February 7, 1972
Page 2789
HEALTH CARE FOR THE ELDERLY
(Statement of Senator MUSKIE)
I said in 1961 that "our democracy may well be judged on the contributions it makes to those who have given so much during their active life in building the strength of our communities, states, and nation." I still feel that way.
We have made a great deal of progress in dealing with the problems of the aged. But, as the White House Conference on Aging last fall made clear, we still have an enormous distance to go.
What we need most is a new way of thinking about our aged citizens. We are talking about one out of every ten citizens. And in fifty years, 15 percent of all Americans will be over 65; a third of these people, fifteen million, will be over 75.
The Maine delegation to the White House Conference summed up best, I think, the mental approach we have to take. In their eloquent "The Credo of the Elderly – A Philosophy of Aging," they said:
America must consider and decide ways of achieving purposeful, primary goals to give aging man the choice of a return to a fuller existence, or America shall continue to relegate aging man to the back door stoop of history so he may invisibly and unnoticed slide into extinction. The last choice is not acceptable.
I agree with this credo. My distinguished colleagues of the Senate Committee on Aging are discussing today various aspects of the problems we must face. I want to talk about a field in which I have some special experience, the health problems of the elderly.
My special responsibility on the Aging Committee is as Chairman of the Subcommittee on Health. In addition, I have felt that health ranks with income as the twin issue of crucial importance to almost all older Americans.
I want to outline briefly the dimensions of the current health care crisis as it affects the elderly. In doing so, I will draw upon the findings of hearings conducted last year by my Subcommittee on Health of the Elderly as well as other special studies and inquiries made by that Subcommittee.
Then, I want to turn to the health recommendations of the White House Conference on Aging. These recommendations – if implemented promptly and effectively – can serve as a meaningful agenda for the '70's in the field of health care for our senior citizens.
The key to the health picture today for older Americans is rising costs and reduced programs. This situation is well documented in a report of the Senate Committee on Aging entitled, "A Pre-White House Conference on Aging Summary of Developments and Data," released immediately prior to the Conference. The following paragraph from that report summarizes the current crisis:
"Health care costs keep going up for all Americans. But for the older person the problem is compounded. He has only about half the income of those under age 65, but – even with Medicare – he pays more than twice as much for health services. He is doubly likely to have one or more chronic diseases than young people, and much of the care he needs is of the most expensive kind. And, while costs go up, services available under Medicare and Medicaid go down – a process which was accelerated considerably in 1971."
Several illustrations – out of many which could be cited – will demonstrate the problem of rising costs.
The premium for Part B of Medicare has increased greatly since the program went into effect in July of 1966. At that time the Part B premium was $3.00 monthly. By July 1 of 1971, the figure stood at $5.60 a month. And on December 31 of last year, the Administration – through HEW Secretary Richardson – announced that, as of July 1, 1972, the monthly premium would be raised to $5.80. That means the elderly will be paying almost twice as much for B premiums as they did when Medicare began.
Secretary Richardson made yet another announcement – earlier in 1971 – that again led to increased health care costs for the elderly. On October 1 of last year, he declared that the deductible on the hospital bill of the elderly would increase to $68 on January 1, 1972. This deductible for Part A Hospital Insurance was $40 when Medicare began in 1966. Subsequent increases were to $44 in 1969; to $52 in 1970; and to $60 in 1971.
And still another increase in cost was placed on the shoulders of the elderly who became ill at the start of 1972. Medicare beneficiaries with hospital stays of over 60 days began paying – as of January 1, 1972 – $17 a day for the 61st through the 90th day, up from the prior cost of $15 daily.
Charging Medicaid recipients for benefits received has recently emerged as a new problem affecting the indigent elderly citizen who is trying to cope with medical expenses.
In March of 1971 the Governor of California proposed co-payment charges for the welfare poor on Medi-Cal, which is the Medicaid program in California. The Department of Health, Education, and Welfare in Washington approved this plan in May of 1971, under a waiver of its regulations allowing States to initiate "small-scale experiments" in welfare administration.
A Medi-Cal Reform Bill became law in October of 1971. It required co-payment for provider services and prescription drugs.
