be made available to all persons sixty-five or older (whether eligible for other Social Security bequests or not) was originally estimated at $1.25 billion...

...The liquid assets of one aged family in three total less than $100...

...The second important point is that regardless of the final form of the legislation adopted by Congress, it will still fall far short of the needs of the aged and will be of much more limited scope than the health insurance programs of a number of other advanced countries...

...We are opposed," he said, "to this invasion of the voluntary relationship between the patient and the physician...

...It enables men and women to invest a share of their earnings, at a time when their income is highest, to help meet the greater health needs of later life, and gives them assurance that at least some of these needs will be provided for as a matter of right and not as charity...

...Notoriously sensitive as the medical profession is to anything which smacks of outside controls, it would regard any such governmental action as an unwarranted interference with the individual doctor's judgment...

...It is within the context of this grim picture that we must view the report of Walter J. McNerney, president of the Blue Cross Association, that Blue Cross subscribers in the sixty-five plus group use, on the average, between two and two and a half times as many hospitalization benefits as do those who are younger...

...At the time of their retirement because of age, many workers automatically lose the protection of Blue Cross-Blue Shield or other group health insurance paid for, wholly or in part, by their employers...

...But this would require a tremendous expansion of nursing home facilities and nursing personnel, and the upgrading of nursing home standards for which provision is yet to be made...

...To millions of older Americans the skyrocketing costs of the medical care required by serious illness are a staggering blow...

...Many simply go without the care they need...

...The first is that some form of governmental action is imperative to meet at least some of the health costs of our steadily growing army of older citizens, whose medical needs are more than twice as great as those of younger people while their incomes are only half as high...

...Some are able to manage on their own with the aid of insurance...

...This would have meant a maximum additional payment of $13 a year by a worker...

...Cumbersome procedures, required by complex limitations on ele-gibility and benefits, result in excessive administrative costs of the program in many states...

...One out of every.six older persons is hospitalized in the course of a year, and his hospital bill—exclusive of physicians' fees—averages about $525...

...The strident and confusing propaganda campaign conducted by the American Medical Association, and other conservative opponents of Medicare, has to a considerable degree obscured some of the basic issues in the area of health care for the elderly...

...The Federal government already pays all or part of the hospitalization costs for some of the needy aged, for veterans, dependents of military personnel, and civil service employes, and there is no evidence that the voluntary hospitals have to any degree been "socialized" but such Federal contributions...

...In fact, with the exception of limited hospital outpatient diagnostic services, the government would not provide medical services of any kind...

...The prerogatives of physicians and patients would remain unaffected...

...The proposed legislation does offer incentives for more economical non-hospital services in the form of care in nursing homes and nurses' visits to the homes of patients...

...The 1960 Kerr-Mills program of Federal grants to the states, to provide medical aid to the aged who are not so destitute as to qualify for the relief rolls, has so far had little material impact...

...The reason why the health insurance coverage of most older persons is inadequate is no secret...

...On the contrary, the measure explicitly forbids the government to interfere with the practice of medicine or with hospital management...

...Since the states are required to match the Federal grants, many of them are providing grossly inadequate benefits and have established stringent eligibility tests which severely limit participation...

...But the cost projection has been challenged by a number of experts in the field of medical care administration...

...It broadens the base of support by relating compulsory contributions to the level of income, and by taxing employers as well as employes...

...It is highly ironic that while organized medicine has based its bitter opposition to the Kennedy-Johnson Medicare proposal on the argument that it would not only lead to bureaucratic controls and inferior care but would bankrupt the Social Security system, it has been the most ardent backer of the Kerr-Mills law...

...It gave him three hospitalization options—up to 45 days without any extra payment, up to 90 days with payment of $10 a day for the first nine days and a minimum of $20, and up to 180 days with payment of the full cost of the first two and a half days...

...While there is room for deductibles in commercial casualty insurance, penalizing the patient by forcing him to pay part of the bill will cause some low income aged to forego needed medical treatment and thereby boost the ultimate overall cost...

...About one in four of the total number of aged have little or no income beyond their Social Security payments averaging $77 a month...

...It has been estimated that the Administration plan would pay only about one-fourth of the average older person's medical expenses...

...The patient would choose his own doctor and, with the advice of the physician, would choose his hospital, just as he now does...

...The use of deductibles is frowned upon by many authorities and is particularly inappropriate for the aged and for low-income groups in general...

...A recent government study showed that insurance payments meet no more than one-sixth of the medical costs of the insured aged and only about one-fourteenth of the total medical expenditures of all older men and women...

...But he insisted—and was overwhelmingly supported by the profession's supreme policy-making body—that the doctors will remain firm in their opposition to intervention by the Federal government in the medical care field in any way which might tend to interfere with, or control, medical practice...

...It does not cover doctors' bills, drugs, and numerous other items of medical costs...

...No amount of statistical juggling can refute the fact that the aged have much higher medical costs than younger people do at the very time when their income usually declines sharply...

...Even when they have the option to retain group coverage by paying the full premium, a large number give it up because of the added expense when retirement cuts deeply into their income...