Nor, according to Dr. Lord, can we look-as some think they can-to the established health plans of the Scandinavian countries and the British Isles for guidance, because, he writes, "in these countries health care of the aged is inadequate and inappropriate as in the United States." He holds that health officials abroad admit the care of these people is inadequate, but are doing little to demonstrate better, and perhaps less costly ways of handling the problem. "Why," he wants to know, "should the United States make the same mistake?" Because we lack so much knowledge now about what the finest care should be and how it can best be dispensed," Dr. Lord concludes, "large sums of money made available at this time would only perpetaute the chaos and inadequacy." Well it certainly is something to think about-and something to discourage undue haste. And thank you for listening; this has been Al Quinn with "Maryland Report." [From the Sun, Baltimore, Jan. 7, 1964] HEALTH CARE GRANT ASKED DR. LORD BACKS COMMUNITYWIDE PROJECTS FOR AGED (By Thomas T. Fenton) As Congress prepares to debate medicare, Baltimore's coordinator of chronic diseases announced yesterday he is seeking $9 million from Congress for urgently needed mass demonstration projects of health care for the aged. At present, neither the administration-favored nor organized medicine-backed schemes of health care for the aged can provide adequate care because of lack of appropriate medical services in the United States, Dr. Mason F. Lord said. MEETING ARRANGED Dr. Lord said a meeting has been arranged Thursday in Washington with Maryland's congressional delegation to explain details of his proposal. Dr. Lord, who is physician in chief of the department of chronic and community medicine at Baltimore City hospitals, said the projects could demonstrate that care of the long-term illness-the major financial and social problem in health care for the aged-can be provided far more effectively and at less cost than at present. The Federal matching grants sought by Dr. Lord would be used to set up communitywide projects for 3 years in six selected areas of the United States, including Baltimore. WHAT SERVICES ARE NEEDED Based on his experience in Baltimore-which has the most comprehensive program for care of the chronically ill in this country-the mass projects would demonstrate in large urban and rural areas what services are needed for health care of the aged and what they should cost, Dr. Lord said. In a sharply worded editorial appearing this week in the Journal of Chronic Diseases, an international medical publication, Dr. Lord criticized existing medical services for the aged in the United States as "grossly inadequate." APPROPRIATE AND ADEQUATE He warned that full implementation now of either payment scheme for over-65 medical care could freeze the present situation and result in a substantial waste of money. In the editorial, based on the experience of the 3,000 chronically ill patients which have been referred in the last 4 years to the internationally recognized city hospitals program, Dr. Lord said the national debate, which is raging over which method of payment for medical care of the aged is needed, overlooks the question of whether either program can assure appropriate and adequate care at this time. If either type of bill is implemented, the marginal terminal nursing homes and hospitals, which everyone bemoans, will continue to flourish. If either type of bill is implemented, payment for this type of inadequate care will be made and will make up the largest share of the cost of any program. COSTS AND SERVICES In the British Isles and Scandinavia, where inadequate care was frozen because national health plans provided money before appropriate care was developed, the situation is as bad as in the United States, he said. "The general hospitals are crowded to capacity with the chronically ill aged; chronic hospitals are giant custodial care homes; nursing homes are taking care of people either in desperate need of acute hospitalization or not needing institutional care at all." Although the Federal Government spends more than $30 million annually on a number of small community health service projects, none covers an entire community, Dr. Lord said yesterday. Before a decision on how health care for the aged is to be paid for, he said, there is an urgent need to demonstrate what costs and services are needed for the entire aged population of a community. Dr. Lord said a major purpose of his program would be to change chronicdisease hospitals from custodial institutions into relatively short-stay hospitals for the chronically ill, and nursing homes from "terminal" institutions to reha bilitation centers. With appropriate services, he said, an elderly stroke victim could be returned to the community independent within 5 months at a cost of $2,000, after relatively short stays in an acute hospital, a chronic disease hospital and a nursing home. INADEQUATE CARE Under the present system, after a month in an acute hospital and perhaps 6 months in a chronic disease hospital, at a cost of $5,000, the result may be a patient who remains in a nursing home for the rest of his life, he said. After reviewing problems in other States, Dr. Lord said he was “disturbed by how much severe disability is promoted by inadequate care in general hospitals." An elderly person with acute pneumonia, he said, might die of shock because of poor nursing care after becoming disoriented, then incontinent and then developing a bed sore which becomes infected; or an incontinent patient may die of a resistant urinary tract infection caused by catheters which are used to save bed linen. Hon. WILBUR D. MILLS, House Office Building, Washington, D.C. DEPARTMENT OF PATHOLOGY, DEAR REPRESENTATIVE MILLS: Please consider the enclosed compromise plan for financing medical care for the aged. It has been approved by the Bucks County (Pa.) Medical Society and by others in our county including the county AFL-CIO council. I fully approve of the intent of the Kerr-Mills law which is, as I understand it, to help those who need help. Unfortunately, the most ardent supporters of the present law have, in their zeal to forestall a King-Anderson type of law, implemented your plan in a manner that is far from what was orginally intended. Please consider