SUMMARY

The truth is, as we have noted before, that we physicians helped to create the problems of the aged, and we feel we can help to eliminate them. Our sole interest lies in helping our aged patients to receive the best possible medical care.

We firmly believe that the numerous controls placed on the physician, the contracts that must be signed by the hospitals, the qualifications that nursing homes have to meet, the limited benefits of the program, and the fact that the KingAnderson bill is not flexible enough for the needs of the aged, will all work to the detriment of our patients, our own mothers and fathers, and our grandparents.

We are confident that, beginning July 1, 1964, we will have no problems in Minnesota. All of our aged will be able to pay their health care bills through use of the MAA program, their private resources, or by the private insurance companies. We know that this is the way people want it. Elderly people are not looking for "something for nothing." They have said it time and time again. They want to pay for their care if they can. If they cannot pay, then we in Minnesota feel that complete care must be provided for them, for as long as they need it. No one will ever again be forced into indigency because of health care bills in our State. The State of Minnesota has taken care of this responsibility to our aged population.

When a patient is sick, he sees a doctor. The doctor gives the patient a complete physical examination. Sometimes X-rays are taken, or sometimes he is subjected to special tests. Then the doctor collects the results, analyzes them, and then decides what he should do to help the patient. This is exactly what we have done with respect to the problem of health care for the aging. In the course of the last 4 years, we have analyzed the problem and arrived at a solution. The doctor does not perform a surgical operation when it is not necessary. We feel that the Government should not pass the King-Anderson bill when it is not necessary either.

Two years ago we pointed out that modern rehabilitation of the disabled and the aged calls for self-help and self-discipline programs. They were set up to help the disabled or aged person to regain his self-confidence, to learn to work again, talk again, and to maintain his own independence and self-regard.

The same principle applies to health programs. The aged do not want to be given health care for nothing. If possible, they want to help themselves. Our program in Minnesota does help the aged person to help himself. We feel that this type of program must be fostered and that the King-Anderson approach is unnecessary. We continue to be unalterably opposed to the King-Anderson approach, and we will use all of our resources to develop our Minnesota plan for giving full assistance to those who need help, and for helping all others to help themselves.

STATEMENT OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION WITH RESPECT TO H.R. 3920

The Mississippi State Medical Association is a 10-year-old scientific professional society for more than 1,300 physician-members. This statement reflects the views of our members based on thorough study and discussion of H.R. 3920 and resultant policies established by our board of trustees and house of delegates.

PURPOSE OF TESTIMONY

Our goal as physicians is to provide the best possible medical care to all persons with full respect for the dignity of the individual. We believe your committee seeks this same goal with serious concern in your study and deliberations regarding H.R. 3920. As individual physicians, we are acutely aware of the needs of our patients and we have a natural concern about means for providing these needs. As a professional society of physicians, we have worked productively in concert with public and private groups for the extension of knowledge and technique with respect to health care of the aging. Within this context, we, therefore believe that we can authoritatively and appropriately examine H.R. 3920.

H.R. 3920

H.R. 3920 neatly compartmentalizes medical care into so much hospitalization, nursing care, home care, and diagnostic services; packages eligible patients into one of these limited-care categories; and claims to prohibit control over the practice of medicine. All should realize that there is no "Mrs. Murphy's boardinghouse" in medicine. We, as physicians, must deal with whole persons and give total care. It is in this light that we urge your committee to consider the provisions of H.R. 3920 and their effect upon whole persons.

CARE OF THE AGED IN MISSISSIPPI

Enactment of H.R. 3920 would provide no solutions to Mississippi's health care problems which are not already or cannot soon be met by local means and existing legislation. A brief review of the positive program in the field of service to the aged, which continues to gain momentum in our State, demonstrates that passage of H.R. 3920 would actually be a step backward.

Since 1936, Mississippi has conducted a State-local tax-supported program of care in private hospitals for all its needy citizens. The State's share of per-day hospital costs was recently increased from $7 to $10 per day. Members of the Mississippi State Medical Association have given their services gratuitously to the program since its enactment. In 1962, the program provided 74,000 patientdays of care.

