percent were opposed to any program of care for the elderly financed by social security. The Medical and Chirurgical Faculty is interested, as is this committee, in providing our Nation's elderly with the best possible standard of medical care. The faculty membership urges you to oppose H.R. 3920. STATEMENT OF JOHN B. BUTTS, M.D., CHAIRMAN, COMMITTEE ON NATIONAL LEGISLATION, MASSACHUSETTS MEDICAL SOCIETY, Boston, Mass. The Massachusetts Medical Society, now the spokesman for more than 7,000 physicians in the Commonwealth, is the oldest medical society in the United States with a continuous existence, having been incorporated in 1781. The Massachusetts Medical Society is in complete agreement with, and subscribes to, the basic policy of the American Medical Association on the responsibiilty for personal medical care as approved by the house of delegates of the American Medical Association in June 1960, and which we quote in part: "Personal medical care is primarily the responsibility of the individual. When he is unable to provide this care for himself, the responsibility should properly pass to his family, the community, the county, the State, and only when all these fail, to the Federal Government, and then only in conjunction with other levels of government in the above order. The determination of medical need should be made by a physician and the determination of eligibility should be made at the local level with local administration and control. The principle of freedom of choice should be preserved. "The use of tax funds under the above conditions to pay for such care, whether through the purchase of health insurance or by direct payment provided local option is assured, is inherent in this concept." Based then on the above principles, and also the fundamental principle that the purpose of a medical society is to advance the art and science of medicine and make this advancement available to all the people, the Massachusetts Medical Society has approved the basis of the Kerr-Mills law; namely, payment for medical care for the needy or near needy by the use of Federal funds as grantsin-aid to the States, with the determination of need established by each State in accordance with the interpretation of the law as set forth in Federal regulations. The effectiveness of the Kerr-Mills law in Massachusetts is illustrated by the increasing number of people who have been provided with medical care either as in-hospital patients, nursing home patients, or who have been rendered care in their homes or in physicians' offices. The number of days spent in hospitals or nursing homes by these same patients and, also, the amount paid for such care is illustrative of the increasing utilization of the provisions of Kerr-Mills. However, as physicians, we believe that the law could be better implemented to the advantage of the patient, the providers of medical service, and the taxpayers who are the providers of the funds used to pay for these services. An explanation of the situation in Massachusetts relative to implementation of Kerr-Mills will be useful in suggesting how to render more effective the purpose of a law based on the sound foundation of helping those in need or near needin contradistinction to proposed King-Anderson type legislation, which has as its basis chronological age irrespective of need, and which proposes the imposition of increased social security taxes on the younger element of the population to pay for health care for many people not in need. The first OAA plan in Massachusetts, in 1956, was implemented by decree of the commissioner of public welfare on the basis of a 15-mile limit. This limit provided that all patients requiring hospitalization and residing within 15 miles of a teaching hospital, must be hospitalized in a teaching hospital within that limit and that no payment be made for physician care. If the patient lived beyond the 15-mile radius, he could be hospitalized in a community hospital beyond that radius and physician services in the hospital would be paid for at the rate of 80 percent of plan A Blue Shield fees. This plan, which was called a concession by the commissioner, was based on the fact that since there were no interns or residents in the smaller community hospitals the staff doctors would be so overburdened with patients who were nonpaying that their source of income could be reduced to subminimal standards. This plan worked in Massachusetts largely through the cooperation and dedication to their work on the part of the medical profession. The passage of Public Law 86-778, or the Kerr-Mills law, made changes in OAA by making more Federal dollars available to the States on a matching basis for medical care, and also established a new Federal grant-in-aid under the second part of title VI of Public Law 86-778, which designed to pay all or part of the cost of medical services for people 65 years of age or over, whose income is sufficient to maintain them but who cannot maintain themselves when struck down by illness. Eligibility requirements