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CONCLUSION

One of the fundamental issues of providing medical care to the over-65 age group is whether the supply of that care should be based on the principle of individual choice or be made the subject of collective provision; whether the providers of medical care to this group should charge for their services; or whether medical services should be supplied free with costs being met from social security taxes and the quantity of services being regulated by Federal administrative decision.

The issues cannot be decided upon technical grounds; they lie beyond economics and are based on one's beliefs of what constitutes a good society. The Illinois State Medical Society takes the position that the provision of medical care rests firmly on individual financial responsibility, then on local private resources to which have been added health care programs designed to meet the specific need financed by local government, State government, and finally, as a last resort, by the Federal Government. In keeping with the principles of providing for those in medical need, the Kerr-Mills program is designed to finance the cost of health care for that segment of our population not on public assistance and who fall within certain need criteria.

We favor the Illinois Kerr-Mills law as a way of helping those who need help, and voluntary health insurance and prepayment plans for those who can afford them. Our society reaffirms its position that no patient, aged or otherwise, need go without medical services because of inability to pay.

In the interest of the general welfare, and the promulgation of programs sponsored by the Illinois State Medical Society and other voluntary groups, as well as for other reasons included in our statement, we strongly oppose medical care costs being met from social security taxes and care being made available to all as a matter of right.

We have set forth the views of the Illinois State Medical Society on financing medical care for the aged and submit them for your wise deliberations.

APPENDIX

TWELVE-POINT POLICY STATEMENT, ILLINOIS STATE MEDICAL SOCIETY, JANUARY 1961 1. The society is exerting its effort to maintain the older individual as a healthy participant in the family, civic, economic, and political life of the community. 2. The society feels that the responsibility for financing health care of the aged rests primarily on the individual, then his family, then voluntary community agencies. Should these be inadequate, the responsibility should rest with government on an ascending level with Federal participation limited to financial assistance to the State for locally administered and locally operated programs. 3. The society is taking active leadership in the development of prepayment and insurance plans for the aged in low-income groups.

4. The society reaffirms its position that no patient, aged or otherwise, need go without medical services because of inability to pay.

5. The society supports the extension of governmental programs for medical aid to the aged through the Kerr-Mills approach.

6. The society is continuing its efforts to expand skilled personnel training programs at all levels in the health field.

7. The society is continuing its efforts to improve medical and related facilities and services for the aged.

8. The society strongly advocates health maintenance programs.

9. The physicians of Illinois support the development and wider use of restorative and rehabilitative services for all who need them.

10. The society endorses community activities for older people such as may be found in churches, senior achievement groups, "Golden Age Clubs," and day centers.

11. The society strongly supports the extension of research and is cooperating with organizations in undertaking research on numerous socioeconomic aspects of aging.

12. The society urges all county medical societies to form special committees on aging and to take local leadership in the development of specific programs to improve the care of the aged. Thirty-one county medical societies in Illinois currently have active committees on aging.

ILLINOIS STATE MEDICAL SOCIETY,

ISMS MEMBERS OPPOSE SOCIAL SECURITY COVERAGE

Chicago, Ill.

The Illinois State Medical Society has been on record for many years in opposing mandatory social security coverage of physicians. Several polls have been taken on this subject.

The most recent poll which

was taken of 10,000 physicians asked the following questions: 1. Are you now covered by social security?

2. If you are now covered by social security, do you wish to remain so? 3. Are you in favor of compulsory social security coverage for all physicians?

4. Your age?

Over 6,000 survey forms were returned to the State society for tabulation. Of the 6,132 physicians who responded to the key question (Are you in favor of compulsory social security coverage for all physicians?), 54 percent or 3,323 voted their opposition to compulsory social security coverage.

[From the Chicago Tribune]

THE DOCTORS FACE SURGERY

When a doctor is about to perform surgery, it is customary whenever possible to obtain the consent of the patient before wheeling him into the operating room. This is so even when the patient is a Member of Congress.

