fully, we believe, in connection with deliberations on the bills which are now before the Congress as successors to the Forand bill of 1959.

In the course of these surveys, statistical material was secured for an interesting factbook entitled, "Minnesota's Aging Citizens: A County-by-County Statistical Report," and I should like to give you the following pertinent facts from that book as summarized in "A State Report of Developments and Activities in Aging.” Of a population of 3,400,000 persons in Minnesota, 10 percent are more than 65 years old, the total number being 340,000 and both the actual number in this category and the proportion of this number to the population as a whole are likely to increase as the years go by. About 46,000 (13.7 percent of those more than 65 years old) are indigent and are entered on old-age assistance rolls in the State. This group constitutes approximately 1.3 percent of the total population. Furthermore, only 7 percent of the persons more than 65 years old were found to be medically indigent and receiving medical care. through the old-age assistance program. These 24,000 constitute only 0.7 percent of the entire population.

It should be emphasized, also, as it was noted in 1959, that Minnesota's oldage assistance program provides comprehensive medical services, including— (1) The services of all licensed practitioners of the healing arts; (2) Hospital and nursing home care;

(3) Drugs and prosthetic appliances, including glasses;

(4) Dental care;

(5) Special diets; and

(6) Transportation, if needed.

The plan provides for free choice of vendor, also. The program is administered in the local community by the local county welfare director, and it costs about $20,160,000 a year. Of this total, the Federal Government pays about 52.8 percent; the State about 25.6 percent, and the county about 21.6 percent. Obviously, the Minnesota plan provides complete medical care for all those who are known to need such attention. In Minnesota, according to figures supplied by the Department of Public Welfare, 34.1 percent of the people who are more than 65 years old are not receiving social security benefits, either because they have never been employed in occupations represented in the social security system or because they earn more than the stipulated maximum figure under the law.

For purposes of gathering additional material on the health status of Minnesota's aged, medical grants made to recipients of old-age assistance were examined for a sample month. The month's sampling reflected the 1960 experience of the old-age assistance program in general. Of the total 1960 caseload, 52.2 percent (or 24,426) received $20,160,000 in medical services during that year. The average monthly cost per medical case was $68.78, and the medical dollar was divided as follows:

(1) Acute hospital care

(2) Licensed nursing-home care, these two items alone accounting for nearly 70 percent of the medical dollar).

Cents

38.5

29. 6

11.9

10.1

4. 1

1.5

1.1

3.2

Dr. Marvin J. Taves, associate professor of sociology and supervisor of rural sociology at the University of Minnesota, directed a survey which was designed to find the attitudes, characteristics, and status of persons more than 65 years old in Minnesota. Included in the sampling were 300 social security beneficiaries whose eligibility was determined on the basis of income from farming. Samples of persons living in small towns and metropolitan areas also were obtained. In the report is the comment that "one's financial well-being, after age 65, is often more dependent upon previous accumulations of wealth rather than on personal earnings." One half of the persons interviewed during this survey had a net worth of $10,000 or more. In the whole group interviewed 49 percent reported that they had enough income on which to live comfortably; 35 percent said they had enough for subsistence only, but no more, while 16 percent reported that their means were not enough to live on.

When the people interviewed were asked about their health needs and whether or not they had received the medical care they needed, 87 percent declared they had no uncared-for needs. Only 5 percent said that they had medical needs which had not been met because medical care was too expensive. Approximately 3 percent said their ailments were chronic and not susceptible to treatment.

About 85 percent of those who were interviewed said they had seen a general practitioner for one reason or another during the previous year. The remaining 15 percent reported they had not seen their physicians during the previous year. Of all those interviewed, 40 percent had not been hospitalized at all, and 60 percent had spent varying amounts of time for one reason or another in hospitals during the year.

