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Specifically, the Louisiana State Medical Society objects to this bill because: It is not needed. The Kerr-Mills law makes adequate provision for assisting those 65 or over who need help.

It would unquestionably lead to governmental regulation of the practice of medicine.

It would eventually be expanded through the liberalization of social security benefits to lower and lower age groups until all citizens of all ages were covered. It would be the beginning of complete socialized medicine in the United States. It would put an unfair tax burden on the young and benefit those who can afford to care for themselves at the expense of the poor.

It would change the concept of the social security system from that of providing cash benefits to services.

It would discourage the purchase of private health insurance.

It would weaken the financial status of an already shaky social security system.

It is not the American approach to the problem.

The Louisiana State Medical Society could list many more objections to H.R. 3920. We feel, however, that others who will present testimony to the committee are more qualified to cover these points.

H.R. 3920 is bad medicine. It is bad medicine for the people, for the country, and for the medical profession. The Louisiana State Medical Society respectfully requests that the House Ways and Means Committee give an unfavorable report on H.R. 3920.

Representative WILBUR MILLS,

MAINE MEDICAL ASSOCIATION, Brunswick, Maine, January 16, 1964.

Chairman, House Ways and Means Committee,
Washington, D.C.

DEAR MR. CHAIRMAN: Please include in the printed hearings on H.R. 3920 the following statements that reflect the views of members of the Maine Medical Association.

This association is vigorously opposed to passage of the King bill, H.R. 3920, or of any similar proposal that would incorporate a health-care plan in our social security system.

Pressures for passage of current compromise proposals should be recognized as merely a continuation of the 20-year campaign to substitute a centralized health-care system for decentralized and voluntary programs that have given Americans the best medical care in the world.

Limitations in current proposals do not make them less of a threat to basic principles and merits of our system of medical care. Such initial limitations would certainly be subject to politically irresistible pressures for modification or removal by future congressional action.

The obvious tactics of many proponents of centralized plans is to attempt to downgrade recent unprecedented progress in health care. Such tactics are a special challenge to Members of Congress who conduct the public hearings on these plans, as well as to all citizens who understand the overriding importance of maintaining our system of decentralized government and individual freedom. Your committee is urged to continue its opposition to Federal intervention in health care such as that proposed in H.R. 3920.

Very truly yours,

ERNEST W. STEIN, M.D., President.

STATEMENT BY KARL F. MECH, M.D., LEGISLATIVE CHAIRMAN, MEDICAL AND CHIRURGICAL FACULTY OF THE STATE OF MARYLAND

INTRODUCTION

Mr. Chairman and members of the committee, my name is Dr. Karl F. Mech. I am presenting this statement as chairman of the legislative committee of the medical and chirurgical faculty, the State Medical Society of Maryland. I practice general surgery in Baltimore, Md., and I am a teacher-consultant to the Army and the Veterans' Administration. In addition to my membership in the

faculty, I am a fellow of the American College of Surgeons, a member of the Baltimore City Medical Society and the American Medical Association, and a member of the Maryland State Board of Medical Examiners.

The medical and chirurgical faculty represents more than 3,300 physicians in Maryland and has been in existence since receiving its charter from the State legislature in 1799. Since its inception, the organization has worked to advance medical science and knowledge within the State, to raise health standards, to promote satisfactory health care of the people, and to secure the enactment and enforcement of just laws relating to the practice of medicine.

In accomplishing these aims, the faculty serves both the people and physicians in Maryland. The faculty helped to initiate the present State medical care programs, which provide complete, free medical care for indigent and medically indigent people in the counties and medically indigent people over 65 and all indigent people in Baltimore City. It now works constantly to improve these programs and the services they offer. Faculty committees examine with vigor local and national medical problems and attempt to aid in their solution. Faculty officials also confer periodically with representatives of the State hospitals and medical agencies, and this coordination pays dividends in the form of better understanding of mutual problems, leads toward the settlement of differences, and results in more efficient and less expensive medical care for the people of Maryland.

