I am accompanied by Mr. Robert Craig, a member of the staff of the society.

We are appearing in opposition to H.R. 4222.

May I request, Mr. Chairman, that our prepared statement, which has been filed with the committee, appear in the official transcript, and that I be permitted to present a condensed form of the same? The CHAIRMAN. Yes, sir; without objection.

(Dr. McCreary's prepared statement follows:)

Statement of THOMAS W. MCCREARY, M.D., PRESIDENT, Pennsylvania MEDICAL SOCIETY, HARRISBURG, PA.

Mr. Chairman and members of the Ways and Means Committee, I am Thomas W. McCreary, a medical doctor, now in my 35th year of practice in Rochester, Pa., where I specialize in pathology. I am appearing here today as the president of the Pennsylvania Medical Society, a nonprofit organization of 12,000 physicians.

The organization I represent is 113 years old and is actively engaged in extending medical knowledge, advancing medical science, elevating and maintaining medical education and upholding the ethics and dignity of the medical profession. In addition, the Pennsylvania Medical Society advocates and supports such legislation as will accrue to the health and well-being of the public and enlightens and directs public opinion in regard to health and hygiene.

The Pennsylvania Medical Society is a constituent of the American Medical Association and has 60 component county medical societies in 62 of Pennsylvania's 67 counties.

In the specific field of medical care for the aged, our society was one of the first to have an active committee studying the problem and disseminating information on the proper care of the elderly to our members and to the public. It was in 1959 that a society program for improved medical service was launched in western Pennsylvania and it is now spreading throughout the Commonwealth. This program seeks to insure the provisions of high-quality health care at reasonable cost through acceptance of a group responsibility by physicians acting through their medical society and by cooperation among the health care partners-physicians, hospitals, prepayment agencies, health insurance carriers, and the medical society-to serve consumers more efficiently. A system of evaluation and review procedures guided by established standards for the quality, cost, and utilization of health care facilities, provides the controls against misuse and the stimulus for progressive improvement in performance. The Pennsylvania Medical Society has always supported progressive welfare legislation in Pennsylvania that has had either a direct or indirect effect on the aged indigent and has supported the public assistance law since it was originally passed. Through the years we have supported amendments which would give the recipients of public assistance as much additional coverage as the State could afford. We supported, during the 1959 session of our general assembly, a bill which was passed to provide that aged, indigent persons may be taken care of in foster homes at State expense. Pennsylvania physicians feel that this represents an honest approach to at least a part of the problem. In 1958 the State department of public welfare began to pay for the care of the medical indigent in nursing homes where such nursing-home care was indicated. The society has always been one of the organizations in the forefront in insisting that nursing homes achieve their maximum efficiency. Also, we have encouraged the enactment of appropriate practical nursing licensure laws in order to assure all of our citizens, especially those over 65, of home nursing care by competent individuals. Currently, the society has successfully advocated the passage of legislation in the general assembly which would bring Kerr-Mills funds having correspondingly broader program of health care for the aged to the Commonwealth. In planning the implementation of the Kerr-Mills Act, we have been working closely with the Pennsylvania Hospital Association and the Pennsylvania AFL-CIO.

I am happy to report to the committee that as of the date of the preparation of this testimony, legislation providing for the implementation of Kerr-Mills in Pennsylvania has passed both houses of our general assembly and is cur rently before the Governor for his signature. The bill before the Governor provides essentially a new program of medical assistance for the aged as follows:

(1) Inpatient hospital care for 60 days. If the person has been out of the hospital for 60 days or more, he is again eligible for additional inpatient hospital care for 60 days; (2) posthospital care in the home for the condition for which the patient was originally hospitalized, and (3) nursing care provided in the home by a registered nurse and when ordered by a physician.

Of course, this program is limited to those persons who are 65 years of age or over who are not recipients of old-age assistance and who fall within the income limitations of $1,500 for a single person and $2,400 for a married person living with spouse. There are certain property limitations specified in the bill but we consider these extremely adequate and I might add that in determining the liquid assets, the resident property, household furnishings, life insurance, and automobile are excluded.

A second bill which has already passed our senate and is at the moment before the house of representatives is an amendment to the Pennsylvania support law making relatives responsible for the illness in the family. It is expected that this measure will also pass very shortly and that the entire Kerr-Mills package will be signed by the Governor in the very near future.

