INDIGENT MEDICAL CARE An indigent medical care bill was enacted by the Legislature of Alabama in 1958. The passage of this bill was strongly supported by the Medical Association of the State of Alabama and the Alabama Hospital Association. This program, administered by the State department of health, allocates funds to each county on a matching basis. These funds are available to residents of Alabama who are seriously ill and need hospitalization but are unable to pay for the services. The determination of ability to pay is rendered on the local level, by nonmedical personnel. The physicians of Alabama, at the annual meeting of the Medical Association of the State of Alabama, agreed to render services to the medically indigent without charge. While there is no age limit in this program, about 25 percent of the recipients were above 65 years of age (1958-59). Sixty of the sixty-seven counties in Alabama participated in this program during 1960. The medical association has engaged in many other activities of a related nature, such as sponsoring or supporting legislation for additional funds for a mental health program, funds for medical education, as well as for all phases of public health improvements. The Legislature of Alabama is presently in session. The administration has introduced into the legislature a bill which would authorize a medical aid to the aged program (MAA). This bill has the complete support of the medical association. Since this bill has already passed the house and it is assumed that it will pass the senate shortly, we have every reason to believe that the bill will become law this summer. Alabama statutes were such that the OAA program under the Kerr-Mills law could be instituted at once. Thus, on April 1, 1961, a program calling for $14 million was started under OAA. Hospitalization was necessarily on a limited basis (10 days) but was instituted for those people who were drawing old-age pensions. In its present form, this program will operate for a period of 6 months, when a new fiscal year will begin. It is anticipated that this program will be considerably enlarged on October 1, 1961. The present session of the legislature will also allocate available funds to the department of pensions and security. The commissioner of this department indicates that he has requested funds which, when matched under Kerr-Mills, will increase the present program under OAA to about $5 or $5.5 million. Under the same general setup the commissioner anticipates that an MAA program will be started shortly and that the funds, when matched, will amount to about $1% million (MAA). The medical association actively supported passage of the Kerr-Mills law, and at its last annual meeting the following resolution was unanimously adopted: "Whereas the Medical Association of the State of Alabama steadfastly reaffirms its support of— "1. The voluntary health insurance mechanism: "2. The free enterprise system which has made this Nation the greatest in the world; "3. The right of the patient to choose his hospital and his physician; "Whereas the Anderson-King bill, which has been introduced in the House and the Senate, would create a compulsory, Government health care system (for those over 65) supported by compulsory taxes under the social security mechanism; and "Whereas this Anderson-King bill is socialized medicine for the aged; and "Whereas physicians know that political medicine will be bad medicine-bad for the patient, bad for the physician, and bad for the Nation; and "Whereas it is the desire of the physicians in Alabama to improve the quality and distribution of medical care for all persons; and "Whereas the Congress of the United States passed the Kerr-Mills bill (Publie Law 86-778) which provides Federal grants-in-aid to the individual States and authorizes Federal participation under old-age assistance (OAA) State plans; and "Whereas on April 1, 1961, the State department of pensions and security and the State department of public health inaugurated a program to provide hospitalization for old-age pensioners; and "Whereas the medical assistance for the aged (MAA) is the most important part of the Kerr-Mills law; and "Whereas enabling legislation in Alabama must be passed by the legislature; and "Whereas adequate appropriations must be voted by the Alabama Legislature to insure a comprehensive program of health care for the aged (MAA): Therefore be it "Resolved, That the Medical Association of the State of Alabama, meeting in annual session in the city of Tuscaloosa, Ala., this the 29th day of April 1961, supports the provisions in the Kerr-Mills law which is designed to provide complete health and medical care for the aged who need help; and be it further "Resolved, That the Kerr-Mills law, with its voluntary provisions at the State level, be given an opportunity to prove that it is the best method to provide medical care for those who need medical care and hospitalization; and be it further "Resolved, That the Medical Association of the State of Alabama strongly urges our representatives and senators in the Alabama Legislature actively to support enabling legislation (Kerr-Mills) and to provide adequate appropriations to initiate a substantial program of medical assistance for the aged under KerrMills legislation; and be it further "Resolved, That