Health Care at the Crossroads

When health care policy is evaluated in terms of its intended goals, a mixed picture emerges. Federal programs have helped to train thousands of health care providers and to fund path-breaking research. U. S. health care, for acute life threatening conditions and injuries, is the best in the world. Public policy, particularly Medicare and Medicaid, has been successful in reducing the financial burden of health care for the elderly and poor and in addressing inequitable distribution of care by lowering financial barriers to medical care. Yet burdens remain for much of the population, and serious problems of access persist.

Moreover, unintended consequences are a major concern, as health education policy contributes to the overspecialization of physicians, and Medicare and Medicaid contribute substantially to the cost escalation in health care. as health care policy reduces the financial burden on specific individuals, it increases it on society as a whole. Successes Some of the most dramatic gains in health are directly attributable to Medicare and Medicaid. People are seeing physicians regularly as a result of their enactment, though gaps between poor and nonpoor still persist.

Approximately 36 million persons each year benefit from Medicaid and 37 million from Medicare. Twelve million persons per year use hospital services covered by Medicare and Medicaid, and 47 million persons receive physician services. Nearly 2 million persons each year receive care in skilled nursing facilities, and 3. 5 million receive home health agency services. Measures of health also show improvement for the poor and aged. Data are not available in death rates by social class, but data by race show that age-adjusted rates fell 10 percent for whites and 13 percent for African Americans and others between 1965 and 1974 infant mortality declined in this period by 38 percent for nonwhites and 31 percent for whites. Yet death rates and infant mortality rates are still higher for minorities.

Health statistics for aged since 1965 show declines in death rates from diseases particularly afflicting the elderly. Medicare and Medicaid achieve these result with extremely low administrative costs, less than 3 percent of the benefits paid for Medicare, a result far better than private health insurance carriers. (Relman). Problems Medicare and Medicaid, however, have failed to do all their sponsors had hoped for and have led to increasingly high costs.

Both programs have, moreover, some structural flaws that inhibit their ability to deal most effectively with the major problems in health care. access to health care remains a problem along geographical, racial, and income lines. Large differences in death rates, life expectancy, and infant mortality persist. Because of state variations in eligibility definitions, half of the poor are not covered by Medicaid. Burdensome procedures on poor, elderly, sick, and often illiterate applicants keep millions of persons from receiving benefits for which they are otherwise qualified.

In the seventeen southern states, the length of the Medicaid application ranges from three to fifty-two pages. Rural residents still find it difficult to see doctors, dentists, and other providers. There is also some evidence of high rates of unnecessary surgery under Medicare and Medicaid. Moreover, because of state variations in coverage, the amount spent per recipient varies widely. Some states, because of cost increases in the program, have placed limits on levels of coverage that amount to very high coinsurance requirements. (Relman). Gaps in coverage exist within the Medicare program.

It is very restrictive on nursing home care; those aged who need this care must “spend down” their financial resources until they are poor enough to qualify for Medicaid. Many of the aged, especially those near poverty, continue to have high out-of-pocket expenditures because of deductibles and coinsurance, averaging 13 percent of income for those near poverty. Medicare pays only about 42 percent of the health costs of the aged. The rest must come form Medicaid, ou-of-pocket spending, or privately purchased “medigap” insurance. (Anders & Hulse).

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