The society has also supported a measure which will eventually allow the department of public welfare to create local welfare units so that the services of this agency will be available at the local level where they are most needed. The society has been instrumental in organizing the Pennsylvania Council on the Health Care of the Aging. The Pennsylvania council is patterned after the joint council to improve the health care of the aging. Similar councils have been established in 33 other States. The Pennsylvania council is composed of representatives of the hospital, nursing home, dental, pharmaceutical, nursing, and medical organizations.

In June of 1961, the council sponsored a conference on health care of the aging which brought together for the first time individuals of the various member organizations. The conference had two major purposes. The first was to inform individual members about some of the problems which the various organizations are facing with regard to the impact of the problems of the aging. The second purpose was to explore ways and means to develop similar councils or groups at the local level, where they can be most effective. Four individuals representing this organization discussed the development of a workable relationship in the Williamsport area which has lead to the development of a local council on the health care of the aging. This particular council has been successful in informing each organization belonging to the council and the aged of the Williamsport area of the services available to the aged needing medical care assistance when ill as well as preventive services that are offered by each organization.

The society's commission on geriatrics, which was established in 1952, has been urging the development of appropriate courses in the medical schools which will acquaint the students with the problems they will be facing in the care of our older citizens. This commission has also been instrumental in developing programs for the X-ray screening of older persons with other committees of the society, and cooperated with the various departments of the State government in advising them on the necessary requirements for nursing homes. The society has also undertaken a project of developing a program of home care services for the aged and has distributed nutritional manuals to guide physicians in providing proper diets for the aging.

Pennsylvania physicians have a long and commendable history in supplying health care to its needy and aged ill. There are in Pennsylvania eight types of medical facilities for the aged and needy which deserve special attention. There are (1) the traditional home and office care rendered by the individual physicians; (2) the 10 medical and surgical hospitals operated by the Commonwealth; (3) the Philadelphia General Hospital; (4) the 182 voluntary, nonsectarian general and special hospitals which apply for and receive tax funds to help defray the cost of caring for the needy and aged sick; (5) the 74 voluntary hospitals which do not receive State aid; (6) the 58 institution district homes or hospitals which are responsible for persons "requiring public care because of physical or mental infirmities;" (7) the 57 voluntary homes and agencies which receive State aid; (8) the nearly 800 voluntary and proprietary nursing homes which, although they do not receive State aid directly, are reimbursed for care of State patients under the public assistance program. Traditionally, physicians working in all of the above mentioned institutions and as individual and private practitioners of medicine, have offered freely and generously their services in furnishing medical care to the aged in Pennsylvania.

Recent figures released by the Hospital Association of Pennsylvania point out that 19 percent of free patients in Pennsylvania voluntary hospitals are 65 years of age and over and that they account for 31 percent of the total annual 600,000 days of free care provided. Our hospitals are reimbursed by the State for the care that is rendered these people, but I would like to point out that the physicians working in these hospitals, caring for these patients, have never received any reimbursement, nor do they seek reimbursement.

The October 1960 issue of New Medical Materia presented data showing that the Nation's physicians annually donate large amounts of their services without compulsion or expectation of public recognition. The report of a random sample of physicians covering the entire United States was published in the May 1961 issue of this publication. This survey reported that Pennsylvania physicians provided $41,969,000 worth of free care during 1960. This free care was ap portioned on the following basis: 28.4 percent resulted from treating private patients without charge; 37.3 percent resulted from hospital ward service; 24.3 percent was provided in outpatient clinic service; 10 percent resulted from free care to all other persons including physicians' relatives, students, campers, amateur athletes, clergymen, emergency cases, and charity cases. This amounted to $3.73 per person residing in Pennsylvania.

The physicians of Pennsylvania have cooperated in the implementation of the old-age-assistance program as well as the general-assistance medical-care program, and have agreed to accept reduced fees for the services they have performed.

The Pennsylvania Medical Society has provided the stimulus for a Blue Shield senior citizen program recently approved by the State insurance commissioner. The senior citizen program is being offered on a voluntary basis to Pennsyl vanians 65 years of age or older who are not already Blue Shield subscribers. The present Blue Shield program permits persons to secure voluntary prepaid medical-care insurance regardless of age or condition of health.