In addition, there are four State charity hospitals in Mississippi giving total care to service patients. The new and modern University of Mississippi Hospital, the clinical adjunct to our 4-year State medical school, is devoted for the most part to service patients. A new 100-bed chronic care wing was recently added to one of the charity hospitals.

Each year, the University of Mississippi Hospital typically furnishes about 66,000 days of inpatient care, 50,000 outpatient diagnostic and treatment visits, and 15,500 emergency room visits to service patients. The 4 charity hospitals provided 93,535 patient-days of care and 20,951 outpatient visits during 1962. Altogether, almost 234,000 patient-days of medical, surgical, and chronic care and 87,000 diagnostic and treatment visits are being provided annually to the needy sick in Mississippi. This is being done under a multiple, nonduplicating, State and locally supported program which gives total care to the patientnot merely the limited care proposed in H.R. 3920.

In Mississippi, voluntary health insurance coverage of our over-65 population continues to grow both in number of policyholders and benefits offered. For example, one company offering a senior-citizen contract in Mississippi reports a growth in number of policyholders of almost 32,000 from 1958 to 1963. This company offers, in addition to regular hospital and medical benefits (1) a $50 per year allowance for X-ray and diagnostic tests in the doctor's office; (2) a minor accident and injury allowance of $300; (3) a $2,500 allowance for each of 11 catastrophic diseases, including cancer; and (4) $5,000 in major medical benefits. Corresponding growth in benefits and number of policyholders reported by other health insurance companies raises serious doubt as to the necessity, advisability, and propriety of the Federal Government's entering the health insurance field with the limited, fragmented, compulsory, and standardized benefit program provided by H.R. 3920.

KERR-MILLS IN MISSISSIPPI

Recognizing that there are some persons in our senior population who can provide for their normal living expenses but who, at one time or another, may be faced with an illness which may seriously diminish their resources, we applauded and endorsed your committee's sponsorship of H.R. 12580, later enacted by Congress as Public Law 86-778 (the Kerr-Mills law). Our association is presently working energetically with other interested public and private groups to secure enactment of enabling legislation for full implementation of Public Law 86-778 at the 1964 biennial session of the Mississippi Legislature. We have recently furnished a committee of physicians to advise and assist the Mississippi Department of Public Welfare with respect to vendor medical programs under this program. Our most conservative estimates demonstrate conclusively that Kerr-Mills can furnish an entirely adequate vehicle for supplying medical care to needy recipients in Mississippi which is greatly superior to means proposed in H.R. 3920.

In 1961, Mississippi wage earners paid $58.2 million in social security taxes. During its first year of operation, H.R. 3920 would require Mississippians to pay at least $7 million additional taxes. A much more meaningful hospital and medical program for those in need can be provided under Kerr-Mills for ap proximately one-fourth this amount. Furthermore, the program can be fitted into our present State, local, and private health resources with a minimum of duplication while furnishing a maximum of care.

SUMMARY

In summary, we emphasize our extreme interest in the medical needs of our patients. We feel, however, that the program offered by H.R. 3920 falls short of the programs available to the people of our State from public and private sources. We believe it exceedingly unwise to repose health care authorities in the Federal Government only to witness the building of more centralism, more encroachment upon State and private endeavor, more denial of local prerogatives, and more tax expenditures.

The Mississippi State Medical Association finds no justification for this legislation and, therefore, respectfully urges that the committee not give favorable consideration to H.R. 3920 or to any similar measure.

STATEMENT OF THE MISSOURI STATE MEDICAL ASSOCIATION RE H.R. 3920

On behalf of the nearly 4,000 physician members of the Missouri State Medical Association, we are submitting to your committee a report concerning several important elements relating to the availability of health care assistance for the aged in the State of Missouri. We believe that these facts will be of value to the committee in its consideraion of proposed legislation to establish a Federal health care program through the social security system.

In June 1961, at the close of the 71st session of the Missouri General Assembly, a resolution was passed establishing a joint committee of the assembly for the purpose of making a complete and thorough study of the problem of providing health care assistance to the senior citizens of Missouri and reporting its findings and recommendations to the session of the legislature convening in January 1963. This interim committee, composed of State senators and representatives of both political parties, held numerous meetings and public hearings throughout the State during an 18-month period, inviting all interested citizens, and professional, business, and labor groups to give both factual information and suggestious concerning health care for Missouri's elderly.