In respect to total dollars spent for health care, 25 percent of the people interviewed had spent up to $49 during the year. About 59 percent had spent less than $200, and only 5 percent had spent $500 or more. One question which was put to all these people concerned the availability of medical care should it come about that they could not afford to pay for the usual type of medical care. It elicited the following response: 68 percent said they knew such care was available to them, and 22 percent said they did not know whether or not it was available. About 10 percent of them said they had made use of free services within the previous 6 months and 73 percent said they never, rarely, or seldom made use of such services themselves.

Another question concerned the services of the public health nurses, of whom there is at least one in each county. About 55 percent of those who were interviewed said they know that the services of public health nurses were available in their communities. More than 30 percent did not know whether or not there were such services, and 84 percent said they never, rarely, or seldom used the public health nurse in their communities. On the other hand, 56 percent said they would make use of the services of such nurses if they were available or needed, while only 25 percent flatly stated they did not want the services of a public health nurse under any circumstances.

On the subject of hospital insurance the response was as follows: About 60 percent of all the people interviewed carried some type of hospital insurance, and the percentage rose to 71 percent among people more than 65 years old in the metropolitan areas. The majority had purchased their insurance after the age of 50 years. Medical and surgical insurance was held, in addition, by about 50 percent of the group. Those who held this type of insurance likewise had purchased it after the age of 50 years. Another question asked of all respondents in this survey concerned how much income they and their spouses needed to live on during a month. Answers to this question varied. About 70 percent said they needed between $100 and $250 a month.

One other significant study of hospitalized patients in a typical rural Minnesota community was made in 1960. The people concerned in this survey were patients in the Renville County Hospital in Olivia, Minn., a general hospital having 41 beds and 10 bassinets. The study was carried out by the hospital administrator with the aid of the medical staff. It covered 256 patients and 350 hospital admissions. All the patients studied were 65 years old or older, and they constituted 21.5 percent of the total admissions. Of these, 14.8 percent were admitted for surgical operations and 85.2 percent were admitted for medical conditions. Their total hospital bills were classified as follows: mode (or most frequent figure) $36; median, $226; and average, $350.54. Three-quarters of the patients used private resources to pay their bills, and 25 percent of the bills were paid by a Government agency. As of February 1, 1961, only 8.9 percent had

not paid their hospital bills in full.

COMMENT

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.

In this connection, the attention of the committee is called especially to the following considerations, presented here in the form of pertinent questions: (1) How many persons more than 65 years old need medical care in Minnesota and cannot afford to pay for it?

As set out above, only 7 percent of all persons more than 65 years old in the State are medically indigent, and this percentage represents only 0.7 of the total

population of the State. These people receive complete care under Minnesota's old-age assistance program.

Furthermore, 87 percent of the people interviewed said they had no medical needs which had not been met, and only 5 percent said they had needs which could not be met because they could not afford to pay the costs involved. At the same time, only 55 percent indicated any awareness of the fact that a public health nurse might be available to help them meet health-care needs. Obviously, this situation points up the importance of better communication with senior citizens to acquaint them not only with the availability of nursing services. but with other community facilities of specal interest to the elderly.

Seventy percent of the people interviewed said they could live as husband and wife on $100 to $250 a month. Furthermore, more than half of all of them had a net worth of $10,000 or more.

More than that, the study showed that 59 percent of our senior citizens in Minnesota spent up to $200 for medical care during 1960, and that 95 percent of them spent less than $500 during the year.

Finally, 60 percent of them carried hospital insurance, the study pointed out. and 50 percent had additional medical and surgical insurance. Most of the people studied had bought their insurance during the last 15 years, and the clear trend is toward more and more health insurance coverage for the aging.

(2) Is the King bill the answer for those who do need help in Minnesota? The answer to that question is a definite "No." It is a fact that 5 percent of the people interviewed said they could not care for medical needs for financial reasons. But the obvious truth of the matter is that these people do not know about the services already available to them. If it is granted, however, that there were people whose needs could not be met by the facilities now at the disposal of the needy, the fact remains that the King bill would do them very little good.

