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We circulated the preliminary summary of the Flemming committee report to all our member organizations and asked for an immediate reply. With a few exceptions the general reaction of our members was that they could accept the basic ideas in the Flemming report provided that the two sections, the public and private, were clearly differentiated. They want no chance of adverse selection to creep in through the administration by insurance companies. Our senior citizens insisted that no added expense be loaded on the cost of hospital care because of insurance company administration. Our widespread membership supports the general idea of pooling on the physicians' insurance protection. On the private insurance provisions (title V), a quick review shows several questions which are beyond our ability to comment at this time.

Would this seriously cut into our basic antitrust laws?

Would this basically weaken the authority of the State insurance commissioners and State laws governing insurance?

If this is the case even to a limited extent (and we are no constitutional lawyers), is it worth it for the sake of the public good?

Should there be room for more than one "association of carriers"? Why shouldn't there be no more than one such association? It is possible that some such alternative might surmount some of the antitrust problems.

These are questions and not a position pro or con.

We have no basis for judging the actuarial soundness of or even the basis upon which the estimates are made of the cost of basic physician health insurance which appeared in the press release. We assume that these are competent studies and estimates, but the Ways and Means Committee and HEW should carefully review these estimates. If these are as low as are announced, it will be excellent.

We urge that the Ways and Means Committee of the Congress periodically review any private insurance program which might be developed as a result of the legislation and to ascertain if this section (as it will the public sector) is functioning correctly. If such programs are not operating in no public interest then it would be necessary to consider changes without delay.

4. The Bow bill and others of the same nature

(a) The Bow bill does not include recommendations on the added taxes that it will require ($11⁄2 to $2 billion a year). How does this square with the con. cept of the balanced budget?

(b) There is nothing in the bill to prevent insurance companies denying protection to old people with existing health conditions which companies may classify as "bad risks."

(c) The Bow bill permits an insurance company to establish a maximum annual and a final lifetime shutoff figure, which would prevent an older citizen to obtain help through the program.

(d) There is no protection against progressive reduction of quantity and quality of health care because of unforeseeable profit and administrative cost demands, except through added drains on the U.S. Treasury for higher premiums. (e) No mechanism is provided in the bill for the operation of group health programs.

(f) The bill would put the Government in the position of fixing fee schedules for physicians and nurses service.

(g) There would be need for Federal regulations to guarantee that participating insurance companies would be reliable; thus Government would need to move into a field now administered by the insurance commissioners of the various States.

(h) No insurance company has worked up the type of policy which the Bow bill envisions and there is serious doubt as to whether any of them would actually do so.

(i) The basic idea of a tax deduction sounds good until you realize that 11 million people over age 65 don't have to file income tax returns; 32 million seniors file but don't have to pay anything. Only 3.4 million in the older age brackets pay taxes now and do already get a tax deduction for medical and drug expenses.

There have been variations on this original Bow bill, but essentially these criticisms hold for all of these proposals.

5. Final summary of recommendations

We can see no other satisfactory approach to the problem of health care for the aged than a prepaid social hospital insurance plan using the efficient social security system which has been developed over a period of years. We see a definite role for private insurance in providing insurance against the costs of physicians. In general, with one technical exception concerning nursing home standards, we support the King-Anderson bill. We are sympathetic with the general ideas stated in the Flemming committee report; the National Council does, however, strongly oppose the omission of provisions for diagnostic services. We have questions about some of the other provisions.

We like the idea of outlining the role for private insurance in the law, but it raises questions which we are not qualified to comment on without furthet study.

There is absolutely nothing in the Bow bill we can approve. It is financially unsound and should be rejected out of hand.

We recommend changes in MAA and OAA including removal of residency requirements and free choice of doctor, and at least equal medical treatment and Federal supports for OAA care as for MAA.

CENTRAL BUREAU FOR THE JEWISH AGED,

New York, N.Y., January 29, 1964.

To Members of the Senate and the Assembly of the New York State Legislature: The Central Bureau for the Jewish Aged is a planning and coordinating agency for services to the aged in the Metropolitan New York area. The experience of its 52 member agencies, homes for the aged, hospitals and family agencies, community centers, camps, has indicated and continues to indicate that the current MAA legislation has failed to extend services to the group of aged on marginal incomes for whom it was intended.

As we wrote you on February 28, 1962, and January 15, 1963, we believe that a major reason for this failure is the requirement that adult children be held legally responsible to contribute to the costly medical care of their parents. Recently, the social service department of one of our member agencies, the Brookdale Hospital Center (formerly Beth-El Hospital), completed a review of inpatients and outpatients referred for medical care to the aged from October 27, 1961, through April 30, 1963. This survey was undertaken because it appeared that scarcely any older patients in the community were benefiting from the program, although it had been in effect for over a year.

Two groups were included in the study, in hospital patients and 127 patients living in their own homes who needed MAA. We believe that you will be interested in several of the case histories which document the report.

"Mr. K., age 74 years, attends a diabetic clinic. He has been separated from his wife and children for 25 years and he lives in a furnished room. He receives $100 a month social security and eats in restaurants. There has been very little contact between himself and his four married children all these years. Mr. K. refused to apply for MAA when he was told his children would have to be contacted. He did not wish, at this stage of his life, to revive the family frictions and hostilities."