THE SITUATION IN MISSOURI

The findings of this committee as reported to the general assembly early this year included the following:

"In this Nation, the State of Missouri ranks second only to the State of Iowa in the proportion of persons 65 years of age and over in relationship to the total population of the State. The 1960 census showed that more than half a million Missourians (503,411) are aged 65 or over, representing 11.7 percent of the total population of this State. Expressed another way, about 1 out of every 8 persons in Missouri is 65 years of age or older. It has been estimated by sources considered reliable that, by 1970, Missouri will have 600,000 persons 65 years of age and over. In many rural counties where living is less costly and, therefore, a good retirement climate exists, the percentage of the total population of the counties of persons 65 or older approaches and even exceeds 20 percent.

"Today about 6 out of every 10 aged persons eligible for retirement (58.7 percent) in Missouri receive payments under the Federal social security program. The actual number of persons receiving these benefits is 295,000 and the average monthly payment is $71.50. At present, about one-fourth of all aged persons in Missouri, about 108,000, are receiving State old-age assistance payments, popularly referred to as the old-age pension. At the present time about 39,000 aged persons are receiving both payments from the Federal Government under social security and the State old-age pension primarily because they happen to have high medical expenses which cannot be met from the benefits received from one program alone and they do, therefore, qualify for both programs.

"It is most interesting to note that the Missouri Division of Employment Security in November 1959, estimated that about 103,000 persons 65 and over in Missouri had some employment. This indicates that about 1 out of 5 aged persons are either employed for wages or self-employed on a part-time or full basis * * "The committee does not mean to infer that all senior citizens in this State are in dire need of medical assistance. This is not the case. Fortunately, as noted by the number employed, many are in very good health and have few, if any, medical expenses. Many others, though not employed, are able to get along quite well through savings and Federal social security payments. Many have been able to provide themselves with insurance to help in their medical emergencies. Many are being assisted privately by families who are able and willing to assist their parents in medical emergencies. Many local government units are presently doing what their financial abilities will allow to assist senior citizens with their medical care problems. The counties of Buchanan, Greene, Marion, and Pettis have unique and admirable local programs of medical care in effect. Also the two metropolitan counties of Jackson and St. Louis and the cities of St. Louis and Kansas City offer considerable assistance. The committee has viewed with pleasure the apparent growth of feeling of local responsibility and the growth of the use of private medical insurance by those senior citizens who can afford it.

*** It is the conclusion of the committee that the greatest need of all (for health care assistance) is found within that group who are presently on the old-age assistance rolls of the State of Missouri. Most of this group of persons do not have the type of employment history that also allows them to draw payments under the Federal social security program. They, by statute, are extremely limited in their income and available assets or they wouldn't and couldn't be on the OAA rolls for State payment. The maximum monthly payment to this group is presently $70 and the average payment is approximately $65 monthly. It is obvious that after present-day living expenses are taken from such an amount that there is and could be little, if anything, left for medical expenses no matter how dire the need might be. The committee does not mean to infer that there is no need for medical assistance in any group other than the old-age assistance group."

LEGISLATIVE ACTION IN 1963

The interim committee's recommendations for legislative action became the basis of bills passed by the Missouri General Assembly of this year, further implementing the Kerr-Mills law in Missouri.

The Missouri State Medical Association favored and worked for the passage of this legislation. It was the result of an intensive year-and-a-half-long study of the problem by 10 State legislators, and presented a program tailor made to the needs of Missouri's elderly.

The first of the two programs, which has been signed into law by the Governor, provides increased aid for health and hospital expenses for persons receiving old-age assistance. The second bill, while passed by both houses of the general assembly, was vetoed by the Governor after the close of the session. It would have established a program of health care assistance for the "near needy" aged-persons who are not eligible for OAA, who have adequate financial resources for normal expenses, but whose income and resources are insufficient to meet the costs of serious or prolonged illness. According to published reports, the Governor's veto was based principally on the uncertainty of the cost of the program rather than its desirability or expense. He was quoted as saying, "I feel that in the future if it is possible to get accurate information as to how much such a program will cost, then it should be given consideration."

