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Some States such as New York do not place a time limit for a hospital stay. Assuming Peter and Paul to be brothers, and both are stricken with the same malady. Peter happens to live in New York while Paul resides in Kentucky. Both qualify for MAA benefits and both go to the hospital. Peter remains 30 days under the care of his own doctor while Paul is denied the services of his own doctor and permitted to remain only 10 days, and is then discharged from the hospital to shift for himself or transferred to OAA.

Where is the equity? Why shouldn't both be treated the same? But this is the way the Kerr-Mills MAA program works. Through the happenstance of fate and geography, Paul in Kentucky receives only what the State program can afford to give him, while Peter in New York receives so much more. 3. Transfers

Three-fourths of the applications for Kerr-Mills (other than transfers) are actually approved.

In Pennsylvania, only two-thirds of the applications for Kerr-Mills (not including transfers) are approved.

In Illinois, only three-fifths of the applications are approved.

In California and Connecticut, less than one-fourth of new applications are approved.

Some States transfer large numbers of cases from other public welfare pro-
grams to the MAA program.
Below are the percentages of authorized cases which are transfers:
Percent

Percent Connecticut 81 Massachusetts.

55 California. 76 Idaho..

44 North Dakota... 62 Utah.

41 The method used to accomplish transfers is simple. Drop skilled nursing home care, for example, from the OAA program and transfer coverage for the service to the MAA program. The OAA recipient in need of nursing home care cannot be provided the care he needs, for OAA no longer includes that service. A few forms are completed and the OAA recipient is swiftly transformed into an MAA recipient. The clear intent of Congress is violated by these paper transactions.

An example of transferees from OAA to MAA took place in the State of Washington about 7 months ago when it reported a total of $187,559 paid out in behalf of 1,176 recipients of MAA during the month of May 1963. For the month of June 1963, however, Washington reported total payments of $1,282,149 for care of 9,623 recipients of MAA. State officials explain this tremendous increase in MAA payments and recipients was caused by the transfer of recipients of long-term nursing home care under the old-age assistance program to Washington's MAA plan.

In New Jersey, the total number of recipients on OAA in June 1963 was 18,469. A month later, after MAA got underway the number on OAA had dropped by 4,431. However, the new MAA program started off with 4,231, obviously almost all transfers from OAA. By this switch, the State was able to reduce its combined OAA and MAA payments by over $55,000. 4. Means test

The means test has been compared with the income test of social security or the statement one makes when seeking admission to public housing, or the financial investigation necessary to get a loan at a bank. This is not a valid comparison.

What must be kept in mind here is that in this area we are dealing with deep feelings and attitudes. You cannot say whether something is degrading or uplifting or a challenge unless you talk with the people who are experiencing it and find out. What is humiliating or degrading differs from culture to culture and from age to age. Here in our time, in our country, people have strong, deep feelings about welfare, old age, and family responsibility. In certain areas of life today and in certain circumstances it is not considered demeaning or degrading to submit to a check on one's credit rating or à scrutiny of income and resources.

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When a man enters a bank to ask for a loan, he is going to prove he is successful, has potential, is a good risk, or is of value. When he goes to the welfare office at the end of his life, the feeling of the individual is that he must prove that his life has been a failure. Even worse, he must be able to prove that his children are failures, too, or that they do not love or care for him. When he goes to the social security office, he simply has to show that he is retiring. He is not asked what resources he has accumulated, even whether he is on public assistance. He may have $100,000 in property or stocks and bonds, but this is not a question that is raised. On the other hand, the public assistance worker wants to know every detail, every dollar, and why. The social security representative isn't going to take over budgeting for you as if you were incompetent to manage your affairs. The OAA worker, however, treats you as essentially incompetent and childlike and not able to operate as a full-fledged citizen. The psychological fact is—and this is a fact as hard as granite that the great bulk of the people feel that asking for a loan and applying for social security are not degrading. Applying for admission to public, low-cost housing or going to a free county clinic or going to a part-pay charity hospital has some stigma, but these are less humiliating and degrading to Americans than “going on public welfare.” For many, this price at the end of a lifetime of self respect and dignity is not worth the few dollars of medical care that they might or might not get. Only one out of four who apply receive any kind of help from MAA. Small wonder that people go without proper medical care. It is hard enough for many to cope with their feelings about illness and possible death, without adding the blow that they must take the means test, which they view as “the pauper's oath.”