The faculty has also devoted time and effort to the improvement of medical care available to the elderly in Maryland. Its committee on aging has been commended by the State legislature for the promotion of "Check Up With Health Month," a period in 1960 during which free medical examinations were given to elderly people.

The faculty also founded the "Maryland Joint Council To Improve the Health Care of the Aged," a committee which works to improve the health care of the elderly by concentrating the efforts of several organizations in one body. The joint council is composed of representatives of the faculty, the Hospital Council of Maryland, the Maryland State Dental Association, and the Maryland Nursing Home Association. A representative of the Maryland State Commission on the Aging attends meetings as an ex officio member.

During the 3 years of its existence, the joint council has assisted the Maryland State Commission on the Aging in the compilation of a directory of health services for the elderly, approved and assisted in the implementation of a program of nursing home accreditation, conferred with the Maryland League for Nursing concerning means of improving geriatric training for nurses, supported expansion of Maryland's MAA program, and is now working on a program to improve the coordination of care between hospitals and nursing homes.

In the field of medical education, Maryland physicians contributed more than $83,000 to the American Medical Association's education and research fund during the past 3 years, and Maryland's two medical schools, Johns Hopkins and the University of Maryland, received more than $85,000 in contributions from this fund during this same period.

The faculty has also assisted the University of Maryland chapter of Student American Medical Association with a statewide medical recruitment program during the past 3 years. Under this program, physicians and members of SAMA have visited high schools throughout Maryland to discuss careers in medicine with outstanding students, and have assisted in the organization of future physicians and future nurses clubs in the schools. The faculty also cosponsors the SAMA Career Day program, which is held in the spring, at the University of Maryland School of Medicine. Students from throughout the State attend an all-day session at the medical school and see firsthand the facilities and medical personnel at work. The result of these career activities has been a quickening interest in medical education in our State.

The faculty has also cooperated with the Maryland Diabetes Association in conducting a diabetes testing program during National Diabetes Detection Week. For several years, a program of clinical testing or self-testing has been conducted, and this activity has resulted in the discovery and detection of many unknown diabetics.

The list of faculty services and accomplishments is extensive, and they need not be repeated here. It should be pointed out that the work of the medical and chirurgical faculty has resulted in an informed physician population in Maryland and better health care for residents of the State.

MARYLAND'S HEALTH CARE PROGRAM FOR THE AGED

Today this committee is concerned with the manner in which the health care needs of our elderly citizens are being met. The faculty has been concerned with the provision and adequate health care for all Maryland citizens, regardless of age and ability to pay, for many years.

In 1938, the faculty's council suggested to our State planning commission that a study be made to determine whether or not the medical care needs of our indigent and medically indigent citizens are being met. The study was made and the result was the establishment of medical care programs in the counties of Maryland in 1945 and in Baltimore City in 1948.

The county program is for indigents and medical indigents, while the Baltimore City program is restricted to indigents only. Under each program, the patient receives hospital or outpatient care, the services of a physician either at the physician's office or in the patient's home, drugs, supplies authorized by the physician, and limited dental and eyeglass care, completely without cost. Nursing home care is also available to indigent patients. The patient has a free choice of physicians and hospital, and there is no time limit on the care as long as the patient is periodically recertified by the State board of health.

Prior to Maryland's adoption of the Kerr-Mills Act, these programs were providing care for 80,000 of our 3 million citizens.

The enactment of the Kerr-Mills Act by the National Congress in September 1960 enabled Maryland to expand an already efficient care program for those over 65. Our State legislature adopted the Kerr-Mills Act in April 1961, and the medical assistance to the aged program went into effect in Maryland in June of that year. The qualifications for the county medical care program for those over 65 were liberalized and a medical indigent program for over-65 residents of Baltimore City was created.

Applicants for the MAA program are allowed to retain ownership of their homes and in addition assets amounting to a total of $2,500. Relatives are not required to contribute to the cost of care. Income limits begin at $1,080 a year for an individual residing in the counties of Maryland and $1,180 a year for an individual residing in Baltimore City.