were to be set up by the States. In Massachusetts an individual over 65 was eligible for MAA (medical assistance to the aged) whose liquid assets amounted to $2,000 or less, a combined income for husband and wife of $225 per month, and a mortgage-free home irrespective of value. The commissioner of public welfare, without consultation with the medical profession, set up the same standards of physician payment, based on the 15mile rule, as had been set up for OAA in 1956. This arbitrary ruling denied many people the right of freedom of choice of hospital and physician and subjected people who were not on welfare rolls to the obligation of requesting the welfare department for inclusion for medical needs. The Massachusetts Medical Society, through its elected representatives, held many meetings with the commissioner, attempting to better implement the KerrMills law. The commissioner remained adamant against change in his method of implementation of this law. Two separate resolutions were passed at different times in the Council of the Massachusetts Medical Society, each attempting to effect a better implementation of the law. The first resolution was unanimously passed by he council in October 1962. This resolution is quoted as follows: "Whereas the basic principle of the Kerr-Mills law is in conformity with the policy of the AMA on the responsibility for personal health services; and "Whereas the resultant accomplishments of this program are determined to a great extent by the method of implementation of the program: Therefore be it "Resolved, That the legal counsel of the Massachusetts Medical Society be requested to act in conjunction with a subcommittee of the Committee on TaxSupported Medical Care, appointed by the President, to study the legal implications on the implementation of the Kerr-Mills law and to make such recommendations as are necessary to insure the accomplishment of the purpose on which the Kerr-Mills law is based." The second resolution which unanimously passed the council in February 1963, is based on recommendations of the American Medical Association for improvement of implementation of Kerr-Mills. It follows: "Whereas, effective implementation is to the benefit of patient, physician, and taxpayer; and "Whereas, the AMA in supporting the Kerr-Mills law affirms the following suggested amendments to the implementation of the law: "(1) Remove the requirement that both OAA and medical assistance for aged (MAA) programs be administered by the same agency; "(2) Provide flexibility in the administration of the income limitations proposed under State law so that a person who experiences a major illness may qualify for benefits if the expense of that illness in effect reduces his money income below the maximum provided; "(3) Include a provision in the law requiring State administering agencies to seek expert advice from physicians or medical societies through medical advisory committees; and "(4) Provide for 'free choice' of hospital and doctor under State program: Therefore be it "Resolved, That the Massachusetts Medical Society establish liaison with Massachusetts legislators for the purpose of establishing legislative means of implementing the Kerr-Mills law so as to effectively fulfill its purposes in the best interest of patient, physician, and taxpayer." In summation, the Massachusetts Medical Society, in its constant effort to make available to all people increasingly improving medical care is in complete accord with the principles embodied in the Kerr-Mills law. We have tried, and shall continue to try, to bring about an implementation of the law which will include the above mentioned four recommendations to the benefit of the recipients, the purveyors, and the providers of medical care. JOHN B. BUTTS, M.D., Chairman, Committee on National Legislation, EXCERPTS FROM REPORT OF THE SPECIAL COMMITTEE OF THE MASSACHUSETTS MEDICAL SOCIETY ON NATIONAL HEALTH LEGISLATION, DATED FEBRUARY 6, 1963 III. STATEMENT OF CONCLUSIONS AND RECOMMENDATIONS (a) Conclusions 1. In the opinion of this committee the legislation known as "Health Insurance Benefits Act of 1961," 87th Congress, H.R. 4222, having failed of enactment by Congress, has also failed in the arena of reason to substantiate the four basic premises stated on pages 3 and 4 under “Findings and Declaration of Purpose"; namely, "(1) The heavy costs of hospital care and related health care are a grave threat to the security of aged beneficiaries, “(2) Most of them are not able to qualify for and to afford private insurance adequately protecting them against such costs, "(3) Many of them are accordingly forced to apply for private or public aid, accentuating the financial difficulties of hospitals and private or public welfare agencies and the burdens on the general revenues, and "(4) It is in the interest of the general welfare for financial burdens resulting from hospital services and related services required by these individuals to be met through social insurance." 