a copy of this resolution be sent to the President of the United States; the Vice President of the United States; the Speaker of the House of Representatives; the members of the House Ways and Means Committee; the Secretary of Health, Education, and Welfare; the Governor of the State of Alabama; the Honorable Members of Congress from Alabama; the representatives and senators of the State legislature; the commissioner of the department of pensions and security; members of the board of trustees of the American Medical Association; and all State medical societies." (Adopted by the Medical Association of the State of Alabama in annual session on April 29, 1961.) The committee on aging, appointed by the medical association, has been working with many of the interrelated aspects of the many problems faced by our senior citizens. The committee was instrumental in the formation of the Alabama Joint Council To Improve the Health Care of the Aged. The medical association took the lead in the formation of this council, which now includes representatives from 1. Alabama Dental Association. 2. Alabama Nursing Home Association. 3. Alabama State Nurses' Association. 4. Alabama Hospital Association. 5. Alabama Pharmaceutical Association. 6. Medical Association of the State of Alabama. The combined objectives of the Alabama joint council are— (a) To determine what each constituent association is doing in regard to the problem of the aged. (b) To coordinate the programs of each association to prevent overlapping. (c) To stimulate a more realistic and practical attitude toward the problem of aging in each component organization. (d) To stimulate a more realistic attitude on the part of the public, by means of proper news releases and by offering speakers to various organizations. (e) To help persuade industry and business that retirement should not come at a certain definite age but that individuals should be allowed to work as long as they are useful and productive. The members of the council played a leading role in the work of the Subcommittee on Health of the Governor's Advisory Committee on Aging, which was preparing for the 1961 White House Conference on Aging. SUMMARY OF THE SUBCOMMITTEE ON HEALTH OF THE GOVERNOR'S ADVISORY COMMITTEE ON AGING In Alabama there are 250,000 people 65 years of age and over. Of this group 40 percent receive old-age assistance; 30 percent receive social security; 10 percent receive veteran's pensions. The aged group (1959): Each person averaged six visits to a physician. Fifteen percent were hospitalized (almost all for less than 1 month). Seventy-five percent required some medical treatment (medical cost less than $100 per person per year). Individuals spent less than $100 per year for drugs (included prescription and self-medication). Five percent purchased eyeglasses. Under 2 percent purchased hearing aids. Under 2 percent purchased dental plates. Thirty percent of the old-age group carried hospital insurance (majority Blue Cross). Two percent were confined to nursing homes. Fifty percent of the total group believed that they could take care of their own medical needs. Alabama is predominately a rural State. Here we have a very strong doctorpatient relationship. Throughout our history physicians have taken into consideration the financial status of the patient. Fees are reduced appropriately for those in the low-income brackets. When a reduction of a fee is indicated, no matter what the age of the patient, physicians have acted in a humanitarian manner and reduced the fees accordingly or have made no charges at all. Surely you realize that there are many reasons why people do not want or desire medical care. Nevertheless, individuals in Alabama are not denied medical care because of inability to pay. Everyone appears to assume that the cost of medical care under governmental supervision and regulation will be infinitely more expensive. The experience of Great Britain is positive proof of almost doubling costs in 10 years, even when people are paying for drugs, glasses, teeth, etc., which was not done at the onset. We, the physicians in the Medical Association of the State of Alabama, are opposed to the socialistic trend of our Government to a complete welfare state. We steadfastly desire to help those who need help; we oppose those who are unwilling to help themselves. We are not in sympathy with Government “handouts" in any form. Everyone who has followed the "socialistic line" knows well that the principal objective of the welfare-minded group supporting health care under the social security mechanism is to establish the principle of health care under the social security tax program-as Aime Forand said, "If we can get our foot in the door ***." As has been brought out many times in various testimonies, the King-type bill will: 1. Lower the quality of medical care. 2. Be prohibitively expensive. 