Pain, Pressure & Politics Make Powerful Medicine

MEDICAL AID FOR THE AGED

Old age is the harbor of all ills.

--Diogenes Laertius (3rd century A.D.)

AT a venerable 78, Speaker of the House Sam Rayburn is acutely sensitive to the afflictions of age. This year his brother Tom, 72, underwent surgery for cancer, lingered for several months, then died. Farmer Tom Rayburn had no money, no health insurance. Mister Sam picked up the bill which ran into many thousands. "I had the money and was glad to do it," says Rayburn. "But a lot of folks don't have the money and can't do it." Rayburn, who rarely recounts personal stories unless they make a political point, was circulating that one last week--along with his word that Congress had better enact some program for federal aid to the ailing aged before it goes home in July.

In the prosperous U.S. of 1960, the nation, like Mister Sam, has become increasingly aware of a general and growing problem: the number of old people in the U.S. is increasing, and fewer and fewer of them can afford the medical care they must have. Medical progress itself is largely responsible for swelling the number of U.S. oldsters over 65 from 3.1 million in 1900 to 15.5 million in 1960, and on to an estimated 24.5 million in 1980. A man or woman of 65 now can expect to live more than a dozen years; one in four will live a score or more years. As people grow older, they become more susceptible to chronic, expensive illnesses. The wonder drugs and radical surgery that add years to lives can alleviate many of the ailments of age, but not cure them.

Meanwhile savings, the time-honored bulwark against the hazards of age, have shrunk in proportion to the demands of medical care. In the years when today's oldsters worked and saved, wages were relatively low. Inflation and the high costs of modern medicine and surgery have scrambled many a nest egg. In the past decade, medical costs for the aged have about doubled. Today the average couple over 65 spends $140 a year for medical care, or $700 if hospitalization is needed. But 57% of the aged have means of less than $1.000 a year, counting social security benefits (see diagram), and most of them have banked less than $200 to meet a medical emergency. Says Dr. Sam Gertman, director of the University of Miami's geriatrics division: "An aged person usually can pay for his first illness out of his savings. On the second illness, he mortgages his home. After the third, he goes on the county.

Bread & Butter Issue. With all their problems oldsters can vote (and now make up 20% of the electorate). So can the increasing numbers of budget-pressed young adults who, busy raising large families, feel the extra burden of carrying the heavy medical expenses of elderly parents and relatives. Result: the age-old problem of old age has become a red-hot 1960 election issue.

The man who struck the political spark is balding Aime Forand, 64. One of 16 children born to a New England loom fixer, Aime Forand quit grade school to help support his blind father ("I know what it means to scratch"), went on to become a Democratic Congressman from Rhode Island. For 22 unspectacular years, Forand was barely noticed in Washington--until he suggested that the social security system be expanded to cover health insurance for the aged. Forand's plan: boost social security taxes 1/4% for employees and 1/4% for employers, use the funds to finance surgical costs and up to 120 days' combined hospital and nursing-home care per year for people over 65.

The American Medical Association immediately damned the plan as the first giant stride to socialized medicine. Congressmen began receiving phone calls from their private physicians, who urged them to vote down Forand's plan but only succeeded in arousing their curiosity. Labor unions scooped up the Forand bill as a major legislative goal. The campaign was helped along when Michigan's Democratic Senator Pat McNamara, 65, longtime (1937-55) president of the Detroit Pipefitters' Local 636, led his Senate subcommittee on aging into eight major cities across the land for well-publicized hearings. It was helped again when Tennessee's Estes Kefauver caught headlines with his hearings on the high cost of wonder drugs (TIME, Dec. 21). From coast to coast, the A.F.L.-C.I.O. staged foot-stomping rallies of aged unionists. The slogan: pass the Forand bill. The unions also mounted a vigorous write-your-Congressmen campaign. The Forand bill has drawn far more mail than civil rights, much of it clearly of the form-letter ("Pass H.R. 4700") variety, but an impressive amount painfully lettered.

In a peaceful, prosperous election year the Democrats were groping for a bread-and-butter issue, and suddenly they awakened to the Forand bill uproar just about the time that the House Ways & Means Committee, controlled by Democrats, was killing it off. Every one of the front-running Democratic presidential hopefuls endorsed the Forand bill or a close variation. Hubert Humphrey and Jack Kennedy introduced bills of their own that approximate Forand's but cut the surgical benefits.

The Facts of Care. Some of the publicity and the political pressure have conjured up the specter of a U.S. all but ready to allow masses of its aged to die untended. There is a problem but no crisis. U.S. citizens, young and old alike, generally receive the best health care in the world. A University of Chicago team recently polled 2,700 people over 65; only 2% claimed that poverty prevented them from getting medical care. All states except ten have programs of medical relief for the aged subsidized by matching funds from Washington, and almost every large county in the land has built a hospital that accommodates the poor. County hospitals vary in quality, and state relief varies in quantity--but some of it is generous. Miami's Dade County, one of the best, spends $350,000 a year on wards in nursing homes, supplements the income of the ailing aged who require rest-home care so that each one has at least $150 a month. California provides a state base pension of $115 a month for five-year residents over 65 who have no income, $95 for those who have some income. Altogether, 21% of California's aged collect state pensions. For the aged who need help, the state pays all nonhospital medical expenses, including drugs and doctors' calls.