Under the new senior citizen program, an individual having an income of less than $1,500 or a person with dependents having an income of under $2,400 will receive covered services without additional charge from the 15,000 Pennsylvania physicians who participate. Subscription rates for this plan are $1.83 a month for a single person and $3.66 for a subscriber with one or more dependents. This low rate includes coverage for home and office visits.

At the present time over 4 million Pennsylvanians have Blue Shield coverage and can continue this coverage past the age of 65.

The Pennsylvania Medical Society, in cooperation with the Medical Service Association of Pennsylvania, which provides Blue Shield coverage within the State, has for years provided coverage of Blue Shield subscribers at low premium rates because of the acceptance of a below average fee schedule. The fee schedule for the senior citizens program has even been further reduced so that the aged with low incomes can afford this protection.

Most of the Blue Cross plans in Pennsylvania are presently offering coverage to persons age 65 and over, or have filed such plans with the insurance commissioner for his approval.

According to the Health Insurance Institute, nearly 128 million Americans, or .72 percent of the civilian population had some form of health insurance through voluntary insurance organizations at the end of 1959. This health insurance helped to pay the cost of hospital, surgical, and medical care as well as replace income lost through illness or injury.

The growth of health insurance coverage has been phenomenal in the past 10 years. Coverage has been broadened in benefits and extended to include many segments of the population through liberalized underwriting practices. In 1960 the Health Insurance Association of America estimated that 50 percent of Americans 65 and older had some form of health insurance. There is much evidence to support estimates made by the association that by 1970, 90 percent of the aged who desire coverage will have it on a voluntary basis.

Among the numerous efforts made by the Pennsylvania Medical Society, I believe it is significant to mention that we have urged the enactment of legisla tion to provide that retiring employees be given the right to retain their health insurance policies with the same coverage at the same premium that was available to them during their employment. Legislation is currently being considered in the general assembly with the full backing of the Pennsylvania Medical Society to accomplish this.

Many of us, after discussions with our patients, are of the opinion that the majority of the citizens of Pennsylvania would prefer to provide for their own health care upon retirement on a voluntary basis. The provisions of the Kerr

Mills law passed at the last session of Congress are adequate to provide care for the indigent and the medically indigent who are no longer gainfully employed. We would like to see consideration given to the following at the local level:

(1) Continued contributions by the Federal Government in the existing State medical care phases of public assistance programs for the needy and aged indigent.

(2) More emphasis on outpatient care by individual State welfare departments. (3) Expansion of the Hill-Burton program to provide existing community facilities with additional equipment, beds, etc.

(4) Coordination of services and objectives by State agencies working on these problems.

(5) Creation of new local facilities or services in all States if and when a qualified survey of needs, goals, and resources so indicates.

(6) Creation of counseling centers for the aging, these centers to be used both for individuals and their families.

(7) Rehabilitation teams, working out of hospitals for planned long-term and rehabilitation care. Such a team would also review all of the possibilities of home care, homemaker service, sheltered workshop, etc.

(8) Centralized information services or centralized provision for comprehensive services to aged and/or chronically ill or disabled as they currently exist in Chicago and Cleveland.

(9) Creation of State coordinating committees on chronic illnesses and problems of the aged, composed of representatives from the interested departments and qualified voluntary organizations.

(10) Education of employers, union officials, employees, parents, children, and professionals in the meaning of long-term illness and chronologic retirement. (11) Workshops and educational courses be established for nursing home operators, homemakers, or practical nurses for the aged, and operators of foster homes.

(12) Increased use of State tuberculosis sanatoria for selected types of other chronic diseases.

(13) Screening clinics for the purpose of ascertaining the eligibility of candidates for nursing homes or county institution district facilities.

(14) Public housing modified to suit the handicapped and/or elderly; educating architects in this regard for public or private housing.

(15) Urging that all of these programs achieve individual self-help and health care rather than greater institutionalization and dependency.

We respectfully request that all of the above avenues be investigated fully before any action is taken relative to current proposals.