But Congressmen don't seem to feel the same obligation toward doctors. The House Rules Committee has approved a number of social security changes, one of which would force the country's 170,000 self-employed doctors under compulsory social security even though most of them, according to the American Medical Association, do not wish to be dragooned into the system. A doctor would be separated from 5.7 percent of the first $5,400 of his annual income. Nearly all doctors would thus pay the maximum, $307.80 a year (subject, of course, to later increases by Congress).

In recent years the social security maelstrom has sucked in self-employed architects, lawyers, and dentists. Medicine is the largest profession not yet under control.

Doctors have particularly valid reasons for wanting to stay out. A selfemployed doctor can rarely count on retiring at the age of 65, partly because he probably won't want to retire; partly because his patients won't want him to retire, and partly because there is a shortage of doctors and his services will be needed as long as he can provide them. More than half the Nation's doctors, according to the AMA, don't retire until they are 74 years old or older and thus would not begin receiving social security benefits until age 72 when the law permits payments regardless of earnings. Most of them are well able to care for themselves during their remaining years and to provide for their widows. The only doctors who have to retire at 65 are those employed by others, such as corporations and institutions, and they are covered by social security already. As long as there is no evidence that most doctors want to be under social security or that it would benefit them, the administration's proposal must be regarded as a means of extracting sizable payments from self-employed doctors in order to subsidize other beneficiaries of social security. The fact that our so-called old age "insurance" system is already so full of glaring examples of trickery is no reason for Congress to add another.

We can think of one more outrageous possibility, and that is that the present plan is a calculated threat which the administration might be willing to forget if the medical profession consented to go along with an even more ominous extension of social security. That is the Kennedy-Johnson plan to extend the system to cover medical care for the elderly. Any such step would be nothing less than blackmail.

STATEMENT OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION, JACKSON, MISS., WITH RESPECT TO H.R. 11865

Purpose of statement.-The Mississippi State Medical Association is a scientific professional society of physicians founded in 1856. It is a constituent asociation of the American Medical Association and the authoritative voice of the medical profession in Mississippi. The association is grateful for the opportunity of presenting its views to the Senate Committee on Finance with respect to one portion of H.R. 11865, Social Security Amendments of 1964. Although the association has formally stated its opposition to proposed amendments to the act relating to compulsory Federal medical care for the aging, as contemplated in the various Forand-King-Anderson bills, it has never voiced approval or disapproval of the act itself.

It is the purpose of this statement to reiterate a policy of long standing with respect to compulsory inclusion of self-employed physicians under title II, OASDI, which is opposed by the association. Such compulsory inclusion is proposed in H.R. 11865, now pending before the committee, as passed by the House of Representatives. An identical position as assumed by the association in 1960 when the Senate removed the requirement for compulsory inclusion of selfemployed physicians in the enactment of amendments to the act at that time. Position of the association.-Our association has, on three occasions since 1959, conducted record votes in its house of delegates with respect to compulsory inclusion of self-employed physicians under OASDI. In all instances, delegates voted to oppose inclusion. Our delegates to the American Medical Association have so voted, and it is a matter of record that the American Medical Associa tion has voiced opposition to this proposal at least annually for several years, including action at its 113th annual convention at San Francisco, June 21-25, 1964.

The compulsory social security tax upon self-employed physicians would escalate to 7.2 percent on the taxable base of $5,400 per annum or $388.80 in taxes under the pending legislation. Since OASDI is founded on the so-called social insurance concept of taxing all individuals included in a compulsory scheme in amounts sufficient to meet current payments made to beneficiaries, the tax can be expected to rise, as has been the constant and consistent pattern since 1935. Compounding the paradox of there being no vestment to the credit of the individual so taxed nor guarantee of benefits, very few physicians could or would ever avail themselves of OASDI benefits.

Pattern of medical practice.—Historically, American physicians in overwhelming numbers continue to practice until death. As recently as July 13, 1964, the American Medical Association reported that, as of that date, there were 282.928 physicians in the United States and its territorial possessions. Among these, only 10,790 have retired, less than 4 percent. A total of 4,168 are known not to be in practice (but not necessarily retired from other or nonmedical endeavor). a combined total (with the retired) of slightly over 5 percent.