3. Promote waste and overutilization of hospitals, physicians, nurses, and all ancillary personnel. The passage of Federal legislation such as the King bill will deal a deadly blow to States rights, which has been suffering under the canopy of federalism. The Medical Association of the State of Alabama preferred to testify before the committee in opposition to the King bill, but because sufficient time was not available, we would like to request that this report be included in the record. STATEMENT OF DR. LESLIE B. SMITH, PRESIDENT OF THE ARIZONA MEDICAL AssoCIATION, INC., SCOTTSDALE, ARIZ. The following statement was prepared by Leslie B. Smith, M.D., president of the Arizona Medical Association, Inc., who has been authorized to present the expressed opinions and beliefs of the vast majority of the 1,125 doctors of medicine members of our State medical association as they relate to the medical needs of our citizens and their conclusions as to how the best medical care may be provided, with particular reference to our beloved elderly citizens. The Arizona Medical Association is of the opinion that the major fallacy of providing medical care for these aged under title II of the Social Security Act is that it is based on the erroneous assumption that a majority of the aged are unable financially to provide self-care, as inferred by H.R. 4222, section 2. "Findings and Declaration of Purpose." In Arizona the respective counties are responsible for the care of the indigent sick. Before and following the enactment of Public Law 86-778 (Kerr-Mills) the thoughts and actions of our people, including our doctors, and the legislators were guided by their personal observations and the conclusions reached by Mr. Fen Hildreth, commissioner of the department of public welfare. The commissioner recommended that "no medical program for aged nonrecipients (OAA) be considered at this time and that continuing study should be made (3)." The commissioner further stated "1. The economic status of the aged is much better than is customarily pictured, with the large majority of our millions of older people able to meet their health care costs without undue difficulty (4)," continuing to quote "2. Contrary to popular conception, the majority of our aged are not at any particular time in need of medical care, neither are they sick or disabled (5)." "3. The needs of those who are sick or disabled are being met primarily through private resources, health insurance, and prepayment plans and the voluntary efforts of their families and private citizens working together at the community level (6)." According to the 1960 census, there are 89,849 persons in Arizona over 65 years of age; 50,195 of these people receive OASDI and therefore would be eligible for the proposed King-Anderson measure medical care benefits if enacted. There are 14,138 OAA recipients in our State, only 4,470 of which receive OASDI; therefore, 9,668 known needy would not receive medical aid under H.R. 4222. We realize that the eligibility for OAA is probably too low to use as a basis of determination for eligibility for help in all cases for medical care. If a new criteria is established such as a maximum of $2,500 yearly income, $1,000 liquid assets and a home valued at $8,000, it is estimated that 6,500 additional of our senior citizens would then qualify for help. H.R. 4222 would provide care for 50,195 persons, of which only 7,776 are really needy. This means that 42,224 persons-47 percent of our total senior citizens, who are capable, without hardship, of providing for their own medical care would be included under this bill, while 12,700 persons who need help would not be covered. We believe that the inclusion of this 47 percent of our senior citizens in a compulsory system which uses tax dollars to provide a service they do not need and possibly do not desire, is unwarranted and contrary to the preservation of their individual dignity. The Arizona Medical Association is now aiding in the drafting of proposed legislation which would enable the implementation of Public Law 86-778, in Arizona pursuant to a resolution which was unanimously adopted by its house of delegates, April 28, 1961, the final resolved of which reads "Resolved, That the Arizona Medical Association through proper agencies within that organization actively and intensively promote the passage of enabling Arizona State legislation to implement the Kerr-Mills bill benefits for the needy aged of Arizona in the coming legislative session and thereafter as necessary (11).” We are sponsoring this program so that it will be firmly determined whether the elderly people of our State are in need of Federal aid to help provide their medical care, and if such a need is found to be present we will be able to provide it through the best mechanism; namely, the Kerr-Mills law, which will guarantee that we will be helping those who need help, but that we will not be wasting tax dollars on help for those who are perfectly willing and able to take care of their own health care costs. Our association, in its last meeting of the house of delegates, expressed their stand in a resolution which ended with "Resolved, That the Arizona Medical Association reaffirms its opposition to any pending Federal legislation or any future legislation proposing socialized medicine by way of any blanket and nonindividualized medical care plan for the aged 65 and older segment of our population, or any other segment of the American people, and which is not limited to individuals with proven need, demonstrated by way of suitable means tests, and which does not clearly provide for local or State government administration (12)." A recent private nonprofit hospital (13) survey in Arizona shows that the