The Administration – through HEW – ruled that the Governor of California could implement on an experimental basis the co-payment plan in the so-called reform legislation. The HEW ruling allows California to experiment with the co-payment approach for 18 months, beginning January 1 of this year.
The HEW approval of the California co-payment plan represents the first time that any jurisdiction has been permitted to impose charges on those receiving Medicaid. Such payments are prohibited by Federal law, but HEW lawyers have maintained that the law does not exclude experimenting with them, which is what was authorized in California.
My Subcommittee on Health of the Elderly conducted a hearing in Los Angeles in May of last year which attempted to assess the impact of cutbacks in Medicare and Medicaid. At the outset of that hearing, I said:
"Recent cost-cutting cutbacks and regulations have saved money, but at the price of denying urgently needed health care to our older citizens. By placing limits on care available and by increasing costs, we have merely decreased the health and happiness of our older people. Too often, the choice for them must be made between food and medicine."
Witnesses at my Los Angeles hearing discussed the co-payment provisions of Medi-Cal and other Medi-Cal cutbacks as well, including limiting reimbursements to two doctor visits a month; requiring prior authorization by a State consultant for all except emergency hospitalizations; and a slash of 10 percent of reimbursements to providers of health services.
Dr. Robert Peck, Chairman of the Los Angeles Chapter of the Medical Committee for Human Rights, called the co-payment provisions "heartless and hopeless." "And if, in fact, the doctors will attempt to collect this one dollar per visit," Peck asserted, "they will find they will spend five dollars in the collection procedure and will end up not collecting after all."
One month after implementation of the Medi-Cal cutbacks, Los Angeles County faced a backlog of 26,000 cases. Dr. John Anthony Smith, President of the Interns-Residents Association of Los Angeles County, told us that the hospital where he is employed in Los Angeles saw 1,164 Medi-Cal patients in April of 1971, 218 of whom were referrals by private physicians. The 218 were a ten-fold increase over referrals of the previous month.
Another witness, Dr. Hugert L. Hemsley, President of the Charles Drew Medical Society of Los Angeles, testified that the Medi-Cal cutbacks were depleting the poverty area of badly-needed medical resources.
Further cutbacks – in both Medicare and Medicaid – are written into the provisions of H.R. 1, which is scheduled to reach the Senate floor sometime soon.
H.R. 1 would increase the deductible under medicare part B supplementary medical insurance from the present $50 to $60, effective January 1, 1972.
H.R. 1 would also make the elderly subject to a $7.50 daily co-payment charge for each day in the hospital from the 31st to the 60th day. Under present law, the patient is subject to the $68 deductible, and, after meeting that charge, pays nothing on his hospital bill through the first 60 days.
H.R. 1 contains at least four cutbacks affecting medicaid.
One provision in H.R. 1 would repeal the existing provision requiring States to have comprehensive medicaid programs by 1977.
A second H.R. 1 provision requires maintenance of effort by the States for only the basic medicaid services. States can thereby reduce – without prior HEW approval or utilization control – other services, including outpatient prescription drugs, dental care, and eyeglasses.
Another H.R. 1 provision would impose cost sharing on medicaid recipients.
A fourth provision in H.R. 1 is designed to encourage greater outpatient care under medicaid. To accomplish this, there would be a cutback of Federal matching funds for medicaid by one-third after 60 days of care in a general or tuberculosis hospital; 60 days of care in a skilled nursing home unless the State establishes an effective utilization review program; or 90 days of care in a mental hospital.
From this summary it is easy to see what we face: for the elderly seeking decent health care, there are rising costs and reduced programs. We see this situation in announcements from HEW. We see this situation in the medicaid co-payment schemes in California implemented with the approval of the administration. We see this situation in those provisions of H.R. 1 which, if enacted, would lead to further cutbacks in medicare and medicaid.
What did the President have to say about the health care crisis when he spoke to the delegates at the White House Conference on Aging just last month? And how did his remarks compare to the response of the delegates themselves to the serious and deepening health problems of the elderly?
The President – I am sorry to report – gave scant attention to health care in his remarks to the Conference delegates.
Mr. Nixon spoke of eliminating the $5.60 monthly premium for part B of medicare.
