Health-Care Research Indicates Reagan Is Wrong--Fund Cuts Will Hurt

President Reagan is asking Congress for yet another round of reductions in expenditures for publicly funded health-care programs. He wants to cut $1 billion from the federal contribution to Medicaid and to increase the deductible for the outpatient part of Medicare from $75 to $100. The President contends that these program modifications would harm no one, while his ideological opposites believe otherwise.

This is a case in which health-care research can inform public policy discussions. Studies published in leading medical journals over the last two years suggest that the President is wrong.

There are really only four ways to achieve savings in health programs: Cut the number of beneficiaries, reduce payments to providers, diminish the range of services covered or make patients pay part of the cost.

California pursued the first of these options in 1982, when 270,000 “medically indigent adults” were dropped from Medi-Cal (as the Medicaid program is called in California). These were the working poor--people with household incomes of $250 to $500 per month but who were not eligible for welfare. Clearly they couldn’t pay for their medical care. It was expected that they would obtain the care from the county health departments.

A group of 186 UCLA patients who lost Medi-Cal coverage at that time were followed up to see if they suffered in any way. Three-quarters of those with hypertension had good blood-pressure control before the cutoff; six months later only one-third did. Access to care also became much worse. Before losing benefits, 96% could identify a regular source of medical care; afterward, only 50% could do so. Overall health status and satisfaction with care also plummeted.

The experiences of individuals in that study may become commonplace as more dollars are shifted away from health programs. One patient with hypertension sought care from a private practitioner when she lost Medicaid eligibility, but was unable to afford her medications. She died of a brain hemorrhage, a well-known complication of uncontrolled hypertension. A man with an ulcer, who was vomiting blood, did not seek care because he felt that he could not afford the emergency-room fee. He finally went after 10 days, but not in time to save his life. Another patient collapsed and died at home of a probable heart attack after prolonged chest pain. He had run out of medication for his heart condition, and could not afford new prescriptions.

The Medicaid program is already a national disgrace. Reimbursement is so low and restrictions are so many that most physicians do not participate. In Los Angeles, as in many other communities, hardly any psychiatrists or obstetricians in private practice will accept Medicaid patients, who must depend on the beneficence of public institutions. Physicians who will not care for the poor should not be excused; they are parasites of the worst kind. Still, it is entirely predictable that as government slashes Medicaid further it will fall ever shorter of its goal of providing comprehensive care to the needy.

What about Medicare? Will a $100 deductible stand in the way of anyonewho really needs medical care? A study published last month compared the effects of free care and co-payment (paying a deductible or part of the fee) on 3,539 Americans. The investigators at UCLA and Rand Corp. found that co-payment reduced the use of care and overall expenditures. However, this was deleterious to the disadvantaged--the one-fifth of the participants who entered the study in poor health and low socioeconomic status. If they paid part of the cost of care, they experienced more serious medical symptoms--like chest pain, fainting and shortness of breath on exertion--than they did if care was free. Presumably, access to medical care without financial strain reduced the occurrence of serious symptoms through reassurance, prevention and timely control of disease.

The study did not include the elderly who participate in Medicare, but we might anticipate that their experience would be the same--or worse. Already the poor and nearly poor elderly spend 25% of their income for health care.

The Medicare program is also being eroded by reimbursement inferior to that in the private sector. Government freezes increase this disparity. The other day a colleague told me that he had decided against taking over a particular medical practice largely because 50% of the patients were on Medicare, making it economically disadvantageous.

In this year of the restoration of the Statue of Liberty, it is worthwhile to ponder the dreams and hopes that it represented to immigrants. If their descendants are yearning for decent medical care, they might be better off returning to the lands of their ancestors, so many of which now provide government-funded comprehensive health care.