discussed here.

THE CHOICES AHEAD

Eveline M. Burns, Ph.D.

HERE appears to be universal agree

Tment that the passage of the Social

Security Amendments of 1965 opened a new era for the health services. On all sides one meets the expectation that nothing will ever be the same again. And yet at first sight it is not obvious why this should be so. For at least in comparison with the social policies of other countries, what was enacted by the 1965 amendments was modest indeed. Our adoption in Title 18A of the principle of compulsory social insurance was extremely timid. We limit it to paying for hospital and certain types of hospital-related care, and indeed only to some types of care received in hospitals. And the benefits are restricted to people 65 and over. This must seem a very conservative step to the over 50 countries which have, in some cases for generations, used compulsory health insurance as the basic method for meeting the costs of health and medical care with no age restriction on the bene

ficiaries.1 Even in the United States the use of social insurance for health care is not entirely new. We have utilized for half a century a primitive form of social insurance, namely workmen's compensation, to pay for the costs of medical care received by those suffering from occupationally connected injuries or illnesses.

The use in Title 18B of a different method of meeting the costs of physicians' and certain other services, different in that coverage is voluntary rather than compulsory and in that people have to continue to pay premiums instead of benefiting from fully paid-up insurance at age 65, while the benefits take the form of indemnification or reimbursement rather than service, involves no major departure from our well-established systems of private insurance.

Even the potentially more radical Title 19 which opens the door to an extension of free health services to those higher up the income scale than the

public assistance recipients must seem a very tiny step toward universal access to needed health services to countries, such as Great Britain, which operate a comprehensive national health service available to everyone regardless of income. In any case, Title 19 is primarily an extension to more people of a policy we had already adopted in the KerrMills Act of 1960.

Yet I believe the general view that things have changed is justified. The 1965 amendments are the culminating step of a change process that has been with us for some time, and the tempo of which has greatly accelerated in recent years. Starting with the Hill-Burton Act in 1946, we have witnessed a long series of acts providing for federal aid for health research, for mental health, for community health facilities, for medical and nursing education, for training other types of health personnel, and for the health care of the medically indigent aged.2 Historically viewed, therefore, the 1965 amendments are but one more step in this cumulative process. There are, however, three facts that justify our attaching a special importance to them. To begin with, for the first time a public medical care program has been enacted which brings people of all social classes within its scope. Except for veterans and workers covered by workmen's compensation, governmental action to help people meet their medical bills has hitherto been limited to people who are found to be poor or indigent. This inclusion of middle-class people in a publicly operated program has important consequences. For it is the unfortunate and shameful truth that by and large we have been little concerned about the quality and adequacy of the medical care received by those we classify as "poor" or "indigent." Once middle-class people are involved, however, we become more sensitive about quality of service. Means test medicine is apparently not good enough for

them. Quality standards are embodied in the legislation and the scope of government action becomes broader than the mere removal of a financial barrier.

Second, the very magnitude of the new programs places them in a different category from previous legislation. As a federal program Title 18 is in effect in all parts of the country, the people covered run into millions, and the dollar costs into billions. More people who, remember, are voters, will have a stake in how the program operates. Perhaps even more significantly for the long run, the administrators of public programs have to be accountable to the public and accountability means visibility. From now on we shall have much more adequate and precise information about the availability, adequacy, and costs of our health services in the nation as a whole and in its various subdivisions. The alibi of ignorance will be ever harder to maintain and the pressure for reform will be intensified.

Third, the 1965 amendments were passed in the face of the active and highly publicized opposition of organized medicine. By the very violence and duration of its opposition to compulsory health insurance the American Medical Association has unfortunately created the impression that it was challenging the right of the people to use their government to achieve objectives to which they attached importance. Inevitably, therefore, passage of the legislation is viewed as a "victory," symbolizing and legitimating once and for all the fact that there is indeed a public interest in health and that the opinions of professional groups cannot prevail when in conflict with that interest. Never again will the medical profession be able to assert, as it did in 1946 when testifying on the National Health Program Bill, that doctors and only doctors were "in a position to pass upon the medical side of it, as to the determination of medical care and how to obtain

it, and the effect upon medical care of the system." ." Already this assertion has an archaic sound.

The Main Issue

Now that it is established that the functioning of our health services is a legitimate concern of social policy and that public action will be invoked when necessary, it is imperative that we clarify the ends of policy, assess the efficacy of available ways of obtaining them, and reformulate the role of the professional and other groups who must play a part in the enterprise. The overall goal is not difficult to define. The New York Academy of Medicine summarized it for us when, in a recent Policy Statement, they asserted that all people should have the assurance of an equal opportunity to obtain a high quality of comprehensive health care and that the availability of services should be based on health needs alone and not on ability to pay. In moving toward that goal there would seem to be three important choices facing the nation." First, shall the financial barrier to receipt of health services be lowered for more people and, if so, how? Second, shall social policy be concerned solely with removing the financial barrier? Third, is the primary concern of social policy with health services or with health?