"Mr. B. is one of a number of patients who refused later hospitalization as a consequence of the impact of one MAA investigation.

"Mr. B., a 73-year-old patient, suffering from a.s.h.d. and emphysema, was having difficulty with urinary retention. This patient had been known to our clinic and hospital intermittently for the past 10 years. He had been hospitalized prior to MAA and family provided information necessary for department of hospitals financial investigation. He was found eligible for city status. Following establishment of MAA, a second brief hospitalization resulted in referral to Chelsea Welfare Center. The two adult married sons, with three children each, who had contributed to the support of the patient, were so disturbed by the contact of the welfare center, that there was a period of many months when relations between this patient and his sons were seriously estranged. "The patient had been referred to the social service department by the doctor, who could not persuade patient to reenter hospital for a procedure to relieve the urinary retention. The patient discussed with us the fact that he could not again risk his relationship with his sons. Despite persistent effort and

followup by caseworker and the physician, Mr. B. remained adamant in his refusal. In fact, he discontinued all hospital contacts. He stated he was aware of the danger to his health and life, but he would risk that rather than the unpleasantness involved with establishing his eligibility for MAA in the hos

pital.

"Mr. C.'s sense of self-worth was impaired at the very end of his life. "Mr. C., an 83-year-old cardiac patient, lived alone in a very low rent apartment and was able to manage on his income from social security plus occasional contributions from two married daughters who lived out of town. In the fall of 1962, he was admitted to our hospital for pneumonia and coronary insufficiency from which he did not recover. During his stay he was visited by the MAA investigator who told him that his daughters would be contacted for financial information. One daughter had a brain tumor and was a chronic invalid. The other had a husband recently discharged from a mental institution. No amount of reassurance on the part of the caseworker could relieve Mr. C. of the anxiety created by the very fact of this investigation to establish financial eligibility for MAA, kindly though it was, for his hospital care. Until he expired, one of the great disappointments of his life was that he had to end up on relief.

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"Mrs. D., age 68, chose to risk the pain and possible danger of neglect of her health condition, rather than submit to the investigation under MAA for hospitalization.

"Mrs. D. was to be admitted to the hospital for cholecystitis. She and her husband lived on social security, an amount of $140 per month. They had three sons, all factory workers with families of their own, who contributed about $5 per month each, to their parents' support. Mrs. D. was told that she would be admitted to the hospital under the MAA program, explaining that her children would be investigated.

"Mrs. D. refused to come in to the hospital because she did not want her children to undergo investigation, saying that they were only poor workmen, and they could not pay hospital bills."

The review points up sharply that a major problem for the older individual stems from the fact that New York State legislation requires adult children to take financial responsibility for the medical care of their aged parents. It contains the following findings with which our member agencies and our board of directors are in full agreement:

"For both the out-patient department patients, as well as the in-hospital patients, the fact that their adult children had to be involved in establishing their need for medical care, held special, sometimes overwhelming, threats to their status in the family and to their self-esteem. In a number of cases there had already been estrangement from the children. In other cases the parents feared the resentment of the children in the involvement of the department of welfare, inasmuch as this had been the thing they had all been trying to avoid, so that some of the children had contributed to their parents far beyond their means in order to avoid public assistance. The elderly already felt that they were a 'burden' to the children who have their own problems and 'their own lives to lead.' Many of the elderly were quite concerned because of the fact that the children themselves are aging and had responsibility for the education of their own children who were of college age and/or were being married, and some even had responsibilities as grandparents. It is to be noted too, that adult children frequently could not accept the legal basis for the fact that their resources were being investigated. Despite explanations to the contrary, they thought of this investigation as a consequence of a complaint against them by the parent, or at very least as an evil or inconvenience against which it was a parent's duty to have protected them. Lifelong patterns of independence upheld at great cost by many of these people resulted in their preferring to neglect their health needs rather than be classified as indigent or to involve their children."

Based upon the evidence presented in the Brookdale Hospital Center review and supported by the experience of all our member agencies, we continue to urge that the filial responsibility requirement be deleted from medical aid to the aged.

MYRON MAYER, President.

LEO H. IRWIN,

THE COOPERATIVE LEAGUE OF THE U.S.A.,
Chicago, Ill., November 27, 1963.

Chief Counsel, Committee on Ways and Means,
House Office Building,

Washington, D.C.

DEAR LEO: If my statement submitted for inclusion in the record of the hearings on legislation to finance medical care for the aged through social security has not yet been printed, then I would like to submit the enclosed copy of the testimony in place of the one previously sent you since it contains four minor corrections in the text which I would like, if possible, to make.

Sincerely,

JERRY VOORHIS,
Executive Director.

TESTIMONY OF JERRY VOORHIS, EXECUTIVE DIRECTOR OF THE COOPERATIVE LEAGUE OF THE U.S.A., ON THE SUBJECT OF MEDICAL CARE FOR THE AGING

My name is Jerry Voorhis, and I appear before the committee representing the Cooperative League of the U.S.A. of which organization I am the executive director.