The King bill would not provide the best solution to the problems of these people because many of them would not be covered, and the King bill itself does not provide complete coverage for those who have a real need for expensive health care. There are limits to the benefits which the King bill would provide. Under the Minnesota plan there is complete care for those who need it. If it becomes obvious that others not now eligible need help, they can be included in broader coverage under the principles of the Kerr-Mills legislation.

(3) Will private insurance companies be able to provide the coverage needed by aging citizens in Minnesota?

The answer to that question appears to be that they will be so able. We have already pointed out that more than 50 percent of Minnesota's population older than 65 years has insurance coverage, and that the types of policies available increase each year. Minnesota Medical Service, Inc. (Blue Shield) offers a policy for everybody more than 65 years old at the very nominal cost of $2.40 a month, and all participating physicians in the State have agreed to accept the reduced fees provided for under this contract. Blue Shield also is making available a new hospital plan at a modest cost. This contract has just been devised with the needs of the aging primarily in mind. Moreover, private insurance companies have sold plans to many people more than 65 years old in Minnesota. (4) What would the King bill do?

The answer to the question of what this bill would do involves a consideration of what the social security program really is. It is a method of collecting taxes from the worker and the employer or the self-employed which are to be returned to the worker or the self-employed at a certain age in the form of cash money. This money is to be used by the taxpayer as he sees fit. It has been established as a leading principle of social security that the recipient shall spend his money as he may choose. The King bill would establish a new principle. It would set up a dangerous precedent of Government control, and it would purchase hospital and some physicians' services for the employee or the selfemployed and, in addition, tax him for it. It would take away the right of choice from the recipient and force his doctor to send him to the hospitals which meet Government requirements, and which agree to accept a Government schedule of fees. These hospitals might not, in fact, be the ones the patient and his doctor would choose; and the same holds true for the services of nursing homes. In every case the recipient would have surrendered his right of choice.

Physicians of Minnesota are opposed to the King bill, even though the proposed benefits would be devoted mainly to hospitalization, because it seems clear that the action proposed in the bill is only a preclude to the inclusion of physi

cians' services which might be subjected to the same degree of governmental supervision.

We are convinced that the King bill is not needed in Minnesota. As physicians, we recognize that some of the aging have problems, including health problems, but we do not believe that Government aid under the social security system will solve them. We do believe that these people need the best medical care available, including constant research into the medical and health problems of aging, so as to help them retain their activity and independence and self-regard. We believe, also, that all of us must encourage the trend toward universal coverage under private health and hospital insurance plans at premiums which all who are self-sustaining can afford to pay. Finally, we believe in a generous, well-administered program of medical care for all who are not self-sustaining, and who need financial help in the settling of their medical and hospital bills. We have such a program now in Minnesota.

WHAT PHYSICIANS ARE DOING IN MINNESOTA

Here is our program, in more detail, for the aging in Minnesota. We have already dedicated ourselves to the following program :

(1) The statewide advisory committee of the Minnesota State Medical Association will continue to work in close cooperation with the welfare officials of the State of Minnesota to enhance and strengthen our already unlimited program of medical care for recipients of old-age assistance and for the medically indigent in Minnesota.

(2) Our representatives, the physician-members of the Governor's Citizens' Council on Aging, will continue to serve and advise the council on the medical problems of the aging. We will continue to participate in State and regional meetings on these problems and do our full share of the work indicated in this area for the State. Immediate plans call for active assistance in organizing local community councils to define local needs and to stimulate action to take care of such needs.

(3) We will continue to work with Minnesota legislators to assure adequate support for the old-age assistance program and to promote implementation in Minnesota of the Kerr-Mills Act, which our association fully supports. In this general area we have already accomplished much in the improvement of standards for nursing homes, in the building and staffing of rehabilitation facilities, and in the institution of the system of regional mental-health clinics which has now become an effective reality in the State. We have also encouraged the removal of senile patients from State mental institutions and the placing of them in nursing homes with advantages to all concerned, and particularly to the patient who several years ago would have been lost in an asylum.

(4) We will continue our program for the improvement of hospital facilities in the State, and in this area we are particularly proud of our record. We have already reached 93 percent of the ideal number for first-rate general hospital beds in Minnesota, as established by standards based upon the Hill-Burton Act as it affects our State.

