A Job Half-Well Done

The observance today of the 20th anniversary of the signing of Medicare and Medicaid legislation is muted by a preoccupation with costs and by a realization of how much more is required. Those realities cannot be ignored, but they should not be allowed to obscure the extraordinary contribution that this legislation has made to the health of senior citizens and the disabled through Medicare and to the health of poor people through Medicaid.

Today Medicare is serving almost 31 million persons--27.9 million aged and 2.9 million disabled--while Medicaid, known as Medi-Cal in California, is serving 22.1 million--more than half of them adults and children on welfare, but including more than 3 million senior citizens under programs designed to supplement for low-income persons the basic Medicare programs.

The cost has exceeded the estimates, and has become the most conspicuous problem in the burgeoning price of health care in the United States. The nation is now paying more than a billion dollars a day for health care, 11% of the gross national product--a higher proportion of national income than any other nation. Of that total, $70 billion, almost one-fifth, is for Medicare, and $23 billion, about 6%, represents the federal share for Medicaid.

But even with these immense infusions of federal dollars, and even with the large investment of state matching funds for Medicaid and Medi-Cal, these programs meet scarcely half the total costs of health care for those 65 and older, and protect only about 35% of the poor and near-poor.

“Older citizens will no longer have to fear that illness will wipe out their savings, eat up their income and destroy lifelong hope of dignity and independence,” Lyndon B. Johnson, then President, declared when he signed the legislation 20 years ago today. But that promise has been fulfilled only partly. Old people continue to be pauperized by debilitating, long-term illnesses requiring care beyond the lifetime limits allowed under Medicare, forced to exhaust their life savings before they are eligible for supplementary support under Medicaid. And there are millions more in the poverty sector, young and old, who have been disqualified by cost-cutting rules or who are otherwise ineligible for Medicaid, left without organized health protection. The anniversary finds the Reagan Administration and Congress so preoccupied with controlling costs that little is being done to fill the gaps and broaden the coverage despite clear evidence of the cost-effectiveness of extending protections. The success of Medicare in slowing the rate of cost increases through the imposition of fixed diagnosis-related fees for hospitals has demonstrated that there was room for more efficient use of the health-care system. But refinements are called for. The arbitrariness of decisions, and the acute pressure to cut hospitalizations, has placed some patients at risk and created injustices in the compensation of both physicians and hospitals.

There is now a need to return to the fundamentals that prompted the enactment of Medicare and Medicaid 20 years ago. The United States was among the last of the industrialized democracies to provide basic protections in health care. These protections fall far short of what is appropriate, of what is in the public interest. Access to good care is still denied to millions of poor people. And thousands of senior citizens still live in fear of exhausting their life savings in meeting the costs of long-term illness. Policies and programs now need to be designed to address those problems, pursued with the same rigor and concern for equity that have been applied to efforts to control costs.