The Cooperative League is a national federation of consumer supply service and marketing cooperatives. Its affiliated member organizations include in their membership approximately 15 million different families who have invested in the shares of cooperative business of various kinds through which they market their crops, or obtain their farm supplies, insurance, consumer goods, electric power, savings and credit, health services, housing, and other needs. These people are providing the solution to their own economic problem and supplying their own economic needs without relying upon the Government or any other outside agencies. They are giving real meaning to the term "people's capitalism" for the rank and file of the American people.

I appreciate the opportunity of testifying in these important hearings. For the Cooperative League is for obvious reasons concerned about the welfare of our older people.

I wish to make only two major points:

First, the Group Health Association of America is a member organization of the Cooperative League. GHAA has done and is doing an outstanding pioneering work for the better health of the people of our country. It works for the development and growth of prepayment, group practice, comprehensive health plans which-at costs the average family can afford on a budgeted basis-not only provide curative medical care but also preserve health of their members. The continuing care which members of such plans are able to receive has meant a definite reduction in the rate of hospitalization by the members of such "plans and consequently a reduced cost of medical care.

These cooperative and voluntary group health plans are examples of American resourcefulness and self-dependence at their best.

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But please, note that I said a moment ago the voluntary group health plans are able to provide comprehensive health care and maintenance at costs the average family can afford. High-quality medical care is by no means cheap and should not be.

The poorest population group cannot, without some assistance, afford the kind of health care which our country needs to have them have.

Especially this is true of our older people. Many of the voluntary plans have put forth great effort to solve this problem. Some have had some success. But the dollars just don't add up. Our older people just cannot, except in rare cases, afford the monthly charges.

7: This brings me to my second point:

I shall not burden the committee with a volume of statistics which I know will be presented by other witnesses. The following roughly accurate statistics will be enough:

01. The per capita income of our people 65 years of age and beyond is about half that of the rest of the population, and

2. The cost of the medical care needed by our people aged 65 and over is about twice what it is, per capita, for the rest of the population.

Which means that it is insurmountable.

That is, it is insurmountable if people wait until they actually are 65 before they begin to try to make provision for their health needs and expenses. Unless, therefore, the medical needs of the older people are to be taken care of out of general taxation on charity there must be a means whereby people in their younger years can save for their health care needs in their older years. There is:

It is already in operation. It covers most of the American people already and could cover practically all of them with a few amendments.

I speak of course of the social security system.

Here we have a self-respecting, self-financing, orderly established system whereby the American people can in their earning years set aside for themselves the funds they will need to pay for decent medical care when they grow old. The use of social security for this purpose will put an end to our older people's dependence upon charity. It could enable them to enroll themselves in the prepayment health plans if they wish to. It can solve the financing problems.

Other problems will remain of course. I could discuss them but I won't. The burden of our testimony is that we have been utterly unable to conjure up a single valid argument against the use of social security system as the means of financing medical care for the aging.

So we hope the committee will pass appropriate legislation so to provide.

STATEMENT OF AMERICAN NURSES' ASSOCIATION ON H.R. 3920

The American Nurses' Association is the national organization of 170,000 registered professional nurses in 54 constituent. State and territorial associations. As one of the professional groups deeply concerned with providing health care for the American people and as the largest single group of professional persons giving that care, we welcome this opportunity to again present our views on the proposal before this committee.

The American Nurses' Association has supported the provisions of the Social Security Act and extensions and improvements of the system since its adoption. In 1958, the highest policymaking body of the association, its house of delegates, voted to support the principle of extending the social security program to include health insurance for recipients of old-age, survivors, and disability insurance. The house of delegates reaffirmed this position in 1960 and in 1962.

The ANA testified before your committee in favor of including health insurance for retired beneficiaries of the OASDI in 1958, 1959, and 1961. Our primary reason for support is stated succinctly in the following resolution adopted in 1958 and reaffirmed at the two subsequent conventions:

"Whereas necessary health services should be available to all people in this country without regard to their ability to purchase, and

"Whereas prepayment through insurance has become a major and an effective method of financing health services; and

"Whereas certain groups in our population, particularly the disabled, retired, and aged, are neither eligible nor able to avail themselves of voluntary health insurance; Be it therefore

"Resolved, That the American Nurses' Association support the extension and improvement of the contributory social insurance to include health insurance for beneficiaries of old-age survivors and disability insurance; and be it further "Resolved, That nursing services, including nursing care in the home, be included as a benefit of any prepaid health insurance program."

The association further believes that using the social security mechanism as a means of solving the problem of financing health care for the aged is more dignified and appealing to the people of this country than an approach through public assistance programs.

In taking this position in support of the extension of social security to include health insurance coverage, the association indicated its concern for the health needs of millions of Americans who are faced with the problem of financing health care at a time when income is lowest and potential disability at its highest.

Because of their own economic situation, nurses identify with those facing retirement on a limited income. In 1961, the average annual salary of general duty staff nurses in hospitals was $325 a month. This group of nurses comprises over 60 percent of those in practice. Private duty nurses, who are inde

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