2. The present voluntary system of medicine in the United States, having achieved universal primacy, is endowed, as seen from within, with even greater potential as a national and world force. 3. The code of the present voluntary system of medicine, mutatis mutandis, is capable, through its inherent flexibility, of solving what is actually a marginal problem. 4. Massachusetts statistics fail to show need for Federal intervention in the medical care of the over 65 other than through the Kerr-Mills law. (b) Recommendations 1. The immediate enactment of tax incentives which would lighten the economic burden not only of the over-65 population but also of the under-65 citizens. These tax reforms should provide equitable tax deductions and tax credits with carryback and carryforward options for taxpayers of all ages. 2. Immediate provision for higher nontaxable incomes for social security beneficiaries in order to complement the "economic floor" with an “earning ceiling" of appropriate height. nomic burden not only of the over-65 population but also of the under-65 citizens. limitation should be adjusted to the phenomenon of increasing life expectancy. 4. The immediate review and revision of the principal causes of increased cost of medical care including possible provision for deferred payments of major expense hospital costs at minimal interest rates payable through private or Federal funds. 5. Further intensive study by voluntary private health insurance and Blue Cross-Blue Shield organizations, to provide greater coverage at the lowest possible cost. This study should include devising means of providing low cost insurance for those individuals now considered uninsurable because of illness. 6. Serious studies of proposals aimed at cooperative efforts between the Federal Government and private insurance companies to make comprehensive prepayment medical care available to every American citizen. 7. A thorough study of public-assistance plans with the view of their reorganization for equitable and adequate service, with consideration of utilizing voluntary health insurance plans to cover the indigent of this State. 8. Full support and implementation and, if needed, appropriate amendment, maintaining the original intent and spirit, of the Kerr-Mills bill, which in September 1962 was operative in 25 States and 3 territories. 9. Reaffirmation of Resolution 26, AMA houses of delegates, 1962. 10. The creation in the Massachusetts Medical Society of a standing committee on medical service, the function of which would be the comprehensive and constant surveillance of the medical needs of the citizens of all ages. 11. That the committee on medical service be set up as a liaison committee with the Governor's office to discuss such medical matters as it may be concerned with, or that may concern the State. * "Indeed the idea of a profession is incompatible with performance of the profession's function, exercise of its art, by or under the supervision of a government. "The service state easily becomes an omnicompetent state *** the step from it to an absolute state is easy and may be made quickly. "It is characteristic of the service state to make lavish promises of satisfying desires which it calls rights."-ROSCOE POUND.1 STANLEY J. G. NOWAK, M.D., Chairman. JAMES R. BROWNING, M.D. STATEMENT OF THE MINNESOTA STATE MEDICAL ASSOCIATION ON H.R. 3920, 88TH CONGRESS (By John P. Medelman, M.D., president, St. Paul, Minn.) THE MINNESOTA STATE MEDICAL ASSOCIATION'S POSITION ON H.R. 3920 In 1959, and also in 1961, the physicians of Minnesota had an opportunity to présent a statement to the House Ways and Means Committee on the Fórand and King-Anderson bills. We appreciate this opportunity to communicate with the committee again, because conditions which might have appeared to justify such legislation have changed materially in a period of 2 years as more statistics have become available. Four years ago in our statement, the Minnesota State Medical Association said: "In summary, the physicians of Minnesota are aware of the problems involved in providing health and medical care for our senior citizens. We are pledged to do everything possible to meet this challenge by implementing existing plans, and we wish to be permitted to carry out this pledge." You have given us the right to implement the "existing plans," and today thousands of persons over 65 years of age are reaping the benefits. By July nearly 38 percent of all the aged in Minnesota will come under our new comprehensive health care plan. On August 4, 1961, Dr. J. Minott Stickney, an actively practicing Mayo Clinic physician, pointed out that we in Minnesota had collected many "solid facts about our aging population." After enumerating much new data collected by the Minnesota Department of Public Welfare and other agencies, Dr. Stickney made this statement: "On the basis of the facts uncovered in Minnesota, the question arises as to the need for the King bill in Minnesota. We believe that these facts warrant the conclusion that the bill is not needed." Since then we