The same national studies show that of 177,314 physicians in active private practice, only 22,027 are over age 65, slightly over 12 percent. This demonstrates the "younging" trend in the medical profession, resulting from greatly accelerated training facilities development and the progressively increasing numbers of M.D. graduates in the United States.

In 1947 in Mississippi, 45.5 percent of all physicians were aged 60 and over. On December 31, 1963, only 21.6 percent of the State's physicians were aged 60 and over. Astonishingly enough-as a result of our Mississippi State Medical Education Board program and our new and excellent University of Mississippi School of Medicine 61 percent of all Mississippi physicians today are under age 49, and 34 percent are under age 40. Yet, our total of physicians has increased 22 percent since 1946, a rate much greater than that of general population increase.

It is therefore obvious that compulsory social security inclusion with respect to physicians is both unnecessary and grossly unfair. They would generally receive nothing in return for taxes thus exacted.

Practice incentives and tax equality.--From enactment of the Social Security Act in 1935 to passage of the Keogh-Smathers measure for voluntary retirement programs for the self-employed, the latter, including physicians, were at a distinct disadvantage as to tax benefits for retirement accumulations. This has been partially corrected by the Congress. Enactment of compulsory inclusion under OASDI cannot and does not assist the goal of tax equality. On the contrary, it negates the partial degree of correction so recently provided.

Studies published by the Illinois State Medical Society show that a decreasing term life insurance policy equivalent to a capital investment of $31,000 affords a physician or other self-employed individual the same protection the selfemployed social security tax (now proposed at a final tax cost of $388.80 per year) for a premium of only $98 per year. A $20,000 ordinary life policy with a 20-year family income rider would provide a physician acquiring it at age 30 more survivor income protection plus a final lump sum of $18,160 than social security can provide under similar circumstances-in brief, much more guaranteed benefits for the same costs.

Finally, a social security beneficiary is limited to a very small earned income, if his eligibility for OASDI retirement is to continue. Yet, it is clear that physcians do not, in fact, retire. To do so would be to decrease the quantity of medical care and to force those retiring to lower income levels. This appears highly undesirable both from health care resources and general economic standpoints. The sum of American medical manpower and knowledge should be utilized to the utmost, and retirement based upon chronological age alone is both wasteful and fallacious.

Position on H.R. 11865.-The Mississippi State Medical Association, therefore, opposes that portion of the pending legislation which would force doctors of medicine under OASDI, and for the reasons stated, respectfully urges your committee to delete this provision from the bill.

Hon. HARRY F. BYRD,

MONTANA MEDICAL ASSOCIATION,

Billings, Mont., August 7, 1964.

Chairman, Senate Finance Committee,
Senate Office Building, Washington, D.C.

DEAR SENATOR BYRD: On behalf of the members of the Montana Medical Association, and with the approval of its house of delegates, may I submit for the record of the Finance Committee of the U.S. Senate the following statement in opposition to the passage of any health care legislation under the social security system:

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Our medical association in Montana was founded in 1879. It has, as of August 1964, 585 active members, which represent more than 95 percent of the physicians actively engaged in the practice of medicine in our State. There is in Montana a ratio of 1 physician for approximately every 1,000 people.

The purpose of the Montana Medical Association as stated in its constitution is "to extend medical knowledge and advance medical science; to elevate the standards of medical education; to secure the enactment and enforcement of just medical laws for the protection of the citizens of Montana; to promote public health; to be active in the prevention and cure of diseases and in prolonging and adding comfort to life."

The Montana Medical Association has constantly endeavored to carry out these general purposes and has, through its members, devoted its energy to the task of helping to provide medical care to all of the aged of our State. One of the efforts of the Montana Medical Association to insure ample medical care for the aged, and, in fact, for all age groups, is our support as an association of the Montana public welfare program. Physicians of Montana have always provided medical care for all persons whenever necessary regardless of the patient's ability to pay.

