Medicine: The Mess in Medicaid

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Medicaid and Medicare. Few words relating to America's health have been mouthed so often since Congress wrote them into law in 1965. Yet few Americans understand them. As a consequence, the Department of Health, Education and Welfare has printed 550,000 copies of a deliberately cute, three-color booklet entitled MEDICAID—MEDICARE—Which Is Which? Medicare, it points out, is a federal program and is the same all over the U.S. Medicaid, on the other hand, is a federal-state partnership under which states design their own programs. How widely these vary and how grave are their defects became clear last week as Medicaid passed its fourth birthday.

Whereas Medicare has drawn predictable criticism for costing more than was estimated and invited abuse by a few unscrupulous doctors, dentists and druggists, it is in general a successful and effective program. Not so Medicaid, which is a shambles at both the federal and state levels.

Patchwork Program. In Washington, Medicaid is a headless monster. To the extent that it is run at all, it is controlled by one of the most cumbrously named offices in government: the Medical Services Administration of HEW's Social and Rehabilitation Service. Its commissioner, Dr. Francis L. Land, was summarily dropped from the post last July at the height of congressional criticism over Medicaid's failings. The Administration has still not replaced Land.

Congress designed Medicaid as a patchwork program. Each state could join after its plan was approved by HEW. The minimum benefits, which every state must provide for all "public assistance" (meaning welfare) recipients, are 1) in-and out-patient hospital care, 2) other laboratory and X-ray services, 3) nursing-home treatment and physicians' services. The patient's eligibility depends on the state's definition of need. That may be anywhere between $2,448 family annual income, as in Oklahoma, and $5,000, in New York.

Enmeshed in Tape. Through 1969, Wyoming was the only state offering nothing beyond minimum benefits and only to welfare families. Forty states had operating plans offering additional services such as dental care, prescription drugs, home health care, eyeglasses, clinic services and a variety of diagnostic services. No two states had all the same benefits for the same type of people. In 22 states coverage had been extended beyond the welfare population to the stratum classed as the "medically needy" —those who can subsist only if they have no doctors' or hospital bills to pay.

It is largely in determining what constitutes medical indigence that many state plans have become hopelessly enmeshed in red tape. In New York, which ranks with California as one of the two most liberal states, an applicant for medical-indigence status must supply information about the annual income of each family member, the total of savings, stocks, bonds, and the cash value of insurance policies, including dividends, Social Security payments, and contributions from legally responsible relatives. The applicant should then receive a qualifying card, which is valid for no more than a year, during which time the whole process has to be repeated at least once.