Retired Americans discover gaps in their health-care safety net. Questions of cost, quality, access grow as number of citizens over 65 soars

The safety net for Americans may be fraying anew. Concern this time centers on health care for retired Americans: Will they be able to afford, and receive, the services they expect? Specialists in the field say major problems of cost, quality, and access loom. There are several ideas but no consensus on what to do.

These issues will be increasingly important in the decades ahead when the number of elderly Americans is expected to skyrocket. Today 28 million Americans - almost 12 percent of the population - is over 65. That number is expected to rise steadily; by 2030, estimates are that 65 million Americans - 21 percent of the population - will be above 65.

At the moment the most impelling health issue for retired Americans is cost. Medicare, the government's program to help pay many of these costs for the elderly, now covers only about half of them. Health-care costs are rising at twice the rate of inflation; they already make up nearly 11 percent of the gross national product. Unless something can effectively slow them down, they are expected to be 15 percent of GNP by the end of the century.

Nearly 7 million retirees face a special concern. They had expected that the health-care insurance plans provided by their former employers would pay most of the medical costs not covered by medicare. For many, their expectations are jeopardized.

Most companies with health plans for retirees have not funded them and have been planning to pay their costs out of revenues. US Secretary of Health and Human Services Otis Bowen estimates the amount of this unfunded liability at ``more than $100 billion.''

Because of rising costs, diminishing profits, or bankruptcy, however, a growing number of these companies are trimming retiree health-care benefits or abolishing them, leaving many retired people without important financial resources they had thought were guaranteed.

``We're facing an awesome problem in the future,'' Thomas R. Burke says of the future of retiree health-care plans. He is chief of staff of the Department of Health and Human Services. Few specialists would disagree with his statement. ``We need to plan now,'' Mr. Burke says, to ensure that elderly Americans are able to afford desired medical care, and to try to keep costs within bounds.

Sen. Howard Metzenbaum (D) of Ohio offers one suggestion. A bill he has introduced would forbid any company that files for Chapter 11 bankruptcy from unilaterally ending retirees' health-care coverage (or life insurance). Instead, his bill would require that such a firm negotiate with retirees to provide some continued health coverage. Late last month the Senate Judiciary Committee approved the Metzenbaum measure. But it faces a long congressional road to become law.

Many businesses have a different recommendation. They want tax breaks for any company that funds in advance the health plans for its retirees. At present no tax advantage exists, which is a major reason, business spokesmen say, that so many retiree health plans are not funded. In recent years Congress similarly required that most employer-provided pension plans be funded by the time individual employees retire.

Such a proposal, if it were to become law, would put health-care plans on a sounder economic footing. But it would also reduce the income to the US Treasury and increase the already yawning budget deficit. For this reason, neither Congress nor the administration is likely to support the concept in the near future.

The Department of Health and Human Services has a quite different idea. It proposes a series of demonstration projects through which employers or unions would administer health plans for retirees. These would be alternatives to medicare, which would provide specific amounts of money. The department holds that a cost saving would be produced because medicare benefits and a company's own retirement benefits could be combined in one package, and managed by single administration.

Whatever approach is taken, says John Rother, tinkering will not suffice. ``To really fix'' the health-care problems of retirees ``you have to go back to basics and talk about [containing] health-care costs.''

Mr. Rother, legislative director of the American Association of Retired Persons, says three basic health-care problems in the United States require attention. They are, he says, ``out-of-control prices of health care, deteriorating quality of health care, and uneven access'' - in general, the poor have less access to high-quality care than do the affluent.