The taking of a means test, or to the senior citizens, “the pauper's oath,” in the view of those who have taken it, is both degrading and humiliating and explains why many of the old folks want no part of Kerr-Mills. One little elderly lady, in testifying before Senator Harrison A. Williams on October 24, 1961, in Trenton, N.J., said, “I would rather die than ask for State assistance under the Kerr-Mills law." Another remarked heatedly at a public meeting of senior citizens in Philadelphia on January 20, 1962, “I will see myself dead first before I go to my children for help or ask for help under Kerr-Mills." Both of these women reflected the inner feelings of millions of old folks who value and prize their independence more than their lives.

After a lifetime of independence and thrift, submission to the humiliation of a test of need is a painful experience for an aged person to accept-particularly when he is under the emotion and stress which accompany serious illness. A report received on a prospective MAA applicant in Michigan illustrates this point:

“Mrs. A and her son called at the bureau office on February 7, 1963, to apply for medical assistance for the aged for Mr. A who was a patient at a local hospital. It was revealed that Mr. and Mrs. A owned their home free and clear and had bonds valued at $1,350. Their income consisted of $85.10 per month social security for Mr. A, and Mrs. A had part-time employment earning about $80 a month. Mr. and Mrs. A did not have any hospital insurance. A caseworker explained the Medical Assistance for the Aged program. Mrs. A said that she would like to discuss the matter with her husband and would return to the bureau later. The next day a phone call was received from Mr. A requesting that the medical assistance for the aged application be withdrawn and also stated that they would pay the doctor bill themselves.”

This is a case where an individual who would have, based on the above data, and assuming no relatives who would have been required to assist, qualified for medical assistance for the aged in Michigan. But, rather than accept public assistance, it would appear, Mr. A preferred to pay for the necessary care out of his limited assets and income. These assets, it should be noted, are irre placeable and in any event are insufficient in the face of a serious illness.

A Plea From One Who Shuns the Means Test

FREWSBURG, N.Y., January 1964. This is an urgent plea. Please do not glance at this letter and cast it in the wastebasket. Read it word for word, and, in so doing, you may agree that it was worth it.

I am nearing the age of 70 years in this high-cost-of-living era and unable to obtain any employment that my health will permit. I was forced to retire at 65 years and accept social security benefits, which nowhere near compensates for the formerly earned wages, to take care of my wife, a 15-year-old son in school, and an 83-year-old mother-in-law who has no income; also, upkeep, taxes, fuel bills, light bills for my home, plus the essential drugs and medicines I must have, the high cost of doctor's fees, the high cost of food and clothing for myself and family, which have risen enormously since my retirement about 4 years ago. Yet the social security remains as is, and was then, leaves us in a position where we do not live, but just barely exist. I had the misfortune in October 1963 of having my wife nearly blind in one eye and paying four specialists for examinations and treatment and finally having to send her to a Boston hospital for an eye operation costing well over $300 for hospitalization alone, and for which I had to sell appliances and much-needed things, and go in debt by borrowing to obtain the wherewithal to pay these expenses because the hospital would not admit here without a payment of $200 in advance, and would not release her the following week without payment of $100 more. I appealed to the county aid, to agencies for the blind, and others, for help and was refused.

When my wife returned home from the hospital she received $40 from the organization for the blind of our community, and a small donation from our neighbors to cover her transportation to and from Boston, Mass. She must still have further examinations and treatment ($15 each) and new glasses for her eyes (cost unknown yet), and all this must be paid from social security benefits. How can I do it? When I was in the shop I had hospitalization for myself and family for which I paid the other half. Today I have no hospitalization because I cannot afford to pay for it with social security benefits and no other income. At present, I myself am in need of medical care and possibly hospital care, for over 4 months, and no way to get it because the hospitals won't admit until they know where they are going to get their money, and I won't pauperize myself and family and lose my home to get State or county aid.

It seems to me that the elderly must die for want of hospitalization and medi. (are care while waiting for the Congress and the House to fight and argue over it before doing something for our benefit. And still the social security funds pile 1.

When I worked in the shop, an office call to my doctor was $3, when I retired it was $4, and now it is $5 and $15 to an eye specialist for my wife. I need help, and so do millions of others. Respectfully, your obedient servant,

Mr. JAMES U. YAGER.

