Page images
PDF
EPUB

PROBLEMS IN DELAYED AUTHORIZATION OF MAA

There is also the problem of providing MAA to eligibles in time for it to be effective. As table X indicates, it takes an average of 3 weeks to complete the processing of an MAA application.

TABLE X.-Medical assistance for the aged: Applications received and disposed of and estimated average time lapse from receipt of application to disposal, from inception of program through September 1962, by jurisdiction 1

[blocks in formation]

A few States have attempted to cope with this problem by means of "precertification"—that is, the determination of eligibility prior to actual need.

Precertification of eligibility is valuable in at least two regards. The aged person in need of medical assistance will seek early and timely care if he knows that he has been declared eligible for MAA benefits. On the other hand, uncertainty of eligibility and the possibility of major expense (almost any expense is a "major" charge on the limited resources of the elderly) will frequently deter the seeking of the early care that prevents or minimizes serious illness. In addition, precertification aids in preserving the irreplaceable resources of the older individual. If application is made subsequent to the onset of illness, the applicant may very well have exhausted or

seriously depleted his resources by the time he applies or is certified as eligible for MAA. At that point, instead of being "medically indigent" he is simply "indigent." He is on relief. MAA was supposed to keep people off relief. As table XI indicates, illness and the need for medical care have been major causal factors behind the presence of so many of our aged citizens on old-age assistance rolls.

TABLE XI.-Old-age assistance: Percentage distribution of cases opened by reasons for opening, by social security status, 31 States, January-June 1962

[blocks in formation]

Source: Bureau of Family Services, Social Security Administration, "Reasons for Opening and Closing Public Assistance Cases," January-June 1962.

Statements concerning the desirability of use of precertification procedures in the administration of the MAA program have been made in previous publications of the Special Committee on Aging. The legislative message of Governor Scranton, of Pennsylvania, to which previous reference has been made, included this passage on the subject of precertification:

We must establish machinery whereby the eligibility of elderly persons to receive aid can be determined before illness strikes. A system of determining eligibility in advance will remove the additional suffering needlessly imposed by the present law 8 a

Precertification of eligibility would, of course, be built into any social security approach to the problem.

The problem of prompt and timely determination of eligibility for MAA is further compounded by the complexity of the eligibility requirements the means tests and variations in definitions of medical conditions covered. These, in conjunction with the complexity of the limitations on benefits, make it virtually impossible for a person to understand his rights. It is very doubtful that a person would know whether he is eligible for help. He can feel nothing but insecurity in a situation of this kind. Lack of understanding of the eligibility requirements leads to failure to apply in many cases which could qualify and, as a result, needed care is foregone.

88 Pennsylvania has commenced issuing identification cards to qualified individuals prior to actual need for MAA services.

Recognizing this problem, Senator Dirksen has proposed an amendment to the Kerr-Mills legislation (S. 305) which would provide that an applicant's statement as to his financial status, if made under oath, shall be "presumed to be factually correct for purposes of determining his eligibility." While passage of this amendment might expedite certification of eligibility, it would not, of course, climinate investigation of the applicant's financial status to evaluate the accuracy of the statements made under oath.

CHAPTER IV

THE LIMITED AND INADEQUATE SERVICES OF MAA PLANS

Having navigated the tortuous eligibility maze successfully, albeit reluctantly, the applicant's expectation of relief is all too often not realized. As is frequently the case, the range of assistance available does not include what he needs or else it is inadequate. And, assuming the necessary services are available, his "freedom of choice" of doctor or hospital may be nonexistent, with care available only in specified facilities or from specified physicians.1

SCOPE AND EXTENT OF MAA BENEFITS

Question. "In Kentucky, what happens if the hospital patient is still sick after 6 days?"

Answer. "We pay only for 6 days. If the patient is in the hospital longer, the care may be paid for by a relative or a charity, or the hospital may discharge him. We do not know what happens after our responsibility is met."

The above question was asked at the Fifth Annual Medical Services Conference of the Council on Medical Service of the American Medical Association, held in Los Angeles, Calif., on November 25, 1962. The answer to the question was supplied by Earl V. Powell, commissioner of the Department of Economic Security of the State of Kentucky. The theme of the conference was "Kerr-Mills in Action-1962."

Commissioner Powell's response is indicative only of an inabilitynot of an unwillingness to provide help beyond the minimal aid authorized under Kentucky's program of medical assistance for the aged.

Kentucky has since been able to extend the duration of its responsibility to 10 days for each hospital admission. Given the financial resources available, this extension is a signal achievement. Given the health care needs of the elderly, however, it is not enough. And, given the forum where Commissioner Powell offered his revealing reply, the situation is not without a touch of irony. The American Medical Association had, in full-page advertisements, hailed Kerr-Mills MAA because, "its benefits are unlimited."