Since June 1961, more than 15,000 people have been enrolled for care under the MAA program, and the State health department has predicted that about 7 percent of our 230,000 elderly will eventually be cared for under this program. The care available is similar to that available under other State programs. Nursing home care has not yet been added, but this should be available in the foreseeable future.

In addition, the latest reports indicate that nearly 10,000 people over 65 are receiving medical care under the old-age assistance program, and others are receiving aid through the aid to dependent children program, public assistance to the needy blind, aid to the permanently and totally disabled, and from general public assistance. The total number of over-65 people receiving care is believed to be close to 30,000.

The cost of the medical assistance to the aged program, and all other care programs, has been kept within reason by the willingness of physicians to accept token fees or no payment at all for their services. Physician care within the hospital is rendered free of charge, and fees of $2.50, $3.50, and $4.50 are allotted for office visits, home visits during the day, and home visits at night. The faculty has opposed payment of in-hospital services under all medical care programs, and its house of delegates reaffirmed this position in April 1962. During the first 18 months of operation, the MAA program cared for 10,610 people at a cost of $1,869,883. This money was spent as follows:

Hospital care..

Physician services____

Drug services__.
Dental services__

Eyeglass services__

1 For postcataract patients.

$1,522, 222

121, 905

221, 503

3, 186

11, 067

Much of the credit for the success of these programs can be attributed to the cooperation between the Maryland and Baltimore City Health Departments and the medical profession.

On several occasions, health department officials have referred matters of policy to our council or one of our committees for action or comment. Several conferences have been held during the past 2 years to discuss ways and means of

improving the medical care programs and offering more efficient and complete services to the beneficiaries. Health department officials have been more than gracious in interrupting their schedules to discuss matters with physicians or with the faculty staff members.

Maryland's adoption of the Kerr-Mills program has lead to some problems. Medical assistance to the aged is the only care program requiring administration by the welfare department, since our State programs have traditionally been run by the health department. Faculty representatives and State health department officials have expressed dissatisfaction with this arrangement in conference with State and Federal legislators, and, as a result, Representative Charles McC. Mathias, of Maryland's Sixth Congressional District, has introduced H.R. 4388. This legislation provides for local designation of the authority for the administration of the Kerr-Mills programs, and the faculty and the American Medical Association have endorsed it. I believe that Representative Howard Baker, of this committee, has introduced similar legislation.

Expansion of the medical assistance to the aged program to provide additional services has also been a problem. Experience has shown that the program would profit from the addition of nursing home care and increased dental and eyeglass care. The adoption of flexible income limits has also been suggested, since a fixed income limit is sometimes unfair to those attempting to qualify for care.

In the recently concluded session of the Maryland General Assembly, the State health department recommended the inclusion of flexible income limits for the chronically ill and increased dental and eyeglass care under the MAA program, and requested $150,000 in State funds to pay for this care. Unfortunately, this was deleted from the budget. The additional money for the chronically ill would have allowed a chronically ill person to be certified for care, even though his income may have exceeded limits by as much as $465. This exception was made because the chronically ill are faced with a continuous need for medical care and supervision.

It is hoped that these items, and a program of nursing home care, which is now being studied by the State health department, can be included in the MAA program next year.

I think that it is evident that Maryland's medical assistance to the aged program is not perfect. There are additions and changes that must be made, and it is hoped that the work of the medical profession and the Baltimore City and State health departments will result in these changes being made in the near future. In the meantime, I think that the success of Maryland's care programs is evidence that State governments can meet their responsibilities in providing care for those who cannot afford this care, and that there is no need for Federal interference in this area.

MEDICAL INSURANCE FOR THE AGED

The faculty has recognized the value of private health insurance plans designed especially for the elderly and has encouraged their development. The Maryland Hospital Service and the Maryland Medical Service, our State's Blue Cross and Blue Shield organizations, have accepted applications from people over 65 on an individual basis and have extended coverage available under group plans to this age group since October 1959. This action was taken at the suggestion of the medical profession. Until June of 1963, elderly individuals were accepted under the standard Blue Cross and Blue Shield coverage without a physical examination, but they had to submit the standard health questionnaire for consideration. An employee retiring from a company with the standard Blue CrossBlue Shield coverage could continue his group coverage without the questionnaire and could benefit from a group rate and above-standard protection.