Dr. C. H. Peters, in a speech before the American Medical Association (inserted in the Congressional Record, Apr. 11, 1962, pp. A2777-A2778), underlined the major problems in the usage of means tests in MAA programs. : These comments are equally pertinent now:

"The ‘means test is a second argument our opponents repeatedly throw at us. This is a more difficult, and politically more formidable objection. It is said that this is one of the reasons that more individuals have not availed themselves of this program. The stigma of failure, of going on relief, often creates deeprooted emotional bias on the part of the conscientious old individual. We have attempted to counter this feeling and argument by logic of one type or another. But logic frequently fails to sway individuals as all of you know from daily application in the practice of medicine.

“Before the public attitude can be changed, some members of the medical profession may have to change their own attitude.

"If the doctor himself looks down on assistance medical care, and upon the people who receive it, the public cannot be expected to accept this as anything but last-ditch aid.

"The AMA survey shows that in many States MAA is being considered as “just another welfare program,' an OAA medical care program for a slightly higher income level. The applicant must go through the same routines, the same type of tests, the same type of investigations, and he receives his care through the same channels as the OAA recipient.

"Too stringent a means test can force the applicants to pauperize themselves past the chance of recovery before they can obtain aid. Rigid administrative methods developed to deal with the long-term needy can discourage applications for help.

Lack of differentiation between the totally needy and the medically needy, and the way care is providel, can be so humiliating that many will not apply, except as a course of desperation, and again be unable to regain independence once the medical crisis has passed.”

5. The Belden Associates study

We raise questions as to the worth of this study. Considering the source of the funds for the study and the fact that this firm is not known nationally in this field, we can only comment on the report as it is written. We cannot tell from the report whether those who are currently in hospitals or institutions (5-6 percent) are included. These are usually the people who are having the greatest problems. To analyze-graph No. I:

(1) It states 221,000 OAA insured.

How many would not have been on OAA had they had medicare? Evidence presented during the hearings indicated one-third seek and obtain 0AA because of high costs of illness. How many of these people would rather have had medicare than OAA coverage?

(2) The Belden Report states 283,000 have at least 1 health policy. Evidence shown in the hearings indicates that only about 10-15 percent of the health insurance policies held by people over age 65 are even remotely adequate protection against major illnesses.

(3) Of the group reporting "sufficient savings or income" (60,000), how many were realistic about the size of the average hospital bill ($7,000) or a major operation? Most people are not aware of what the actual costs are.

(4) Finally, of those who had less than $100 medical expense (15,000), how many need to be protected against illness during the coming years?

K. AMERICAN MEDICAL ASSOCIATION POSITION

Dr. Edward R. Annis, president of the American Medical Association, has been and continues to be the recognized spokesman for the principal opponents of the social security approach to health care for the aged.

The American Medical Association has spent millions in fighting this legislation and has used some very questionable tactics. Doctors around the country have been persuaded or pressured to do things in the course of this campaign that are out of keeping with the high moral standards of the medical profession. One individual who ran for Congress on a promedicare platform has charged that members of the American Medical Association tried to bribe him with a handful of $100 bills.

We feel that the manner in which the leadership of the AMA has operated has had an unfortunate impact on the ethics of the doctors of this country during the period this proposal has been a subject of debate.

Dr. Annis continued to state as late as October 28, 1963 (8 p.m., on WBAL in Baltimore) that “Kerr-Mills is active in 50 States for those on QAA.” Actually, as of September 30, 1963, 15 States had not basically altered their QAA medical assistance programs since the Kerr-Mills law was enacted. While it is true to say that 50 States have OAA medical care, it is untrue to say that Kerr-Mills law is active in 50 States.

Dr. Annis was quoted in the Los Angeles Times on March 30, 1963, as saying, "The administration supported legislation would cover 75 percent to 80 percent of the needs of the elderly—the Kerr-Mills bill can cover 100 percent." This is totally incorrect.

In Peoria, Ill., on September 1, 1963, Dr. Annis, in an interview with Michael Burns of the Herald Tribune staff, repeated his statement that Kerr-Mills is operative in 50 States. The article then went on to say, “The second (MAA) operative in 34 States, provides medical aid funds to those over 65 who do not normally need assistance but who would be unduly burdened by major medical expenses.” “Some $2.5 million was spent on 4,200 Illinois residents last year," the AMA head said.