Under the constitution of the State of Montana, it is the responsibility of the 56 counties to care for the indigent and the medically indigent citizens. Το do this, each county may levy a tax, not to exceed 17.5 mills, on taxable property valuation. State and Federal funds to supplement the county mill levy are used only in the following areas of public assistance: old-age assistance; aid to the needy blind; aid to dependent children; aid to totally disabled; and certain other categories of general assistance. All medical and hospital care activities of the public welfare program are financed entirely by county funds except in those rare instances where the county has levied the maximum permissive tax and is still unable to finance the complete care program. In the past year only three counties required grants-in-aid from the Department of Public Welfare of the State of Montana. These were Silver Bow County, Cascade County, and Lincoln County. (The latter county received only about $1,700.) The money required for these grants-in-aid from the department of public

welfare is appropriated by the Montana Legislative Assembly from the general fund for this purpose.

Each county in Montana operates its own welfare program. Many counties allow free choice of physicians by the indigent or medically indigent recipients of welfare and in most of these a fee schedule basis is in effect. During the past year two counties (Blaine and Missoula) have contracted with Blue Cross on a per capita basis to supply hospital and medical care to their indigent and medically indigent citizens. Not enough time has elapsed as yet for us to present a report of the efficacy of this Blue Cross contractual arrangement with the counties.

During the recent legislative session of Montana in January and February 1963, two different items of legislation to revise the Montana statutes upon health care of the aged were introduced. One was a bill to implement the KerrMills law and the second, a bill called “Montcare" which would provide for an appropriation of State funds to the counties to supplement their own funds in the care of the indigent and the medically indigent. It is noteworthy that the county commissioners organization in the State of Montana did not press for passage of either of these bills and especially it should be noted that there has been no influence exerted by any of the boards of county commissioners or by the State Department of Public Welfare of Montana for Federal funds. Neither of these bills was passed by the legislature.

Because of the simplicity of the plan used in Montana the amount of administrative work is kept at a minimum. If Federal funds were used, a considerable increase in administrative staff would be required. Even at the present time, the State department of public welfare must report how much time each of its workers spends in old-age assistance or in any of the other categories mentioned above since the Federal Government pays a varying proportion of the cost, depending upon the category in which the time is spent. If the Kerr-Mills law were implemented in the State of Montana, the administrative cost would rise tremendously. A full-time physician doing only administrative work would be required; reporting would increase; statistical work would be increased: it would be necessary to send three to four checks monthly to the hospital for each patient, etc.

There are two other facets of the care of aged in Montana which deserve mention. In the past 3.5 years, enrollment in Montana Physicians' Service (Blue Shield) has shown an increase of 20.9 percent in employed groups over 65 years of age and it may be safe to assume that the increase in the participation in commercial medical and hospital plans of persons over 65 years of age has increased proportionately. A second item concerns a study made by A. M. Fulton, M.D., at the Billings Deaconess Hospital from January to July 1961. A survey of the status of the accounts of a group of elderly patients, age 65 and older, indicated that 93 percent had paid their hospital bills in full within 6 months after their discharge from the hospital. Only 1.4 percent of the patients in this group (age 65 and older) had made no payments on their bills at the end of the 6 months. Furthermore, the unpaid hospital charges of patients over 65 years of age amounted to only 0.2 percent of the total unpaid charges of all patients admitted to the hospital. This study would appear to indicate clearly that the major collection loss of this hospital was incurred by those patients who were less than 65 years of age.

In summary, therefore, Montana feels that it is handling and can continue to handle amply, on a local and county level, its problems concerning the health care of the aged. Montana also believes that it can take care of its indigent and medically indigent with its present type of program at far less expense than it could under a Federal grant-in-aid program because of the greatly increased administrative expense under such a Federal program. Also, Montana feels that the best medical care can be given to indigent and medically indigent aged persons locally. Montana does not feel that it is wise to remove people from their home environment in the later years of their life and to place them in an impersonal. even though aseptic, steel and concrete building, miles or even hundreds of miles away from their friends and families.

Sincerely yours,

JOHN A. LAYNE, M.D., Legislative Liaison Representative.

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