Should the Financial Barrier Be Removed or Lowered for More People and, If So, How?

The main thrust and the main novelty of the 1965 legislation has been the deliberate use of social policy to remove or lower the financial barrier to access to health services. As we all know, this has been achieved by the use of compulsory, and voluntary federally subsidized, insurance for the benefit of people 65 and over, and by increasing

the numbers who can secure publicly financed medical services through a liberalization of the concept of indigency. It seems inevitable in the years ahead that insistent questions will be raised as to the desirability of limiting access to these programs to the presently covered groups. Specifically, we shall surely see (indeed we are already seeing) demands for the extension of social insurance to benefit groups other than the aged, and efforts within the states to broaden the coverage of Title 19 by progressive increases in the income limits.

How far these extensions will go will depend mainly on the degree to which existing private arrangements for the financing of health services prove able to remove or sufficiently moderate the financial barrier for those not now benefiting from Titles 18 and 19. Great hopes are being placed on the ability of private insurance, freed as it now is from the impossible burden of trying to solve the problem of the health costs of the aged, to expand its coverage of both population groups and types of service. Yet despite the levels of affluence of this country which suggest that the potential is great, it seems highly unlikely that private insurance coverage can be extended sufficiently widely and rapidly to ward off demands for further extensions of governmental programs. The percentage of the population with coverage declines sharply as income falls. Much of the rapid extension of coverage of the past has taken the form of health fringe benefits as part of the collective bargaining system. The better-off and the organized workers are the groups that have been easy to reach. But what of the employees of small firms, the domestic servants, and agricultural workers? What of the increasing numbers of older but not yet aged workers, many suffering from a variety of disabilities that limit their capacity to take employ

ment, or the families that have lost their breadwinner through death? Nor will it be easy to deny the claims of the increasing numbers of older people who have exercised their socially accorded right to retire at age 62 and who will surely question the sacredness of age 65, more especially as the pre-65 retiree will necessarily be drawing a benefit that is lower than that of the worker who retired at age 65?

It seems inevitable that there will be sizable groups for whom protection through private insurance is an unrealistic hope. Even more uncertain is the ability of private insurance to offer even approximately complete protection for the population groups who are insured. Deductibles, co-insurance, indemnity payments that fail to reflect rising costs of service, and exclusion of important components of medical care help to explain why by 1964 private insurance met only 33 per cent of all consumer expenditures on medical care. Even if the industry is able to maintain rates of increase in cost coverage characteristic of the last three years (actually since 1961 the rate has slightly slowed down) it will be 20 years before more than half of consumer expenditures will be reimbursed.

Methods of Removing the Financial Barrier

If dissatisfaction with the achievements, and distrust of the potential, of private insurance should lead to demands for the extension of governmental programs to groups not now covered, a choice will have to be made as to which type of program is to be expanded. We have available three major technics for overcoming the financial barrier. People may be given access to health services because they are judged by the community to have incomes and resources too small to enable them to meet their medical bills (i.e., they become eligible

on passage of a needs test), or because they have in the past paid taxes (euphemistically called contributions) as members of a social insurance system (i.e., eligibility rests on the concept of insured status), or because they are members of a population group for whose health status the community feels a particular concern. The last group it should be noted may be as small as presidents, and important public figures, as sizable as veterans with service-connected disabilities, or nursing mothers and their babies, or as large as the entire population.

There is an important difference between the needs-test eligibility criterion and the other two. The latter give access to health services on the basis of legally specified, nondiscretionary criteria. The beneficiaries are claimants and not applicants and are not subjected to the humiliating procedures typical of most means test administration in the past. The absence of a test of income in systems of social insurance or free health services has another important consequence. As I have already indicated, the groups eligible are sizable and, economically, much more representative of the entire population they are not composed solely of "the poor or indigent" and they have a significant middle-class component. This constitutes an important safeguard against the development of two systems of medical care: one for the population covered by the public program and one for everyone else.

It is, of course, not inevitable that publicly financed medical care for the needy should be of inferior quality. Indeed one of the choices we face today is whether or not to take advantage of the new funds and resources available under Title 19 to improve the quality of services instead of just giving more of the same old unsatisfactory service to more people. There are encouraging signs that in many of our communities