CRUCIAL PROBLEMS FOR SENIORS

The Republican Party is now king of Capitol Hill. But just because Republicans will lead the House of Representatives and the Senate doesn't mean that all will be well. On the contrary, difficult problems lie ahead for us.

The essence of the problems can be stated simply. The United States is overcommitted, particularly in its obligations to those of us 65 and over. With our total numbers increasing every year, the costs of Medicare and Social Security are climbing. Meanwhile the budget isn't balanced. So inevitably there are Congressmen who wonder if a big part of the deficit problems couldn't be solved by cutting Medicare and Social Security.

True, Social Security has a trust fund that won't be exhausted for a few years, so the chief pressure for quick action comes from those who want to cut Medicare.

The political oratory suggests we are enjoying the world's most luxurious medical care. But the truth is that Congress has cut payments to both Medicare doctors and Medicare hospitals substantially in recent years, so that in terms of paying our way for the real costs of our care, we in Medicare are only slightly better than the poor people in Medicaid. The rates government pays for Medicaid patients are a real rip off of doctors and hospitals, who naturally often welcome us much as we would welcome bubonic plague.

As a result it's no longer rare for a senior citizen to try to make an appointment with some excellent doctor and to be refused because the doctor "does not see Medicare patients." Such doctors don't see us because fees Medicare pays don't cover doctors' expenses.

But there are those in the Clinton Administration who see another way to economize on Medicare costs. Their preferred solution is to force all of us into health maintenance organizations, or HMOs.

There are hundreds of HMOs in this country, and some are better than others. But the basic business imperative on all HMOs is the same. If I join an HMO, the organization gets a fixed sum each year for my membership, out of which it has to pay for my care. An HMO makes money if it spends less on its members than the sum of the payments for them. It loses money if it spends more money on treating its patients than the amount it is paid.

HMO supporters say these pressures make HMOs more efficient. Maybe. What is clear is that an HMO can increase its profits by doing as little as possible for its members. So each HMO doctor is under pressure to use as few outside consultants as possible, to hospitalize patients as rarely as possible, to use generic and cheap old drugs rather than the most modern and most powerful drugs available, and in general to begrudge us every dollar he has to spend on us.

Many HMOs use a device called "economic credentialing" to force their doctors to behave this way. What this means is that every year they look at the costs of their doctors, and then fire the 10 to 20 percent who have spent the most money.

Most of this unpleasant reality is covered up. HMOs don't have to tell their patients how many operations they've refused to do, how many outside consultants they didn't hire, and how many of the most modern and helpful drugs they refuse to use. So the individuals affected suffer and the world never hears of their pain. Moreover, where Medicare patients are concerned, a substantial percentage who get substandard care eventually die prematurely. But then death in patients 65 or over doesn't cause much excitement.

Our position, I think, must be against both means of further cutting Medicare costs. The doctors and hospitals who take care of us are entitled to fees that enable them to pay their bills. Of course any of us who want to join an HMO should have that right, but the government should not be allowed to force those of us who don't want to join an HMO to do so. And in any case HMOs should be compelled to make a lot more information public about what goes on in them.

I'm writing some notes to my representatives in Congress and to the leaders of the House of Representatives and the Senate to suggest that there are other places in the budget besides Medicare appropriations to make economies. They can cut all those needless subsidies to farmers, big manufacturers, and other special interests. We seniors built this country, and we're entitled to decent care in our later years.

Harry Schwartz, now 75 years old, was a member of the New York Times editorial board for almost 30 years. Since his retirement he has written often for the Wall Street Journal and USA Today. He has also published more than 20 books.