(5) Our association is actively recruiting young men and women to enter the field of medicine and the related professions. We are aware of the problems posed by our expanding population, and, particularly, by the rapidly increasing numbers of people more than 65 years old. We know that we need physicians, more physicians and better physicians, and that standards of medicine must be kept high so as to attract the finest types of candidates to the profession. We are already offering scholarships and loans to medical students, and we shall continue to do what we can to attract young people to the field.

(6) We have recently approved the new hospital plan for senior citizens offered under the auspices of Blue Shield, Inc., which was mentioned earlier. This pioneering new plan is part of our effort to make it possible for every person who has resources of his own to take care of his medical and hospital fees. Another part of this work is our joint effort, with management, labor, and hospitals, to control the costs of medical-care plans and to adjust such plans to the needs of the aging.

(7) Committees of the Minnesota State Medical Association devoted to all aspects of aging, including heart disease, cancer, diabetes, and rheumatic diseases, of course will continue their work and to make reports to the physicians and to the public on new developments in the care of the aging. This is

a traditional and highly important part of our program for all the people of the State.

SUMMARY

In conclusion, we wish to reemphasize the fact that the physicians of Minnesota are dedicated to the provision of the very best medical care possible for everyone, including the aging, in Minnesota. For those who cannot provide this care for themselves, we want the same kind of complete care that is available for others, and we want it to be available for every person who can be shown to be in need. As for those who can pay for the cost of medical care, we take the reasonable and equitable position that they should be encouraged to assume the same responsibilities in this field as they do in others. We want to provide insurance protection at prices which people of small incomes can pay, and we want such people to be able to select their own physicians and their own hospitals without interference from Government agencies.

We are confident that the health problems of the aging can be solved and managed entirely satisfactorily in this way; conversely, we are convinced that use of the social security mechanism to attempt to solve them will simply threaten the self-reliance and freedom of the aging.

Our modern plans for rehabilitation of the disabled and the aging call for self-help and self-discipline. They are designed to help men to walk alone and to maintain their independence and self-regard. We believe that the independence and freedom of patients in the management of their problems are important factors, also, in our plans for good medical care for the aging.

We believe, further, that independence and freedom are important for medicine as well as for patients. We think that a resolute and self-reliant citizenry of any age is of prime importance to the financial solvency of our entire social security system in the United States. For all these reasons, we must unalterably oppose H.R. 4222-the King bill-which we feel sure would curtail the inde pendence of the aging and destroy the possibility of helping them to help themselves.

Dr. STICKNEY. I am Dr. J. M. Stickney of Rochester, Minn., representing the Minnesota State Medical Association, which is composed of 3,650 Minnesota physicians. I am a specialist in internal medicine on the staff of the Mayo Clinic, and I have been a member of the Minnesota State Medical Association since 1936 and have served as an officer from 1954 to the present time. My statement, submitted to your committee, outlines in some detail many facts about the care of those over 65 in Minnesota who cannot pay for their medical needs, the financial and health status of all those people over 65, and the attitudes and activities of Minnesota physicians in caring for these worthy citizens.

We speak in opposition to the House of Representatives bill No. 4222 and the principles embodied in it, because we are convinced that this legislation is not needed. Studies published by the Minnesota Department of Public Welfare support this conclusion. In these studies, 87 percent of the people over 65 who were interviewed stated that they had no uncared-for medical needs. Only 5 percent believed that finances were a factor in their inability to get adequate medical

care.

Sixteen percent reported income insufficient for their needs, but we know that 13.7 percent of the people over 65 are on old-age assistance rolls and being cared for, medically. Although their financial status may vary, and we agree that by many standards it is low, the senior citizens do not report significant medical care needs which are being neglected. For those in need, Minnesota provides one of the most complete programs of medical care in the United States. If there are a few who, because of lack of knowledge of the program or because of financial need, are not now being cared for, they may be included in