If Medicare Fails, What Will Replace It?

Part II

All health insurance plans aimed at the poor have a basic weakness: since all their money comes from the government, any cut off in the government fiscal supply will instantly kill the plan. In addition, the "poor-only" programs may become over-specialized.

(This is the second in a two-part series. Yesterdays article told about the problems American medicine is having delivering its product to the American consumer, and about the plan Harvard Medical School has devised to help ease the strain. Today's article tells about what the plan will do in the ghetto, why John Kenneth Galbraith is on its board of directors, and why government and medical officials across the country are watching to see whether the plan can work.)

WHEN THE Medical School's Community Health Plan opens its first clinics in August, one of its branches will be in Roxbury's Mission Hill discussion. Mission Hill is only a few blocks away from the imposing buildings of the Med School, but mere proximity is obviously not the reason for the plan's outpost in Mission Hill.

Of all the people who suffer because of inadequate distribution of medical care, the poor and the black have always suffered the most. Before the government invented its patchwork medical insurance plans, the poor simply couldn't pay for decent care. And now, even with the advent of Medicare and Medicaid, coverage is usually not complete enough to meet basic medical needs.

The skimpy insurance umbrella under which the ghetto poor live does not mean that needy patients must sometimes forego care; there is a more subtle and more debilitating disadvantage as well. Jerome Pollack, executive director of the Med School's health plan, said last week that "since the supply of doctors here is limited, the poor actually have to compete with the affluent for available care. In effect, private insurance may deprive low-income areas of care by attracting doctors into the well-insured areas."

One overt aim of the Med School's plan is to help those medically-deprived poor patients. By the time the plan reaches its full enrollment in 1971, some 6000 people from the Mission Hill area should be signed up to get Harvard Health Plan care.

The 6000 will all come from Medicaid rolls, and their fees for the Harvard Health Plan will be paid by the government. No one will be forced to switch to Harvard coverage; people on Medicaid will be allowed to choose which plan they want to join. Those who are able to get into the health plan will get virtually all their care for free. There may still be a $1 charge for doctor visits, but many of the gaping holes in Medicaid coverage will be filled.

Pollack and his staff are also tailoring a number of the health plan's tactics to meet the special needs of the poor. Staffs of recruiters will travel through Mission Hill neighborhoods and encourage people to come in for check-ups and preventive care.

The major health problem of poor people, Pollack says, is that they are "under-utilizers of maintenance and prevention, and over-utilizers of emergency treatment." By luring needy patients in for more prevention--and by using the health plan's emphasis on out-patient treatment -- the Harvard center in Mission Hill will offer the poor a kind of medical assistance much different from the mere doles that Medicaid and Medicare pass out.

But despite these efforts at curbing Roxbury's swollen sickness rate, no one is pretending that the Harvard health plan is solely--or even primarily--designed to help the poor. The 6000 poor patients who will join the program will make up only 20 per cent of the plan's membership. The other 80 per cent--24,000 people --will be people who now have Blue Cross or other kinds of private insurance.

If angry liberals pressed them hard enough, the plan's administrators could come up with reasonable excuses for including so many affluent patients at a time when the poor are sicker and more desperate. Other health plans, Pollack might say, are famous for their "social conscience," and only 10 per cent of their patients are poor. So if the Harvard plan takes 20 per cent of its patients form Roxbury it must be twice as socially concerned.

But that kind of simplistic rationalization never comes up. The reason for the plan's economically-mixed clientele is far more subtle. All plans aimed entirely at the poor have a basic weakness: since all their money comes from the government, any cut off in the government fiscal supply will instantly kill the plan. Pollack adds that poor-only programs may become over-specialized. If they only treat sick poor people, they may lose touch with the real world of American medicine; their techniques will be fine for the ghetto, but they won't apply to the majority of the country that isn't poor.

It is fundamentally this fear of drifting away from the medical mainstream that directs most of the plan's decisions -- including drawing the "poor line" at 20 per cent. In each of their moves, the plan's directors are conscious of a national audience. What they are trying to build is not just a plan for treating 30,000 people in Boston. Instead, they are piecing together a model that they hope can reshape medical systems all across the country.

From the beginning, the Harvard Health Plan has deliberately tried to make itself into a model. Tapping the medical wealth of the Boston area, the plan's designers could have cut several corners and come up with special features that would work well --in Boston. In the face of that temptation, the plan's reluctance to cut corners and develop special techniques shows how seriously it takes its role as a national health-care model.