Yet – as I have already indicated – the administration announced afterwards, New Year's Eve, that as of July 1 of this year the elderly would be paying $5.80 a month for this premium, making the charge about double the amount when medicare began. So where does the President and his administration stand on this issue?
The President also spoke of the desirability of extending Medicare to cover prescription drugs. Yet, the President's own Task Force on the Aging – almost two years ago – made this same recommendation.
Eliminating Medicare Part B premiums and extending Medicare to cover prescription drugs are both worthy objectives. Both were favored by the delegates to the White House Conference, as indicated in their recommendations. And I have been a strong supporter of these two Medicare reforms – restating my support for both on the floor of the Senate as recently as November 11 of last year.
It is comforting to know that the delegates to the White House Conference came forth with solid recommendations in the health field, which – if followed by quick and meaningful implementation – can lead to improved health care now for America's senior citizens.
The President has failed to lead – but the elderly are here to show us the way. What do they tell us?
First, the mental health special concerns session recommended the early establishment of a Presidential Commission on Mental Illness and the Elderly, with responsibility for implementing recommendations made at the White House Conference on Aging, and also charged, in general, with policymaking and oversight responsibilities in this long-neglected area. I am deeply gratified by this Conference recommendation, because it supports the bill which I introduced on December 1, 1971 – S. 2922 – for the creation of such a Commission. A proposal for this Commission came from a recent report of the Senate Special Committee on Aging – "Mental Health Care and Elderly: Shortcomings in Public Policy" – which was prepared at the direction of Senator Church and myself.
Second, the Conference section on physical and mental health asserted that "the U.S.A. must guarantee to all its older people health care as a basic right" and the delegates went on to say that "A comprehensive health care plan for all persons should be legislated and financed through a National Health Plan." I am in strong agreement with these sentiments.
I am a cosponsor of the Health Security Act that will provide national health care for all Americans. The time has come for this kind of program. As I said at Einstein Medical College last year, we need a Medical Bill of Rights for all Americans.
I said:
"The first medical right of all Americans is care within their means. Admission to a hospital or a doctor's office should depend on the state of an individual's health, not the size of his wallet.
"The second medical right of all Americans is care within their reach. Even if we guaranteed the payment of health costs, millions of our citizens could not find sufficient medical services."
Third, the Conference section on physical and mental health also declared that special attention must be given "to the development of adequate, appropriate alternatives to institutional care."
Legislation which I have cosponsored in the Congress – S. 882 – would promote this objective by authorizing payment under Medicare for services performed by a household aide.
In addition, there is no doubt but that we have to move toward new and more extensive alternatives to institutional care. We need to do that and we need to think about systems of community health care for the elderly.
Fourth, conferees at the section on physical and mental health urged that "Special attention should be given to increasing the funds available for basic research and for operational research with a strong suggestion that a gerontological institute be established within the National Institutes of Health to provide the essential coordination of training and research activities." This purpose would be realized through S. 887 which I have cosponsored.
We need to pass S. 887. We will not be able to help the aged with their special problems as much as we should until we understand more. We need to know more about the processes of aging and we need to encourage our best scientists to work in this field.
Fifth, the Conference delegates were deeply concerned – as I am – with the cutbacks in Medicare that have threatened to erode completely this program which even now pays only 43 percent of the medical expenses of the elderly. I have outlined earlier some of the suggested cutbacks in Medicare and Medicaid contained in H.R. 1. The section on physical and mental health at the White House Conference called for "expanding the legislation and financing of Medicare" while a national health plan is being worked out by the Congress and the Nation. The hearings on "Cutbacks in Medicare and Medicaid" – conducted by my Subcommittee on Health of the Elderly – have vividly demonstrated the severe impact that any further diminution of Medicare would have on our Nation's older population. The Conference delegates are aware of this. I can only hope that the present Administration can and will show the same sensitivity to this – and every other – health care imperative for senior citizens.
We have at this moment a unique opportunity to move ahead in health – and in every area of concern to the elderly. White House Conference Recommendations are linked to election year momentum to provide this special chance to help those who have done so much for us. This is an opportunity that we must not pass by.