It is our considered opinion that the aged in Pennsylvania who need assistance for their medical care do receive it through the aid that has already been made available by the Federal, State, and local governments and with the continued cooperation of the purveyors of health care.

The physicians in cooperation with the health insurance plans have made available voluntary insurance that will protect those aged whose life savings would be endangered in the event of prolonged illness.

There does not appear to be a need to force each and every working person to be further taxed under social security to provide Government-directed aid to the indigent aged.

The present legislative proposal contained in H.R. 4222 will give aid to anyone over age 65 whether it is needed or not. Many of our social security recipients today have adequate funds to buy the luxuries of life as well as provide for their own medical care. Others being true Americans and believing in the principles of democracy wish to be free and independent and have bought for their own protection private insurance. These individuals can choose their own hospital, their own doctor, and are not being subsidized by a younger generation. We, in the Pennsylvania Medical Society, believe that H.R. 4222, were it enacted, would lead eventually to a full-scale adoption of socialized medicine resulting in a heavy tax burden and governmental control of the hospitals and the medical profession. In fact, already, you have heard testimony that the original estimate of cost of this proposal was too low.

The proposed law will provide care only in hospitals which have made agree ments with the Federal Government. It further provides for the payment of funds to hospitals for care rendered by pathologists, radiologists, anesthesiologist, and physiatrists. These people are all doctors of medicine, practicing in a specialized field of medicine. How soon will you be asked to include the surgeon, the internist or the general practitioner? How soon will you be asked

to provide complete hospitalization and medical care for every man, woman or child in the United States once our aged, regardless of need, have become direct wards of the Federal Government?

With the Federal Government returning tax dollars to the individual States through the Kerr-Mills law, the aged in need will continue to have adequate medical care at the lowest possible cost and without further endangering the freedom of you, me or our children. H.R. 4222 is a threat to our cherished freedom and democracy, and we urge you to abandon it as undesirable legislation.

Dr. MCCREARY. The organization I represent is 113 years old and is actively engaged in extending medical knowledge, advancing medical science, elevating and maintaining medical education for the medical profession.

In the specific field of medical care for the aged, our society was one of the first to have an active committee studying the problem and disseminating information on the proper care of the elderly to our members and to the public.

It was in 1959 that a society program for improved medical service was launched in western Pennsylvania and it is now spreading throughout the Commonwealth.

We would like to leave copies of this plan with the committee for its information, Mr. Chairman.

The CHAIRMAN. We will put that in the record, without objection. (The plan referred to follows:)

A PROGRAM OF IMPROVED MEDICAL SERVICE

"A PROGRAM OF SOLID MEDICAL PROGRESS

"It is our belief that such a basic program has begun to emerge in our State from the deliberations during the past several years of a dedicated group of physicians in the 10th councilor district. Under the leadership of Dr. Matthew Marshall, a philosophy of medical care has been formulated, and some progress has been made in detailing how this philosophy may be transformed into an equitable system for the provision of good medical care under the free enterprise auspices of medical societies.

"*** It is an approach which has already gained a remarkable degree of physician acceptance and approval. * * * It is, in any event, the feeling of the board that it may provide our best foundation for a program of solid medical progress ***."-Excerpt from the "Special Report of the Board of Trustees to the 1959 House of Delegates of the Pennsylvania Medical Society."

FOREWORD

One of the good influences on the health of U.S. citizens is the growing use of voluntary group prepayment or insurance for the financing of hospital and medical care.

Pennsylvania physicians are taking a forward step in protecting prepaid health care from abuse or wasteful use. This is being achieved by cooperation among physicians to assure that care is provided in accordance with accepted standards for its quality, cost, and utilization.

This system of doublechecking will help to slow the increase in the costs of health care. It will spotlight areas for study and improvement. It will promote more responsible relationships among the health care professions and services, and between them and the public.

It will also produce better solutions for such problems as how to provide adequate medical care for the Nation's senior citizens.

The Pennsylvania Medical Society is proud to announce this program, now being perfected where it was pioneered, in the Pittsburgh area. American medicine is in a twin surge of progress: on the technical side, by advance in science; and on the human side, by advance in service. It is fitting that the "renaissance city" should be a notable contributor to both.

ALLEN W. COWLEY, M.D., President, Pennsylvania Medical Society,

MAY 1960.