Behind the headlines bannering the content of coal miners and their contract problems, another drama is [WORD ILLEGIBLE] - an exodus of doctors from the neediest corners of the [WORD ILLEGIBLE] coalfield.
A survey by the federal-state Appalacian Regional Commission indicates that at least 59 physicians have left mining community health facilities in four coal states since last July.
The contract on which 160,000 [WORD ILLEGIBLE] Ming Workers voted yesterday could establish a new health care financing system that some ARC officials expect will hasten the departure of more doctors.
"It is lear that health service in the region will deteriorate, " said Nancy Lane, an ARC health specialist.
"The miner's previous system was attempting to create uniformity of service, and there were some outstanding examples at some of the clinics. That will be gone under the new program."
The departure of physicians from Appalachia, many of whom were recruited only with great difficulty, coincides with problems that have virtually bankrupted a health care program developed by the UMW and the coal industry during the last 25 years.
The all-expenses-paid health care system for UMW members and their families - more than 800,000 beneficiaries - ran into deep trouble last year when a series of wildcat strikes cut back income for the program.
Since its incetption in the late 1940s, the program had been financed by a system of tonnage royalties assessed against the coal companies. The program was administered jointly by labor and industry.
Through the program and the finanicial stability that it promised, some 50 nonprofit medical clinics were developed in mining areas from Pennsylvania to Alabame, providing services for all but aimed specifically at UMW families.
A basic philosophy guiding the clinics has been that a high level of preventive care an outpatient services - subsidized to a degree by the medical fund - would in the long run reduce hospitalization costs for the program.
That subsidy, actually a "retainer" determined in advance according to need and services at the clinics, provided income stability that allowed the centers to attract physicians from outside the region at attractive salaries.
Jeffrey Cohelan, a former California congressman who is executive director of the Group Health Association of America, described the program in these terms:
"Some of the most heroic medicine in the country is practiced down there. There is a missionary spirit. The good doctors down there are just beautiful people."
Cohelan was referring to physicians, many of them just entering practice, who are willing to work at salaries that begin around $30,000 per year in areas where schools, social services and cultural attractions often are less than what they would find in more affluent metropolitan areas.
And, as clinic employees whose income are not dependent upon the volume of patients they treat, the doctors customarily treat charity patients who might be turned away by other health care centers.
At the stern insistence of coal industry negotiators, the proposed new contract abandons the old financing system, requires miners to pay part of their health care costs and assures care on a company-by-company basis.
An estimated 81,000 UMW pensioners, however, will continue to receive health care coverage through the benefit program, although they, too, will be required to pay a small portion of the cost.
This contract has smaller deductibles than an earlier version - rejected in part because of miners' complaints about the payment provision and a reduction in health care services.
The new system would still use the community clinics, but on a fee-for-service basis that seems certain to undercut the preventive care approach encouraged in the past.
Gone from the new contract is language from the old plans that emphaiszed the mission of innovative health care, education and prevention, improved living conditions, vocational rehabilitation and recruitment of medical professionals.
With the change in emphasis and financing, clinic administrators fear that the larger health centers will not recoup the cost of services they provide and that the smaller, more marginal centers face extinction.
"Unless some can set up health maintenance organizations [pre-paid group health plans] - which the new contract would allow - the smaller clinics won't make it because they're not as well organized," said an Ohio clinic administrator who declined to be quoted by name.
Meanwhile, according to the ARC statistics, the proposed new medical financing system seems almost certain to accelerate the departure of more doctors from the coal communities.
A survey, with figures through January, showed that West Virginia, Kenturky, Pennsylvania and Ohio had lost 59 of 298 physicians employed at clinics and hospitals that were heavily dependent on financial aid from the UMW program.
The clinics and hospitals, which serve nonmining familes as well, all have reported a sharp drop in traffic since July 1 when the UMW program began charging miners for part of their health care.
The drop has intensified since Dec. 6, when the UMW strike started and when the entire health care program was suspended.
Clinic administrators and officials at the UMW health fund anticipate that as the new program took effect a countinuing traffic decline might be seen.
That in turn, they, say, would further undercut the clinics' financial stability and in all likelihood blunt their ability to retain physicians attracted to the rural coalfields by the potential for practicing the preventive medicine that the coal-financed system encouraged.