The county hospital in Los Angeles employs a score of doctors who spend full time visiting indigent outpatients. The Los Angeles County Medical Association regularly advertises in local newspapers that free medical care is available to anyone who 1) needs it, and 2) phones in to numbers listed in the ad. The most recent ads ran within the past month. Not one person has telephoned. Says Dr. George Griffith, geriatrics specialist and professor of medicine at the University of Southern California: "No reasonably intelligent person need go without completely competent medical care anywhere in California." Says Dr. Leona Baumgartner. New York City's commissioner of health: "No ailing aged person goes uncared for in New York City. But the care isn't always available in the form people like. Middle-income people find it difficult to accept charity."

How to Insure? The problem is less one of providing care than of providing insurance--insurance that would let oldsters pay for their own minimum care without having to pass a means test or take the dreaded step of applying for charity (the mere name "state" or "county" hospital can be a psychic shock to many). All the Democratic proposals revolve around Forand's plan to graft health insurance onto the social security system. That plan has advantages: the social security system is nationwide and well administered, does a sound and economical job of distributing monthly pensions (range: $33 to $254) to 13.5 million people, mostly oldsters. A compulsory plan could probably offer lower premiums than a voluntary one, would avoid the onus of a handout because everyone would contribute toward his own ultimate benefits. But Forand's plan also has disadvantages. At the outset it would force today's wage earners (and employees) to carry the load for the oldsters. It would subsidize the rich along with the poor, yet do nothing for the 4.000,000 aged uncovered by social security. It would probably raise less in contributions than it would pay in benefits, and the Government would be stuck with the check for the difference, which health insurance officials say would run into billions.

Private enterprise's answer to the Forand plan is private insurance. The insurance industry claims that 49% of the aged have some coverage from private policies, and up to 90% will have some by 1970. But more important than the number over 65 who have limited or comprehensive coverage is the number who have none at all: at least 51%. Many private policies for the aged cost much, pay little, do not cover certain illnesses, can be canceled at any time. One popular policy sells for $78 a year, pays maximum annual benefits of $610--$10 a day for up to 31 days' hospitalization, plus $300 for surgery and related bills. A ward hospital bed usually costs $20 a day, and the bill for treating a malignancy, stroke or fracture--the most common major medical afflictions of the aged--can easily run to $3,000.

Supporters of a Forand-type bill hold that it is economically impossible for the private insurance firms to provide'comprehensive coverage for people in their last years of failing health. Searching for an alternative to the Forand plan, Arkansas' Democratic Congressman Wilbur Mills, chairman of the House Ways & Means Committee, told the private insurance companies to frame a model "group'' policy for 13 million aged persons; they returned with a rate schedule that would cost a thumping 1.8% of the nation's gross payroll. Mills argued that the social security system could provide the same coverage for one-sixth that amount.

How Much Security? President Eisenhower, as he told his press conference last week, is "utterly opposed" to any compulsory insurance. At first, conservative Republicans in Congress prevailed upon the President to hold out for no legislation at all. But a liberal wing pressed for action. It was led by Vice President Nixon, who back in 1949 co-sponsored a bill to subsidize private health insurance for the aged. Ike and Nixon agreed to search for a modest plan that would be voluntary instead of compulsory, and administered less by Washington than by insurance companies and local medical boards.

Many Congressmen in both parties fear that any health insurance program for the aged hitched to social security would be only the first step to broader demands on the social security system. Widows and orphans would start hammering for admission. So would veterans and low earners. The American Public Welfare Association is already demanding that the Forand bill's benefits be extended to cover routine doctors' visits and home-nursing care. Says Thomas Pitts, A.F.L.-C.I.O. secretary for California: "Federal protection for the elderly is only the first step to pave the way for universal coverage"--meaning comprehensive federal medical subsidies for every U.S. citizen.

The U.S. is moving faster than it knows toward universal coverage. Social security coverage and benefits have been extended every election year since 1950. Social security taxes have jumped from 2 1/2% last year to 3% this year, will rise steadily to 4 1/2% (paid by both employer and employee on the first $4,800 of earnings) in 1969. And the taxes are falling behind the benefits. The social security program ran about $1 billion in the red in fiscal '59 and again in fiscal '60. In addition, the U.S. spends about $5 billion a year on other welfare programs, including veterans' benefits, medical and relief grants to the states. Next to spending for defense, spending for welfare is the fastest growing item in the federal budget.

But fiscal arguments are likely to carry little weight when placed against statistics of rising human need.* Morally, the idea of some kind of medical aid for the aged is laudable. Politically, it is expedient. Practically, it is complex, especially in the highly paid, highly individualistic U.S. Instead of rushing for a cure-all in an election year, Congress would do well to act like a doctor who knows his patient is ailing but is unsure of what to prescribe: the problem is there, the solution should be thought through with care.

* The U.S. is the world's only major industrial country without some form of national medical insurance for the aged. Belgium offered voluntary national old-age annuities as far back as 1850. now foots up to 75% of the medical bills for its aged. Bismarck's Germany instituted the first mandatory national health insurance plan in 1883; in modern West Germany, workers and employers alike are compelled to contribute 12% to 14% each to various welfare schemes--which is the main reason why workers get free vacations in mountain resorts when they are ill, and rock-bottom wages when they are not. Among the 30 other countries with governmental health insurance plans for the aged: Britain, France, Canada. Mexico, Japan.

This file is automatically generated by a robot program, so reader's discretion is required.