April 3, 1973
Page 10738
BARRIERS TO HEALTH CARE FOR OLDER AMERICANS
Mr. MUSKIE. Mr. President, genuine economic security in retirement will remain impossible unless immediate action is taken to help solve the grave medical cost problems which now place an unbearable strain on the limited incomes of older Americans. Lack of access to quality care and other major obstacles to adequate medical treatment cause an intolerable situation for senior citizens who seek to secure or maintain good health.
As chairman of the Subcommittee on Health of the Elderly, I intend to do all that I can to assure our elderly of the decent health care they need and deserve.
On March 5 and 6, I opened subcommittee hearings in Washington on "Barriers to Health Care for Older Americans." This first round in the series served two purposes.
First, our witnesses identified some of the key barriers to better health care for our elderly and suggested ways in which these might be removed or their bad effects reduced.
For example, Miss Alice Brophy, director of the New York City Office for the Aging, and Mrs. Marjorie Cantor, research director, told us of the problems encountered by older New Yorkers.
Their testimony was based on their recent, excellent study, "The Health Crisis of Older New Yorkers."
IDENTIFYING THE BARRIERS
Miss Brophy singled out "five major barriers to adequate medical care for older people which desperately call for action." Her list included the following:
First, an incredibly rapid rise of medical costs in the last decade has virtually undermined Medicare and has outpriced all but the very rich from quality medical care.
Second, Medicare as presently constituted fails to cover important medical services, required by older people – drugs, dentistry, podiatry, appliances, mental health care and home health services – despite the fact that this lack of coverage too often results in far more expensive alternatives for city, state and federal governments.
Third, medical services are fragmented and hard to locate. There are serious gaps in both facilities and personnel in almost every community. These gaps and the fragmentation of the present health delivery system prevent an older person from receiving the broad and comprehensive medical care he requires.
Fourth, the older patient currently has little or no input into the policy of the health care delivery system. Too often, he has little recourse when he is unhappy about the care he receives and, in many cases, the whole process of health care delivery is thoroughly confusing and depersonalizing to him.
Fifth, we must face the fact honestly that, with few exceptions, the older person who seeks health care is the unwitting victim of society's prejudice against old age. Young doctors tend to be impatient with the elderly, find them difficult to treat, and have little interest in the illnesses of old age, since most of these hold no promise of reversibility.
Testimony by Dr. Leslie S. Libow, chief of geriatric medicine at Mount Sinai Hospital Services, City Hospital Center, at Elmhurst, N.Y., supported Miss Brophy's fifth "barrier" quoted above. In Dr. Libow's words–
There are very few physicians and nurses in this country trained even for one week with regard to particular skills and care for the elderly ... people are not easily attracted to working in this area. I don't know what the motivations are to work with the elderly. We need more personnel who are trained in these areas.
Mrs. Mae Laufer, president of the Bronx River Senior Center, Bronx, N.Y., told us most effectively what the current health care crisis facing the elderly means in direct human terms. The experiences of Mrs. Laufer and her fellow senior citizens in attempting to secure decent health care at a reasonable price illustrate dramatically the shortcomings in our present health care system.
Mrs. Laufer, for example, shared with us the problem that faces many elderly in trying to pay for prescription drugs:
When a senior citizen of 74 goes into a drug store with a prescription the doctor gave her, and the drug is so expensive, $14, and she looks at the drug store man, and she says, "Can't you give me a little less? I only have $4 in change." But she does not get the drug, unless she pays $14.
As Mrs. Cantor told the subcommittee:
In spite of greatly increased public expenditures for health services for the elderly, the barriers to adequate and comprehensive care are still formidable.
The testimony cited above – and indeed all that we heard throughout our 2 days of hearings – supports Mrs. Cantor's conclusion.
We wanted to learn not only about the barriers to better health care for the elderly, but also some innovative and practical solutions to the problems they cause. Witnesses came forward with a number of interesting suggestions in this regard.
Prof. Charlotte Muller, of the Center for Social Research of the City University of New York, for example, urged "adaptation of the medicare benefit structure to support services and thus to redirect professional and technical manpower and institutional capital over a period of time into the work of health maintenance."
Professor Muller cited as an example of what she had in mind "outpatient drug coverage under medicare for important medications used by the elderly who are neither in hospitals nor nursing homes."
Another witness, Melvin Glasser, director of the Social Security Department of the United Automobile Workers, included among his recommendations the "abolition of the deductibles in part B – of medicare – and eventually of the present coinsurance and deductibles in part A of medicare."
Certainly this proposal would help meet the problem of costs which Miss Brophy listed as her first "barrier" to health care for the elderly.
Our March hearings, then, provided us with valuable testimony for our overall study of "Barriers to Health Care for Older Americans." We received essential information on major problems. And we heard proposals for helping to solve these problems.
