The week before his election, John Kennedy committed himself and his party to obtain promptly—within the first 30 days of the 87th Congress—legislation assuring adequate medical care for the aged—16 million men and women who are 65 or older. That some assistance to those hardest hit by chronic illnesses, diminution of income and rising medical costs must be given is widely accepted. But there is wide divergence on how it should be done. There are, however, certain guidelines which any program entitled to be called "adequate" should follow:
First, the prevention of illness, and the limiting of disability through early diagnoses and treatment should be primary aims.
Second, hospitalization should, wherever possible, be restricted to serious illness.
Third, emphasis should be given to long-term care in the patient's home.
Fourth, high-standard convalescent and rehabilitative services, including nursing homes and out-patient centers, should be provided for.
Fifth, because they are such a heavy item in the medical care budget of older men and women—including those not in need of steady hospital or physician's care—the cost of drugs and medicines should be made part of any balanced medical care insurance program.
Regrettably, this list omits physicians' and surgeons' fees. The governing reason for that is that in order to make the basic idea of medical care for the aged palatable to enough politicians, all the legislative proposals—starting with Aime Forand's HR 4700 a few years ago—have had to peg the percentage deductions from payrolls at one-half percent of the first $4,800 earned, to be shared equally by employee and employer. Given this limitation, the aggregate of taxable incomes under Social Security will be about $210 billion in 1961, a half percent of which is only $1 billion. This amount, which would be placed in a separate medical insurance fund administered by Social Security, sets the framework within which a determination must be made of the wisest manner of distributing funds as between all the kinds and degrees of health services.
There is a further reason for such omission: the lamentable but powerful opposition of organized medicine to the entire notion of financing medical care for the aged through Social Security. Perhaps the doctors gram of medical care for their older patients, even to the extent of advocating an increase in the payroll deduction; for after all, as they are prone to tell us, "somebody has to pay," and what more efficient way is there for arranging such payments than prepayment during one's working years for the costs of adequate health services during the years of retirement? But the physicians have not come around to that yet.
Given, therefore, the present accepted limit of one-half percent of payroll, the following specific provisions should be included in the legislation. They are derived from the recommendations in the bill introduced by Sen. Pat McNamara, as a result of the intensive studies and consultations made by his Subcommittee on Problems of the Aged and Aging, and originally co-sponsored by 23 other Senators, including Mr. Kennedy:
1. 90 days of hospital care per year, with no deductible principle.
2. 180 days of care in a skilled nursing home.
3. 240 days of care at home in a supervised home health program.
4. Out-patient diagnostic services such as laboratory tests and X-rays.
5. Payment of a portion of the costs of major drugs.
6. All retired persons eligible—men over 65, women over 62 who are not employed.
The first three kinds of benefits would be provided on a substitution-ratio basis; that is, for each unused hospital day, the individual would be entitled to two days of nursing home care, or 2 and 2/3 days of home health care (visiting nurses, therapists, etc.). Such a formula, it should be noted, encourages the more rational use of health facilities and services, and would tend to reduce (by at least 10 percent) the number of hospital days per aged patient, which now stands at about 15 days for each hospitalized older patient.
We agree that the Forand Bill would have excluded at least a million persons not eligible for Social Security benefits. The answer to this objection, however, is a simple one: Through direct federal appropriation (the new net cost of which would be minor when one considers the amounts already being expended through such programs as Old Age Assistance), a Medical Insurance Fund, under Social Security, could provide identical benefits to those men and women who retired before Social Security covered their occupations. These appropriations would decline as the numbers of such persons decrease in the future (nine out of lo persons in the labor force today are covered by Social Security). The McNamara bill would provide for such protection
It may be recalled that in the closing days of the special August session in the Senate, there was an attempt to amend the omnibus Social Security measure on the floor by offering a smaller package of benefits to be financed through the Forand-McNamara principles of Social Security payroll deductions. This compromise would have reduced the numbers of persons eligible to 9 million beneficiaries aged 68 and over, and also imposed an undesirable deductible feature (hospital benefits paid by the medical insurance fund only after the patient has first paid a certain amount, which discourages an initial seeking of medical attention, especially among the aged with lowest incomes). Even this compromise failed, by a vote of 51 to 44, because of the threat of a Presidential veto of the entire 1960 Social Security bill, the closing of ranks among all Republicans but one (Case of New Jersey), and the defiant negativism of every single Southern Democrat, still smarting from the Los Angeles convention. None of these circumstances need reoccur in 1961. Four or five Republican Senators (Mr. Javits, for one) will no longer be bound to obey Nixon's August orders to vote "Nay" (he was personally present on the floor—not in the Presiding Officer's chair—on the day of the 51-44 setback). And such Democrats as Robert Kerr, Lister Hill, John Sparkman and Russell Long can be expected to be loyal supporters of the new President's public welfare recommendations.
On the House side, the prospects are somewhat dimmer—not because a majority would vote against the kind of bill Mr. Kennedy wants, but because of the obstacle course it must run (through Ways and Means and Rules Committees) before reaching the floor. But under sustained pressure from the President, the Vice President, the Speaker and liberals in both parties, a satisfactory enactment is entirely possible.