Much of the testimony offered in support of the Kerr-Mills legislation prior to its passage was to the same effect as the advertised claim of the AMA. MAA benefits could, theoretically, be virtually "unlimited" because of the "open ended" matching offer of the Federal Government. It has been said, however, that the reach of the Federal offer far exceeds the grasp of the States. Almost every State excludes or limits benefits for at least one, or in many instances several, major areas of health expense.

Of the 25 States, and 4 other jurisdictions with programs in effect on June 1, 1963, only 4-Hawaii, Massachusetts, New York, and North Dakota-have plans which can be classified as "comprehensive"

1 App. D consists of a summary of the eligibility requirements and the scope and contents of services for each of the 29 jurisdictions with MAA programs in operation on June 1, 1963.

in terms of the definition established by the Bureau of Family Services of the Welfare Administration:

The "comprehensive" programs have been defined as those which include all five kinds of services with no significant limitations on illnesses needing care or the extent of care given. "Irtermediate" programs can have either (a) five kinds of services, with important restrictions on one or more, or (b) three or four services, with significant qualifications affecting one or more. "Minimal" programs provide two of the five kinds of care, with or without limitations.

According to these criteria, the Bureau of Family Services rates the 29 plans as follows:

Comprehensive: Hawaii, Massachusetts, New York, North Dakota.

Intermediate: (a) California, Connecticut, District of Columbia, Guam, Kentucky, Utah, Washington, West Virginia; and (b) Arkansas, Idaho, Louisiana, Maryland, Michigan, Oklahoma, Oregon, Pennsylvania, Puerto Rico, South Carolina, Tennessee, Virgin Islands.

Minimal: Alabama, Illinois, Maine, New Hampshire, Vermont.

Comprehensiveness is an essential element of a good medical care program not just because it meets a broad range of medical expense, but because it is the only way of assuring "appropriateness" of care. The physician caring for the aged person may select the most appropriate site and type of treatment and, at the right time-be it care at home, hospital, or nursing homes.

Any national program claiming to offer unlimited benefits would necessarily have to offer such comprehensiveness in all, not just four, States. And, in one of those four States, the Medical Society has questioned the "comprehensiveness of the program." In testimony before the Metcalf committee in New York, Dr. James Greenough, chairman of the Committee on Public Health and Education of the Medical Society of the State of New York, said:

While the emphasis in present medical welfare cases has largely been on curing the disease after it has occurred, modern medical science provides the knowledge and the techniques for the prevention of certain diseases, the early detection of others before the symptoms begin, and the rehabilitation of the patient. application of this knowledge in the MAA program has not been adequate. [Emphasis supplied.]

The

Table XII indicates the percentage distribution by type of service of the $250 million in vendor payments made under the MAA program during calendar year 1962. As will be noted, 95 percent of the payments went for hospital and nursing home care.

The fact that almost all of the MAA payments are going for hospital and nursing home care, despite the frequent limitations on the amount of such services provided to a recipient, indicates recognition by the States that these two types of medical care are the most needed and press most upon the elderly. This recognition and experience of the States should certainly be considered as justification of the emphasis upon hospital and skilled nursing home benefits as the "floor of protection" sought to be established by proposals such as the KingAnderson bill.

The five services are: (1) Hospital care, (2) physicians' services, (3) nursing home care, (4) prescribed drugs, and (5) dental care.

TABLE XII.-Medical assistance for the aged. Vendor payments for medical care by jurisdiction and by type of service, calendar year 1962

[blocks in formation]

Excludes $26,000 for the Virgin Islands; distribution by type of service not available.

2 MAA program in operation less than 1 year.

Less than 0.05 percent.

NOTE.-Details may not add to totals due to rounding.

Table XIII indicates the number of different recipients who received one or more types of MAA benefits during the fiscal year 1962. The data are, of course, not directly comparable with table XII, for the latter covers calendar year 1962. Nonetheless, table XIII does offer a working guide to the range and frequency of medical services provided. This is particularly true with regard to analysis of the experience of the four States with comprehensive programs. Obviously, little meaningful information may be gained from analyzing the experience of those States which do not include particular types of services in their MAA plans or limit them substantially. Further caution in evaluating table XIII should be taken in view of the fact that there is a vast difference in the cost of the various types of benefits. For example, while more persons received prescribed drugs than received nursing home care, far more money was spent for the latter type of care. (See table XII.)

[blocks in formation]
« PreviousContinue »