what has happened in Pennsylvania, where the original implementation of the Kerr-Mills law covered 20 percent of the aged. (See the testimony of Dr. W. Benson Harer who testified before your committee in November 1963.) Since then the State legislature has made many more of the aged eligible by increasing the annual income limits from $2,400 to $3,840, eliminated responsibility of children, etc. No one knows what proportion of the aged are now covered in Pennsylvania. Some believe that 50 percent will have their hospitalization paid for by the department of public assistance. To me, this is nothing more than a massive medical dole. I am sure that you did not intend for the Kerr-Mills law to work this way, but this is what is happening in my State. Once again, please consider the inclosed plan as an alternative approach. Thank you. Sincerely, JOHN J. MCGRAW, Jr., M.D. OUTLINE OF A PLAN FOR PREPAID FINANCING OF MEDICAL CARE FOR THE AGED FEBRUARY 1963 I. SOURCE OF FUNDS A. Increase the social security tax on employers, employees, and self-employed persons by an amount sufficient to pay for the benefits desired. II. MANAGEMENT OF THE FUNDS A. Sequester the funds for medical care for the aged and nothing else. III. DISBURSEMENT OF THE FUNDS A. The funds shall be disbursed by purchase of approved service-type insurance policies issued by private insurance companies such as Blue Cross and Blue Shield B. The fund may alternatively purchase other approved policies which may better fit the needs of any eligible person. The choice shall be solely that of the eligible person. C. The policies shall have a modest copay feature. IV. ELIGIBILITY FOR BENEFITS A. Everyone who has reached the age of 65 or who has been retired for disability shall be eligible for the insurance policy of his choice without a means test. The policy shall cover the dependent spouse. Payment for the policies shall be as outlined below: 1. Those who have paid into the fund for 10 years or more shall receive the policy of their choice without obligation to anyone. Full payment for the policy will be made from the fund. 2. Those who have not paid into the fund for 10 years shall receive the policy of their choice without a means test. Full payment for the policy shall be made from the fund but the recipients shall become indebted to the Federal Government for 10 percent of the cost of their policy for each year less than 10 that they have paid taxes to the fund. They may elect to pay the difference at the time they receive the policy or, on their own initiative, they may elect to delay payments until death of husband and wife. The estate, after death of husband and wife, shall be liable for payment of the cost of the insurance policies. If there are surviving dependent children, this fact shall be taken into consideration before the estate shall be liable. If the estate is not adequate to cover the cost of the policies, the surviving relatives shall not be held liable. If the estate cannot repay the cost of the policies, the fund shall be reimbursed by the Federal Government from general tax funds. V. COVERAGE A. Hospitalization, medical and surgical care, nursing home care, drugs, and essential appliances. The amount of coverage shall be dependent upon the amount by which the social security tax is increased. Coverage should be, at least, as extensive as that outlined in the King-Anderson bill and include medical and surgical fees. STATEMENT ON H.R. 3920 BY HARVEY RENGER, M.D. Mr. Chairman and members of the committee, I am Dr. Harvey Renger, of Hallettsville, Tex., where I am engaged in the general practice of medicine and surgery. I was born and raised in Hallettsville and, at the completion of my medical education, I returned there to follow in my father's footsteps as a country doctor. As president of the Texas Medical Association in 1961-62, I had the privilege of appearing before the committee when it was considering H.R. 4222 during the 87th Congress. You are again considering a bill, H.R. 3920, which if passed could alter forever. we believe detrimentally, the pattern of health care in this country and, as well, the nature of medical practice. In the course of debate on this bill, and its predecessors, there have been many allegations about the precarious financial circumstances and the health of our older citizens. In an effort to sift fact from allegation and to obtain objective information, I decided last December to learn the facts from personal investigation. Our people in the Ninth District are essentially in similar circumstances to people all over the United States, and a study of these 15 Texas counties can contribute information which is useful to you and to all of us in understanding what capacity elderly people have to manage their affairs and to meet their health needs. The survey's goal was to obtain information on how many elderly were hospitalized and how they met the resultant bills. I sought and received the support and cooperation of the Texas Hospital Association in this effort. A letter explaining the purpose of the survey and a questionnaire were sent to each of the 34 hospitals in this 15-county congressional district asking for the statistics for the 1962 calendar year. I received data from 24 hospitals which represents 82 percent of the hospital beds in the district. According to the U.S. Census Bureau's 1960 figures, there are 18,810 men and 20,814 women age 65 or older in the Ninth Congressional District of Texas, or a total aged population of 39,624. Of these older folks, 7,650 were hospitalized during 1962 in 24 of the 34 hospitals in the congressional district. Their total hospital bill was $2,296,279. Of this total, I learned that 22.7 percent ($521,731) was paid by Blue Cross; 6.6 percent ($150,501) was paid under the old-age assistance program; 49.4 percent ($1,134,238) was paid by private insurance and other private means; 21.3 percent ($489,809) of the total bill was not covered by OAA, Blue Cross, insurance, and the payment of which was the patients' direct responsibility. Restated, 78.7 percent of the elderly in our congressional district were able to handle successfully their health care bills, and the remainder were cared for anyway. It is this latter group, the 21.3 percent, which I would like to comment upon now before completing the