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.