ADMINISTRATION MEDICARE PROPOSALS
A second purpose served by our March hearings was the opportunity to take an intensive look at the administration's proposals to increase the cost of coinsurance and deductibles under medicare. Specifically, the subcommittee wanted to know how and why the administration decided to make medicare patients pay for–
First. Actual hospital room and board charges for the first full day plus 10 percent of all subsequent charges, instead of – as at present – the $72 deductible and nothing else until the 61st day;
Second. The first $85 of doctor bills, instead of the current $60; and
Third. Twenty-five percent, as opposed to the existing 20 percent, for physician services after the part B deductible is met.
None of our witnesses, with the exception of Health, Education, and Welfare Secretary Weinberger, supported these proposed cutbacks. Instead, they declared that the elderly are already faced with a health care crisis of major proportions and that the cutbacks can only serve to make the situation more desperate and intolerable.
Testimony by Mrs. Cantor presented the human story of what these cutbacks would mean in two typical examples.
Mrs. Cantor's first example concerned the costs to an elderly person for 21 days in a New York hospital. That is about the average stay for an older person in that city's hospitals. The average daily cost of $110 for semiprivate room and board charges was used. Excluded were laboratory fees, drugs, nursing care, and other items whose costs are generally completely covered by medicare after the initial deductible is paid by the elderly patient. Today this patient would pay $72 out of his own pocket. Under the administration's medicare changes, the same patient would pay $330, a 358-percent increase in out-of-pocket costs.
The second example Mrs. Cantor cited involved a chronically ill, elderly woman with a common ailment of old age, congestive heart failure. In calculating this patient's doctor's bills, the standard fees in New York City were used. It was also assumed that the fees were within Medicare reimbursement schedules and that the patient would not have to pay any additional costs beyond the 20-percent coinsurance. Today this patient would be required to pay $225 in doctor's fees for the year. If the administration's Medicare cutbacks became law, her out-of-pocket payments for doctor's bills would increase to $285, or almost a one-third jump.
Mrs. Cantor's examples, it seems to me, state a compelling case against the administration's cutback proposals.
What was entirely lacking in our examination of the cutback recommendations was any satisfactory rationale for them. Although Secretary Weinberger and his colleagues from HEW were before us for over 2 hours, we heard not one convincing argument in favor of putting the burden of budget cutting on ill, elderly Americans.
The Secretary says that the cutbacks seek to encourage greater cost awareness by health consumers in order to minimize overutilization of medical services. But the fact is that most social security recipients need no further encouragement for cost consciousness. They are already struggling on low budgets. Furthermore, it is physicians – not patients – who decide when and how medical services should be utilized.
The Secretary says that increasing deductibles and copayments has a positive effect in moderating utilization. But the fact is that existing studies are equivocal on this point. And there is no evidence that the elderly "overutilize" the health care system relative to other groups.
The Secretary says that the long-term patient would benefit from the administration's proposal because patients are generally less able to afford costs of care after lengthy hospital stays. But the fact is that only after 92 days in the hospital would medicare beneficiaries pay less under the administration proposal than they do now. And only around 1 percent of the Medicare population is likely to be hospitalized for 92 days or more. These figures, I might add, are based on conservative assumptions and have been provided by the Congressional Research Service at my request. What the administration proposes, then, boils down to this: increasing cost-sharing for about 99 percent of Medicare hospital patients so as to lower costs for about 1 percent. The Secretary says that the administration proposals would encourage the use of lower-cost alternatives to hospitals or nursing homes. But the fact is that in many cases such alternatives do not exist.'The Secretary says that recent social security increases make possible increased cost-sharing under Medicare. But the fact is that reliable estimates indicate that the administration's proposed Medicare changes likely would cut away half or more of the recent 20-percent social security increase in the case of older persons with any reasonable degree of illness.
So, the question which I asked in my opening statement still remains unanswered:
How can many of our elderly realistically expect to receive adequate medical care, in the face of these proposed Medicare cutbacks?
This question is even more significant in the light of these harsh facts:
Over 3 million older Americans live in poverty;
Most elderly single persons subsist on less than $40 weekly; and
Health care expenditures for the aged averaged $861 in 1971, well over three times that for those under 65.
Medicare is a vital program for the Nation's elderly. But the threat of high medical costs is still a grim reality for many millions of our elderly.
The fact is that medicare covers only about 42 percent of the total health bill for senior citizens. There are many serious gaps in protection, including essential out-of-hospital prescription drugs, and effective provisions for long term care.
The shocking truth is that the elderly paid out-of-pocket in fiscal 1971 almost as much for health care as they did the year before medicare became law. It would seem obvious that today their situation is even worse.
In the face of this, Secretary Weinberger and the administration call for retrenchment.
I say that improvement – not retrenchment – should be our goal. We will do all in our power to mount public and congressional opposition to further dismantling of this program.
I wish to acknowledge with much appreciation the fine contributions of our witnesses. They gave us much to think about and set the stage for further hearings this year in Washington and the field, or in special reports that might be issued in connection with the hearings. We will, as I stated at the hearings, go elsewhere in the Nation in our effort to understand more fully the barriers to health care for the elderly and what can be done to remove them.
No task could be more worthy of our attention. We are committed to a better life for the Nation's elderly. This cannot be realized unless good health care is accessible to all older Americans and at a price within their reach.