Social programs hit budget woes. Spending constraints make near-term solutions unlikely

On a broad range of issues from welfare reform to homelessness to AIDS, American society made modest forward steps in 1987. Yet at year's end, ultimate solutions appear as elusive as ever. Despite areas of progress, overall the plight of society's outcasts, its hungry and its homeless, has deepened. And the number of people with AIDS continues to rise in the United States and in the rest of the world.

The budget deficit problem has sabotaged efforts of some politicians to provide bigger federal programs in several areas, including welfare, low-income housing, child care, and nursing-home care.

Welfare reform

The year was 1967, the place the American South. A welfare worker had just left the dilapidated shack of an impoverished family whose members were barely subsisting on welfare. They had little education, no jobs, and little hope of becoming self-sufficient.

Defeated families such as this one, the welfare worker said, were why the federal government would soon dramatically reform the welfare system: ``It can't continue like this much longer.'' Most experts thought he was right.

But for 20 years there has been no major reform, although the US came close during the early 1970s. Early this year it looked as if 1987 would finally produce major reform that would help the nearly 11 million Americans toward self-sufficiency.

Early in 1987 a broad bipartisan consensus for change seemed to exist. Yet the 12 months have come and gone, and reform is as elusive as ever. As the year began to unwind, the consensus began to lose its force, often superseded by partisanship. Skeptics noted that a vote for welfare reform, unlike most issues Congress considers, has few political benefits.

President Reagan, who had insisted on welfare change nearly two years ago, this year wound up mostly standing on the sidelines, to the frustration of conservatives as well as liberals.

The age-old distrust most liberals and conservatives have for each other on this issue quickly resurfaced and led to failure to pass wide-ranging legislation. The House did approve one relatively liberal measure amid bitter partisanship; the Senate, where more compromise has existed, is to vote next year on a more modest proposal.

In sharp contrast to the federal government, several states are making major progress in experimenting with ways to end welfare dependency.

Reform programs in Wisconsin, California, New Jersey, Massachusetts, and Illinois, among others, may wind up pointing the way for the federal government eventually to go.

AIDS

In the United States, as in the rest of the world, modest progress has been made in dealing with acquired immune deficiency syndrome, as those not afflicted struggle to assist those who are. But immense challenges remain.

On the positive side, medical scientists now feel certain that they know the several ways by which virtually all cases of the disease spread.

They agree that the principal effort to stop the spread of the disease should be to educate Americans to change their behavior. The federal government spent $59.5 million this year to educate members of high-risk groups - homosexuals and intravenous drug abusers.

Many gay men have changed their sexual practices in ways that physicians believe will dramatically slow the spread of AIDS among them. Polls show the public is compassionate to AIDS victims, although individual concerns about contracting the disease show a lack of knowledge about its transmission.

Perhaps most important, federal experts are cautiously optimistic that AIDS may never spread widely among American heterosexuals.

``We're quite sure,'' US Surgeon General C.Everett Koop says, ``there isn't going to be'' an explosion of AIDS among heterosexuals. He notes that the number of Americans who contracted the disease through heterosexual sex this year remained at the same low 4 percent of AIDS cases that it had been. Experts warn, however, that the most likely transmission route into the heterosexual community would be through people who either are intravenous drug users or are the sexual partners of those who are.

And most experts continue to say it is extremely difficult to win the confidence of intravenous drug users, one of the highest-risk groups for AIDS, in order to change their behavior in ways that prevent spread of the disease.

To date some 30,000 Americans are estimated to have AIDS; the best estimate worldwide is between 100,000 and 150,000. No one knows exactly how many people harbor the virus that ultimately triggers the disease; the best guess is between 1 million and 1.5 million Americans, and between 5 million and 10 million people worldwide.

Experts say more accurate numbers must be arrived at to develop effective nationwide programs. Yet producing such numbers requires surveying the population. Wide disagreement exists, for reasons of privacy and efficacy, as to how such surveys should be conducted.

Deep disagreement exists, too, as to the most appropriate kinds of AIDS education programs. Should they emphasize the morality of abstinence or the prevention details of condoms?

Ethical questions concerning AIDS surfaced for the medical profession: Is it ethical for physicians, dentists, and other medical personnel to refuse to treat AIDS patients out of concern for their own safety?

No, says the leadership of the medical community; yet many physicians echo one who says quietly: ``But I have a responsibility to my staff, too.''

Health care

During 1987, recognition grew of other health care issues facing Americans.

For instance, one pleasant weekend last month many issues were discussed without resolution by several dozen top health economists, at a conference convened by William and Mary College in Williamsburg, Va.

One question: How can the 35 to 40 million Americans now without health insurance be provided with meaningful coverage?

What can be done to check the still-rising costs of medical care across the United States? Simply shifting the cost from individual Americans to someone else - an insurance company or arm of government - is not the final answer, it was widely agreed.

If costs continue to rise, will the poor be effectively cut out of good medical care, or at least the more expensive medical procedures?

Some wondered whether the answer to soaring costs was for the US to institute formally what has existed informally for years: a two-tiered health system. The poor would be provided good, basic health care, paid for by government if necessary; the affluent would buy their own, more elaborate services.

Across America a grave medical question involves long-term care, primarily of the aged, in nursing homes. Costs are extraordinary: a national average of more than $20,000 a year.

Everyone - economists, politicians, average Americans - agrees that most Americans cannot afford this cost. Yet little private insurance exists to help. And the only available government program, medicaid, requires citizens to spend themselves into poverty before it will assist them.

In Washington it is widely agreed that some means must be found to help Americans afford long-term care, in nursing homes or their own abodes. But no action has been taken because no one in Washington can figure out where to get the money in this era of soaring national budget deficit. Hunger and homelessness

Greater public recognition exists of the often-related problems of hunger and homelessness, whether it is publicly visible on urban street corners or invisible in city shelters.

The public continues its extraordinary volunteer efforts. Cities are providing more temporary shelters. And Congress this year provided an emergency $355 million for the homeless.

Yet city officials and advocates for the hungry and homeless say far more remains undone and that those problems - and that of poverty - continue to grow.

This month the US Conference of Mayors reported an approximate 20 percent increase in the numbers of both the hungry and the homeless in 26 surveyed cities. Two-thirds of the hungry and one-third of the homeless are children and their parents.

Where can these families find permanent homes they can afford? Their advocates say nowhere and blame the federal government: They note that federal housing subsidies have sunk from $35 billion in 1981 to $8 billion today. Little prospect exists for substantially higher funding next year.

Social security

Over the past 20 years, major boosts in social security payments have played a large role in pulling millions of elderly Americans out of poverty.

Not surprisingly, advocates for the elderly have fought any subsequent efforts to delay or diminish expected future increases.

This past year such an effort occurred: Information leaked from behind closed doors that federal budget negotiators were considering decreasing or delaying year-end cost-of-living boosts to retirees.

Advocates decried such an action as unfair and swung into action. After this happened, the idea of tampering with the cost-of-living boosts was quickly scuttled.

Nor is such a delay likely in the future; the political clout of the elderly, a high percentage of whom vote, will probably see to that.

Third in a series reviewing 1987 and looking ahead to next year. Tomorrow: politics.