"We have been extremely careful not to put in any systems that are unique to Harvard or to the hospital centers here," Pollack said. "All our planning has been directed at getting in the mainstream."

The result of the drive towards the mainstream has been a simple model of a community health care system. Not a utopia, not a complete restructuring of medical capitalism, but a practical set of instructions that other hospitals and insurance companies can follow.

The self-denying care with which the Boston planners have tried to build a national model might be pitiful if the rest of the nation paid no attention. But the relative wave of excitement that has swept through the American medical community since the Harvard plan was announced suggests that Pollack may indeed be setting a pattern for national reform.

"Right away, any program that Harvard Medical School undertakes has a certain audience," Pollack said. When the plan was announced last November, it made front-page news all over the country. Since then, requests from medical planners have poured into Pollack's office. "There is an avid national interest in the plan," Pollack said last week. "We have already received many inquiries; I've already talked with several people interested in following ht model."

Part of the reason for the health plan's national ambitions may come from the backgrounds of the men who direct it. Before he came to Harvard, Pollack had served as professor of administrative medicine at Columbia and director of Nelson Rockefeller's Committee on Hospital Costs in New York. In his years in New York, Pollack used to buy medi- cal service plans for three million people. By the time he came to Harvard in 1965, Pollack says he "came with a national outlook."

When Pollack arrived at the Med School and became an associate dean for Medical Care Planning, the idea of a community health program had already run through the Harvard discussion mill several times. As early as 1961, a committee working on plans for the new Affiliated Hospitals Center recommended that the Center incorporate some kind of new continuous-care pre-payment program as part of its responsibility to the community.

The idea quietly gestated for several years. Then in 1965, Dr. Robert Ebert became the new dean of the Medical School. Dr. Ebert had earlier left Western Reserve to become Jackson Professor of Medicine at Harvard. The Jackson chair is one of the most prestigious in the world of medical academics, but there has been constant speculation that the prestige was not all that drew Ebert to Harvard.

Most Med School officials say that Ebert did not leave Western Reserve because it was opposed to community-involvement health plans. The only evidence is circumstantial: Ebert came to Harvard, and after he became dean, the Med School's health plan finally came to life. Throughout 1965 and 1966, Pollack and others worked on the detailed planning necessary to develop the program. Talking with administrators, chiefs of staff, and insurance directors, the Harvard staff kept working on plans into 1967. Finally last November, Harvard University announced that its Medical School would operate the nation's first university-sponsored pre-paid community health care plan.

In November, the details of the plan's administration were also laid out. The Health Plan was formally incorporated by Harvard University, and the plan's corporation is loaded with Harvard-linked people. The corporation--which Pollack says will provide only the "broadest overview" of the plan's operation--includes Dr. Ebert, President Pusey, Pollack, and Henry C. Meadow, another associate dean at the Med School.

The other members of the corporation retain the Harvard touch. They are John Dunlop, Wills Professor of Political Economy; Dr. Dana Farnsworth, director of the University Health Services; Arthur E. Sutherland, Bussey Professor of Law; Dr. John C. Synder, dean of the school of Public Health; and Francis H. Burr, a member of the President and Fellows of Harvard College.

In light of the parochial make-up of its corporation, the members of the health plan's board of directors come as a surprise. Several of them have Harvard connections--like Dr. Sidney Lee, another associate Med School dean, and Dr. Alonzo Yerby, director of Harvard's interfaculty program on health and medical care, and even John Kenneth Galbraith, Warburg Professor of Economics.

As Galbraith's inclusion suggests, the emphasis of the directors' board is on a wide range of expertise. This too is part of the plan's effort to set a national precedent. All the policy decisions for the plan's operation will be made by the board of directors; the men that Harvard has chosen to serve on its board of directors, then suggests what kind of broadly-based coalition it thinks is necessary to run new health plans.

One third of the directors will be medical specialists--physicians, chiefs of staff and other hospital officers, and doctors from local medical schools. Another third of the directors will come from the consumers of the health plan. None of those members has been chosen yet, but seats are being saved for representatives of labor unions, insurance subscribers, and Medicaid patients who enter the plan.

The last third of the directors shows an even broader reach. This third will be made up of men who reflect what Pollack calls "the general interest"-- men like Galbraith and another director, Rev. James O'Donohoe, a dean of students from St. John's Seminary in Brighton.

"There are times when both the providers of the care and the consumer may act in a shortsighted or narrow interest," Pollack says in explaining the "general interest" directors. "We hope that by bringing in this third element, we will be able to aim the program towards some of the larger social goals and problems."