U.S. “MEDICARE” MEDICAL BENEFITS SCHEME MAKES AN ANXIOUS START

Press, Volume CVI, Issue 31110, 13 July 1966, Page 16

U.S. “MEDICARE” MEDICAL BENEFITS SCHEME MAKES AN ANXIOUS START

(By tht Washington correspondent of the “Financial Times”! (Reprinted from the "Financial Times” by arrangement!

On July 1, the 19m-odd Americans who are fortunate enough to be over 65 became eligible for free (or almost free) treatment in hospital and, if they choose to make a modest extra payment to the State, to free medical attention as well. “Medicare,” as this scheme is universally called, has been ferociously controversial from the day it was first proposed by President Truman in 1945, to the moment last summer when it was finally and triumphantly approved by President Johnson’s still obedient 89th Congress.

It was still controversial on the day it came into force and its future is full of doubt and anxiety. The American Medical Association, after years of opposition, has given its grudging acquiescence, but will the individual doctor cooperate? The hospitals and nursing homes are anxious to benefit from the distribution of federal largesse, but can they provide the doctors and nurses and beds that will be required? The public has at last resigned itself to expecting something for nothing, but will there be a revulsion of feeling if expectations are not fulfilled.

The English observer, casting his mind back 20 years to the National Health debates and the doom-laden forecasts of the British Medical Association, is more likely to wonder how such a partial and circumspect measure as American Medicare can be causing such a fuss. Two Schemes The scheme is generally depicted as giving free medical care to everyone over 65, but it is more complicated than that. In the first place, there is in fact not one scheme but two. The first—to which the patient is entitled through earlier social security payments—is a plan by which the State pays for hospital bills and drugs administered to a patient while in hospital. It also covers a strictly limited amount of outpatient diagnosis and aftercare. The patient on the other hand must pay the first 40 dollars (about £l3 6s 8d) of his hospital bill and 10 dollars per day (about £3 6s 8d) after the first two months in hospital. He must also pay the first 20 dollars (about £6 13s 4d) of his outpatient costs and 20 per cent thereafter.

The second scheme, which is optional, costs 3 dollars (about £1) per month and covers normal medical attention. For this sum, the patient is entitled to up to 100 visits a year from his physician, free diagnostic tests and dressings and the rent of medical equipment such as wheelchairs, artificial limbs and crutches. Even this supplementary scheme, however, does not entitle him to free dental treatment, to spectacles, to hearing aids or to routine check-ups from his doctor. He must in addition pay the first 50 dollars (about £l6 18s 4d) of his medical expenses in any calendar year and 20 per cent of the expenses above 50 dollars.

This catalogue of the limitations of the scheme may sound grudging—and indeed those engaged in the Great Society’s war on poverty are

particularly bitter about the extent to which the poor, and even the aged poor, are likely to be excluded from the benefits of the scheme either through their age or their inability to pay the initial fees. Nevertheless, the difficulties of putting even a partial plan of this kind into operation are such that the Government is showing distinct signs of alarm that national resources will be overstretched. Two Main Dangers Two main dangers are foreseen. First there is the non-co-operation problem. This is acute mainly because the scheme was amended in Congress to meet the doctrinal argument of the American Medical Association, that the traditional doctor-patient relationship would be wrecked by Interposing an impersonal State body between the high contracting parties. The result of this pressure has been an extraordinary compromise under which the doctor is allowed to choose the method by which he will be paid. He can send his bill direct to the patient in the old way, leaving the patient to recoup himself by presenting the receipted bill to the Government’s agent. Alternatively the doctor can himself claim payment from the Government agent, leaving the patient to pay only the first 50 dollars. A group of 300 or so conservative doctors, headed by a past-president of the American Medical Association (who practises, significantly enough in Florida, the favourite retiring ground of the elderly) is undertaking a deliberate campaign to bill patients directly—aware, no doubt, that the poor cannot pay the initial fee and cannot therefore be expected to secure a receipt. How this campaign will succeed against the intelligent philanthropy of the average American doctor is doubtful but it is certainly a menace to the system. ■ The opposite danger lies in the possibility that the public will rush blindly to avail itself of the benefits and overstrain resources. More than 90 per cent of the 19 million eligible old people have signed up for the first scheme and 90 per cent of these, in turn, have taken out the supplementary coverage. Only 11.3 million of the old were previously covered by private insurance schemes leaving perhaps 6 million potential patients to be accommodated who might previously have stayed away. There is also ample evidence that ever since the Medicare Bill was passed, old people have been putting off such'operations as they safely can until introduc-

tion of the plan—hence a rush for hospital beds is now to be expected. Officials are putting their hopes in the fact that the summer is a slack period because respiratory infections are at their minimum, but there is no reason to suppose that the number of beds wiil be much expanded by the winter, when bronchitis and pneumonia begin to take their toll once more. Moreover, the situation is complicated by tho fact that the nursing home benefits of Medicare, which come into force in January, are available only after three days in hospital. This is an incentive to malingering which only the most hardhearted doctor will be able to resist.

There are endless other problems. One for instance, is the racial issue. Many southern hospitals are segregated and many have preferred to opt out of the scheme rather than subscribe to its requirements on integration. In states like Mississippi (where only 17 out of 132 hospitals have toed the line) what happens to sick Negroes? Again, will the new standards laid down by the Federal Government require vast new outlays on equipment and facilities and therefore raise doctors’ and hospitals’ charges? How fair is the “cost-pius-2-per-cent” payment per patient that the Government plans to provide for hospitals? Is there a possibility of a doctor shortage? Only time can answer these questions, if they are answerable at all. Yet in spite of art the difficulties Medicare looks as if it can be made to work. And for all its limitations it is vastly important, even epoch-making, in the American context In practical terms it is likely to prove one of the most significant efforts to combat the effects of poverty that this affluent nation has yet devised. Psychologically It breaks through one of the biggest barriers in the American consciousness—the belief that because self-reliance is a virtue, helplessness must be a vice. Now that this myth is at least partly laid to rest 1 am convinced that within 10 years the United States will have a health service which extends not just to the old but to alt ages alike. And in the meantime the spectacle of- a “welfare state” successfully at work will profoundly affect the climate in which every piece of American social legislation is discussed.