summary of the survey. As you have already heard, I am sure, the old-age assistance provision of the Kerr-Mills law has been functioning most successfully in Texas under the aegis of voluntary health insurance through a program administered by Blue CrossBlue Shield of Texas. Next year the people of Texas will consider a constitutional amendment authorizing our participation in the MAA provisions of the Kerr-Mills law, and we look forward to an equally successful implementation of this part of the Kerr-Mills law if our legislature finds that there is a need for the program in Texas. Further, gentlemen, the Texas Legislature has concurred with the view of Governor Connally, of Texas, and passed legislation permitting private insurance companies to pool their resources in underwriting the Texas 65 plans, which plans offer fine basic and major medical coverage. A considerable number of our Ninth District elderly enrolled during October, the first enrollment period. Hence, in the past few weeks alone, the 49.4 percent of the elderly in our Ninth Congressional District whose health bills were paid by private insurance and other means has been increased, and the 21.3 percent decreased further. In a few weeks, the exact figures will be available to us. Using the study of hospital bed utilization by the aged in the 24 hospitals in our Ninth Congressional District as a base, we projected the figures to include all 34 hospitals. The 21.3 percent of expenses, which I have cited, when applied to all hospitals, amounts to a projected $600,000. At the most, it is this segment of the medical care expenses which needs to be covered. What would be the cost which Texas taxpayers would have to bear under the King-Anderson program to get coverage for all of the $600,000 of medical expenses not presently covered by existing programs? It has been estimated that King-Anderson would cost Texas between a minimum additional $58 million and a probable $69.3 million in taxes; and the Ninth Congressional District taxpayers would bear $3 to $4.5 million of that sum. Add to the minimum $3 million the $90 deductible feature of King-Anderson, and there is a $1 million increase to the cost. Thus the district would be paying at least $4 million for King-Anderson or a minimum of $6.50 for each $1 of benefits to the aged for coverage not already available under existing programs. Is this not an expensive and illogical approach? The study of the Ninth Congressional District of Texas demonstrates that the aged are getting under existing programs the good medical care they require and that existing programs are capable of rational, effective, and economical expansion. For the King-Anderson bill to offer care to all aged, the self-sufficient as well as the needy, comparable in scope to currently available programs, would require an outlay by the Ninth District taxpayers many times greater than the $4 million the currently limited program of hospital benefits under the King-Anderson bill would cost. The Texas prescription for meeting the health needs of its elderly citizens has been proven effective in the Ninth Congressional District of Texas. I sincerely hope that this committee and the Congress of the United States will continue to encourage this progress which we have made in caring for our aged. We are proud of what private initiative has done in the past and what it can and will do in the future in caring for those in need. Thank you very much for providing me with an opportunity to present my views to the committee and to offer to you the results of my survey of the hospital utilization of the aged in our congressional district. Hon. WILBUR MILLS, FORT WORTH, TEX., November 19, 1963. Chairman, House Ways and Means Committee, DEAR MR. MILLS: In 1961 my own county medical society, alarmed by the absence of any real information to support or refute Senator Anderson's claims about the supposed average expense of $1,000 per illness of the elderly, ran a survey to see what the situation was locally. I assisted Dr. Brooks in this survey. We found the amount of money involved to be about half of what Senator Anderson claimed (we included every possible bill, prehospital medical attention, hospital bill, fees for attending physicians and all consultants, past hospitalization medical fees connected with that illness). The report was sent to all Texans in the Congress at that time. Subsequently we found by correspondence with areas in New Mexico, Minnesota, Oregon that surveys there corroborated our findings very closely, that alleged need was not nearly so dire as had been portrayed. Since that time Texas is rounding out its second year of experience of implementation of the OAA section of the Kerr-Mills law. Our experience in Fort Worth has been excellent. By and large physicians and hospitals have been well pleased with the fee-for-service insurance coverage bought with the pooled State and Federal funds. Recipients and their families have been so well pleased that I have heard absolutely no complaints. The alleged indignities of the means test apparently have ruffled no one. Over 18 months ago personal insurance similar in coverage to that under our OAA plan was offered those likely to be in the MAA segment. I do not know how widespread the purchase of such insurance has been. Just last month Texas 65 plan was offered to the public. I purchased it for my own mother-in-law. Of course, it is too early for those of us in practice (or for the hospitals) to judge how effective it will be. Although surveys in our State indicate only a very small percentage of those over 65 who either need or desire the coverage, implementation of the MAA portion of the Kerr-Mills law is now in the legal process (adoption will be up to the voters of this State). From study of the general situation (National and State) and personal observation of the local situation can see no need which cannot be met under existing statutes; hence no need for the present King-Anderson proposal. I respectfully request that this letter be made a part of the record of the hearings. DEAR MR. MILLS: On September 1, 1960, the American Bar Association adopted certain principles on legislation relating to medical care of the aged. Quoting from the proceedings of the ABA House of Delegates for that day, those principles were the following: |