elderly citizens in our State do quite well in payment of their medical bills because 90 percent of all its hospitalized patients over 65 years of age were able to furnish the costs of such care. See chart No. 2. This is substantiated by a survey in another private nonprofit hospital (14) which shows 96 percent of its patients in the aged citizen group were able to provide for cost of their care. The bill before us today, H.R. 4222 would, if adopted, alter the basic principle of the social security law, which is to provide cash benefits whereby the recipient is free to use such benefits according to his individual choice and particular needs. This it would do by providing an isolated service benefit without the individual having full freedom of use, when, where or how he may desire. This change in the scope of the principle of the present social security system, once established, could be the basis for the expansion which could include not only federally controlled medical care for all ages, but all services such as housing, food, clothing, etc., with the paternalized Government replacing our cherished government by the people. We believe that medical care should be provided by Government only to those who are not able to secure proper care from their own or other non-Federal sources. We insist that it is the sacred duty of all those who were divinely endowed with the sufficient attributes to assure their just obligation of being "their brother's keeper," in those instances where an individual's capabilities or circumstances beyond their control, render them worthy. We also believe that we should not thwart the individuals innate potentialities of developing their own prowess and dignity by compulsory provision of that which would block the expression and enjoyment of their individuality. There is no greater joy than that of self-accomplishment. It is further our belief that medical care is and will continue to be more efficiently administered at the local level and at the same time such care will be of a higher quality than by any program which shifts the control to a central national level. The medical care needs can best be analyzed and administered at a level which is closest to the individual, where his psychological makeup and his socioeconomic status is intimately known. It is more fitting and fair to provide service benefits of any need through a general tax as provided by the Kerr-Mills law than by the proposed social security tax, which would not only give care to those who are not needy but would do so by disproportionately taxing the younger workers and those who earn the lower incomes. The number of OAA recipients for those past the age 65 in Arizona is cur rently 15.7 percent of the total (16), which compares with the national figure of 15 percent. The average income of all ages is $1,959 in Arizona, while the national average income of all ages is $2,163 (18). The figures pertaining to Arizona in most instances, as those foregoing, approximate those of the national average, hence it may be concluded that the financial status of the aged in Arizona is comparable to the national figures. The Arizona Medical Association in its resolution No. 4, adopted April 28. 1961, resolved "that the Arizona Medical Association reaffirms its support of the principle of privately administered, legitimate, voluntary health, accident. and disability insurance programs to cover not only the 65 years and older segment of our population, but all segments of our population" (19). At the present time 50 percent of those past 65 years of age in the United States have some form of private insurance, 60 percent of those who need or desire insur ance have it, and the number so covered is increasing at a very rapid rate and it is estimated will approach 75 percent by 1970 (20). This bill H.R. 4222 has clauses (prohibition against interference) which state that it would not "exercise any supervision or control over the practice medicine or the manner in which medical services are provided; [would not] exercise any supervision or control over the administration or operations of any such hospital, facility, or agency" (21). However, the bill defines standards and regulations for the providers, all of which include broad grandfather clauses Contrary to expressed statements the bill proposes to furnish the services of some specified doctors (22). There are clauses such as, "except as otherwise specifically provided," (21); "meets such other conditions of participation under this section as the Secretary may find necessary" (23); and "he [the Secretary] may to the extent he deems appropriate." The sections on agreement and payments, together with his powers to make regulations, also give the Secretary of the Department of Health, Education, and Welfare (HEW) almost unlimited powers to directly and indirectly control virtually all facets of the practice of medicine embraced in this proposed law. The proper and time-honored practice of medicine can only be directed and administered by those who are so educated-the doctor of medicine. They alone are qualified by training to render accurate diagnosis and determine the proper treatment and service to save lives and prevent crippling. Yet in this bill is a provision which would delegate much of this function to a utilization |