In June of 1963, the Maryland Blue Cross and Blue Shield plans opened special programs of hospital and medical service to all Marylanders age 65 and over. These programs require no health examinations or questionnaires from applicants, and they offer 70- or 30-day coverage. The 70-day plan includes skilled nursing facility benefits and visiting nurse services. During the first period of enrollment in June, more than 5,000 people applied for coverage, and this brought to more than 85,000 the number of over-65 people who have Blue Cross or Blue Shield coverage.

In addition to the individual coverage offered, it should be noted that many private industrial, manufacturing, and commercial concerns in Maryland are extending health care coverage to their retired employees as a retirement bene27-166-64-pt. 5-14

fit. This enables the retired employee to receive continuous health care protection without cost or at partial cost.

I might also mention that the Maryland Medical Service and the Maryland Hospital Service have never dropped a subscriber because of age or condition of health.

Other private organizations have also stepped up their efforts to provide elderly citizens with adequate health care protection. The Continental Casualty Co.'s "Golden 65" was opened for enrollment during June 1963, and the faculty allowed Continental Casualty to announce this enrollment period to our members by means of a special mailing. While no enrollment figures are now available for Maryland, this program has a total enrollment of more than 1,500,000 people nationally, and it may be assumed that Maryland has a fair share of these enrollees.

These figures and others available from private insurance companies indicates that more than 50 percent of Maryland elderly citizens have some form of private health protection.

FINANCIAL CONDITION OF THE AGED

The latest figures concerning the financial condition of the elderly are those compiled by the Maryland State Commission on the Aging in the fall of 1960. According to a survey prepared for the Governor's conference on aging, Maryland ranked 10th in the Nation with an overall per capita income of $2,221, and 60 percent of the elderly in Baltimore City and 37 percent of those in the counties stated that their income was above $1,500. The report further stated that these percentages tended to be low since most of the respondents didn't count gifts from relatives or assets in their estimates. It also said that the average income of the elderly has increased tremendously since 1950 and showed signs of continual rise.

Average income under the old-age insurance program in our State is on a par with the rest of the Nation, and the employment situation is good for oldage recipients who wish to hold down part-time jobs. The latest figures show that 22 percent of those over 60 are still working, and in 1961, the Governor removed the age limits on State service and opened more jobs to the elderly.

Another indication of the financial stability of the elderly in Maryland is the fact that 53 percent of the people in this age group in Baltimore City and 66 percent of those in the counties are homeowners. Only 15 percent of those surveyed were found to be living with relatives, while 33 percent of those in Baltimore and 13 percent of those in the counties were renting their living quarters. It is also significant that the percentage of older people living in dilapidated areas is no higher than that for younger people living under similar conditions. Building programs now being carried out in many parts of Maryland will soon provide low-cost public housing for those elderly who are living in substandard

areas.

HEALTH PROBLEMS OF THE AGED

Statistics on the general health of the elderly are available from this same study. More than 46 percent of the people in the 60 to 84 age group reported no serious health problems, and in the 60 to 64 age group, 64 percent of those surveyed reported themselves in good health. Even in the 75 to 79 age bracket, the percentage of those enjoying good health was as high as 40 percent, and major health problems did not crop up for the majority of the elderly until the 80th year.

Another portion of the survey showed that while 50 percent of the elderly had visited their physician during the previous 3 months, 23 percent had not seen a physician in more than a year. Further, over 85 percent had not been confined to a hospital during the previous year.

SUMMARY

In summary, the members of the Medical and Chirurgical Faculty feel that the State MAA and OAA programs can do a better job in furnishing medical care to our elderly than H.R. 3920. The care is more complete; and because it is given on the basis of need, it is economical to the taxpayers of Maryland. I might also point out that the people of Maryland have been continually opposed to programs such as that proposed by H.R. 3920, and the latest poll by Senator J. Glenn Beall, Republican, of Maryland, indicated that more than 77

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