have assembled additional pertinent statistics from local hospital studies, as well as from a comprehensive survey recently completed by the Community Health and Welfare Council of Hennepin County, Inc., the latter being a United Fund agency. We believe that the information presented in the report of 2 years ago, augmented by recent studies and events in Minnesota, demonstrates conclusively that there is absolutely no need for any additional type of health care program in our State. Minnesota's aging population receive top care-New health care plans According to a survey done in 1960 by Dr. Marvin J. Taves, former professor of sociology at the University of Minnesota, 5 percent of the Minnesota people over age 65 said they had a medical need which was uncared for because it was too expensive. 1 "New Paths of the Law," first lecture in the Roscoe Pound Lectureship Series. Omaha: University of Nebraska Press, 1950, pp. 68, 52, and 56. Beginning July 1, 1964, no Minnesotan over 65 will be able to make that statement. The Legislature in Minnesota has now passed a comprehensive medical care program under the medical assistance to the aged portion of the Kerr-Mills bill which will take care of such needs. The State has had a full benefit old-age assistance program, in addition, for the past 15 years. The MAA plan will provide the following benefits for 38 percent of all the senior citizens: (1) Inpatient hospital services. (2) Skilled nursing home services. (3) Physician's 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) The following, if prescribed by a licensed practitioner-drugs, eyeglasses, dentures, and prosthetic devices. (11) Diagnostic, screening, and preventive services. (12) Any other medical care or remedical care recognized under State law. Over 140,800 of the 367,071 persons over 65 in Minnesota will receive $13,700,000 in additional health benefits each year. Those who qualify will be able to own and keep up to: (1) $15,000 in real property. (2) $1,800 annual income if single and $2,400 if married. (3) $750 liquid assets if single, and $1,000 if married. Not included are personal and household effects, prepaid burial plot, or cash surrender value of each person's life insurance up to $1,000. This latter provision may be waived by the county agency administering the plan. The above-named benefits are available to the recipient after he has paid the first $200 of his health care bills in the preceding 12-month period. Health insurance premiums are included in the $200 deductible, and the insurance benefits are applied to the health care costs of the individual beneficiary before the remainder of his bill is paid by the administering agency. Again, the agency may waive the $200 deductible if it causes undue hardship on the recipient. The Minnesota MAA plan will become effective July 1, 1964. One now asks, How are the other 62 percent of the senior citizens going to pay for their care? We believe that guaranteed renewable private and nonprofit health insurance will take care of their needs. Minnesota Blue Cross began selling two new health plans tailored exclusively for senior citizens over age 60 in January 1963. The first, known as series 60 plan A, is a $25 deductible program which pays $10 per day for room and board for 30 days every 6 months. The following hospital services are covered in full, less the deductible: Operating room service, anesthesia when administered by a salaried employee, X-ray, clinical laboratory service, pathological laboratory service, electrocardiograms, physical therapy, oxygen therapy, dressing and plaster casts, drugs, biologicals, etc. The premium is $96 per year. Plan B of the 60 series is a 75-25 coinsurance plan entitling the subscriber to 70 days of hospitalization every 6 months. All hospital services enumerated above are covered as well as daily room and board in a two-or-more-bed room. Outpatient care is covered if the patient is admitted to the hospital within 24 hours after the accident. Nonacute care is covered if the patient enters such a facility within 72 hours after discharge from a confinement of at least 5 days or more in an acute hospital. The premium for this plan is $150 a year. Minnesota Blue Cross has always provided coverage to all persons through group plans or individual contracts when enrollment occurred before the age of 60. Individual contracts are guaranteed renewable beyond the age of 60. A member of a group plan who reaches retirement age may elect to continue protection under the plan for a period of 3 months. The benefits of this coverage include a maximum of $15 a day room rate for hospital care. At any time during the 3month conversion period, the retiree may choose to continue to receive protection by subscribing to a new contract on an 80-20 coinsurance basis. More than 65,000 Minnesotans are covered by the two 60 series plans and the 80-20 coinsurance plan provided for group contract retirees. There are many more thousands over age 65 who are still working and covered by group contracts. |