Recipients of public assistance are now provided benefits for in-patient hospital care for serious illness or injury for which outpatient care will not suffice; the condition need not be, as formerly, a "medical emergency" or an "acute serious illness." Monthly payments to those requiring care in a nursing home have been raised to a maximum of $80 and payments to completely bedfast and totally disabled welfare recipients have been raised to a maximum of $110 a month. For the first time, Missouri will provide benefits for dental expenses, drugs, and medicines-the dental care to be authorized by the division of welfare and provided by a licensed dentist, and drugs and medicine also to be authorized by the division of welfare and prescribed by a licensed physician, osteopath, or dentist. The legislature authorized $4,322,320 in State funds to

implement this program for the 1963-65 biennium. Under Kerr-Mills provisions, this will be matched, we are informed, by about $6 million in Federal funds.

Under the provisions of the proposed program for the near needy, aid would have been provided for in-patient hospital care for serious illness or injury, as well as for drugs prescribed by the attending physician for a period of up to 30 days after the patient's release from a hospital.

We are gratified that this program had the support of the State legislature and believe that a similar bill will be introduced and passed in the next session of the general assembly.

PRIVATE INSURANCE

In the private realm, the nonprofit Blue Shield and Blue Cross Plans of St. Louis and Kansas City recently introduced special medical surgical and hospital protection plans for persons aged 65 and over to supplement the coverage they have long offered Missouri citizens without regard to age.

The St. Louis and Kansas City Blue Shield programs for persons over 65 are modeled on the program developed jointly by the American Medical Association and the National Association of Blue Shield Plans. Both programs include paidin-full benefits for members with limited incomes, and, as of June 30, a total of 9,000 person were enrolled in the two senior citizen programs. Including these special "senior" programs, a total of more than 75,000 Missourians aged 65 and over are now enrolled in various nongroup medical-surgical protection plans of the two Blue Shield Plans.

Many thousands of Missouri's over-65 group are similarly enrolled in Blue Cross hospitalization programs, while still more thousands are covered by commercial insurance.

CONCLUSION

As physicians, the members of the Missouri State Medical Association are deeply concerned with the problem of medical care for the aged. As a group, and individually, we worked for the passage of the two statutes detailed above.

The Kerr-Mills program helps those elderly persons who really need assistance. We believe that this is documented by the close relationship between the findings of the interim committee of the State legislature and the statutes that body passed. The Missouri Assembly found out what kind of medical care program was needed and promptly enacted it.

Statistics compiled recently by the Missouri Division of Health in cooperation with the Missouri Hospital Association concerning the methods of payment by patients discharged from a random hospital sample, made up of 63 outstate Missouri institutions, between July 1962 and December 1962, indicate that the problems of the aged in obtaining and paying for hospital care have been greatly exaggerated.

The figures from this 6-month period show that, of a total of 90,192 persons discharged from care in these hospitals, only 929-or 1 percent-were unable to pay any of their costs. Of this number, just 186-two-tenths of 1 percent of

the overal total-were age 65 or over.

During this same period, Missouri's program of health care for the needy aged an implementation of the Kerr-Mills Act-provided care for 2,122 patients over age 65 out of the 90,192 total cases documented in the study. In addition, 416 persons aged 65 or over received some assistance in paying hospital costs from this State program to supplement resources of their own.

The striking fact is, then, that the remainder of the more than 90,000 cases in this study were able to pay for their own care through Blue Cross, insurance benefits, credit payments or cash resources. Only 2,724 people over age 65, out of more than 90,000 patients, needed assistance through the Kerr-Mills program or direct charity from the hospitals. This is only a little more than 3 percent. These statistics point up the fact that the need for governmental aid is minor. Even at the 1962 level of benefits, Missouri's Kerr-Mills program was taking care of almost the entire problem that does exist. Since this study was made, of course, the Missouri Legislature has authorized the increased and expanded payments under the Kerr-Mills program which have been discussed earlier. It is apparent that what problem there is in providing medical care for the aged in Missouri is being taken care of by the State, and that, therefore, there is no need for the enormously costly and restrictive King-Anderson approach.

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