In another newspaper story, Dr. Annis declared that, “The Kerr-Mills law has already been accepted by 38 States and is being considered by others."

In Denver, in the Register of September 1, 1963, Dr. Annis wrote in a guest editorial, “Forty States and territories have passed this MAA portion of the Kerr-Mills law, but there have been cases of what we might well consider political sabotage on its workings. For example, the Indiana Legislature passed the MAA section of Kerr-Mills, only to have it vetoed by the Governor.”

Early in 1952, Dr. Annis stated, “The American taxpayer, whose payroll tax would be hiked by as much as 17 percent to start with in order to pay for this program, certainly has a right to question the free ride those who do not need these benefits would be taking at the expense of his children."

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The actual facts are, as most of the committee is aware, that only those persons whose taxes would increase as much as 17 percent are individuals earning $5,200 or more a year, and this group would receive for their additional contributions higher cash benefits under OASDI, as well as health insurance protection in old age. The increase in deductions for workers with earnings of less than $4,800 would be about 7 percent not 17 percent.

Dr. Annis has repeatedly told the American public that the scope of Kerr-Mills is unlimited. Dr. Annis must know that no benefit program is unlimited and that all such programs are limited by the ability of the Government to finance them. In this case the limitations are primarily imposed by the State governments. No State has anything like an unlimited benefit program. For example, the MAA program and the OAA programs of medical care in Florida are sharply limited to 30 days of hospital care.

On the matter of medical assistance to the aged in the State of Florida, we point out the following: the MAA program in Florida appears to be the most limited program in any of the States. Dr. Annis said in his statement to the U.S. Senate Special Committee on Aging at its hearing in Fort Lauderdale on February 15, 1962, when he represented the Florida State Medical Association, "Florida has totally implemented the old-age assistance portion of the KerrMills bill and is presently providing complete and total medical and surgical care including hospitalization, nursing home care, and drugs for all of our 70,000 citizens on old-age assistance, if and when they require such medical care."

This just was not true and is not true. “Complete and total” medical care embraces the care and services set forth in section 6(b) of title I of the Federal Social Security Act:

(1) inpatient hospital services;
“(2) skilled nursing home services;
“(3) physicians' services;
*(4) outpatient hospital or clinic services;
“(5) home health care services;
(6) private duty nursing services;
(7) physical therapy and related services;
“(8) dental services;
“(9) laboratory and X-ray services;
“(10) prescribed drugs, eyeglasses, dentures, and prosthetic devices;
“(11) diagnostic, screening, and preventive services; and

“(12) any other medical care or remedial care recognized under State law." Vendor payments for medical care for persons on old-age assistance in Florida are limited to the following:

(1) Hospital care for the treatment of an “acute illness or injury," but “not to exceed 30 days of hospital care during any 12-month period."

(2) Nursing home care in an amount not to exceed $100 for a month's care in homes licensed by the State board of health. (Comment: Such care costs more than this in most instances. Furthermore, there were no old-age assistance recipients reported in nursing homes in 27 of the 67 counties in September 1961. Obviously, there must be licensed nursing homes available before such care can be provided.)

(3) Prescribed medicine. Dr. Annis further stated at the Fort Lauderdale hearing: "In the fiscal year ending June 30, 1961, 124,837 days of hospital care was provided to 14,235 of our public assistance recipients at a cost of $2,920,158. As this figure indicates, in spite of the fact that totai care is available to any and all who needed it among the 70,000 on public assistance, only approximately one-fifth required any such service during the year 1961."

The figures in the first sentence apply to all public assistance recipients receiv. ing hospital care not just old-age assistance recipients. The actual figures for old-age assistance in the fiscal year ending June 30,

894 patients with a disbursement of $2,112,377.73. Thus 14.2 percent or one-seventh of the old-age assistance recipients based on the June 1961 caseload (69,671) received hospital care during the fiscal year 1960–61. How many old-age assistance recipients living in the 31 counties in which there is no hospital on the approved list “required” hospital care but did not receive it is, of course, not known. And how many required “otal care" and did not receive it is likewise unknown, since total care was and is not available "to any or all who needed it” among Florida's old-age assistance recipients.

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