elected proper officials to determine this need and to supply the appropriate help. On January 1, 1954, a statewide plan replaced the authority of the locally elected town officials, especially with reference to the aged, and in October of 1960 Public Law 86-778 was promptly and generously implemented to increase available aid to the aged and to broaden the scope of such care to include the medically indigent as well as the actually indigent aged.

At the present time there are an estimated 530,000 people over 65 years of age in Massachusetts. In the continuing studies and fulfillment of their needs it has been gratifying to note that the average number of these needing to accept public assistance has been slowly diminishing in recent years, from 16.4 percent in 1956 to 15.1 percent in 1960. The actual numbers follow:

Average monthly caseload for the year ending June 30, 1956, 87,285 (16.4 percent); average monthly caseload for the year ending June 30, 1957, 86,106 (16.2 percent); average monthly caseload for the year ending June 30, 1958, 85,678 (16 percent); average monthly caseload for the year ending June 30, 1959, 83,626 (15.7 percent); and average monthly caseload for the year ending June 30, 1960, 80,418 (15.1 percent).

Thus, the economic status of the aged in Massachusetts is slowly but demonstrably improving.

If we consider medical needs specifically, we find that voluntary prepayment insurance coverage for the aging is extending steadily and solidly, though not headlong or precipitously. I shall confine my remarks in this regard to that phase of it with which I am most familiar; namely, Blue Cross and Blue Shield. The Massachusetts Blue Cross-Blue Shield plan is one of the outstanding plans in the Nation. In this plan, an individual covered by group membership has always been allowed to retain his individual or family membership on retirement. Furthermore, a contract never is canceled because of age or physical condition. Presently for $20.15 per quarter or $81 per year-less the deductible $90 for a 9-day hospital stay under the King-Anderson bill-an individual may have a plan A Blue Cross-Blue Shield contract with modified prolonged illness certificate, providing $18 a day for room for 30 days, $12 per day for 90 more days, full coverage of hospital extras (ancillary services), outpatient benefits, diagnostic X-rays, full payment of medical and surgical fees for care in the hospital and after discharge from the hospital, physician's care, visiting nurse care, prescription drugs, appliances, X-rays, X-ray therapy, laboratory and pathological studies, physical therapy, and nursing home or chronic disease hospital care ($6 a day toward room and board for 120 days (per condition)).

If the aged patient in Massachusetts is truly indigent, he is eligible, of course, for the usual old-age assistance benefits or even the benefits of Public Law 86778. If simply medically indigent, he is cared for under Public Law 86-778 (Kerr-Mills Act). This act was implemented, as I have said previously, promptly and generously in Massachusetts and provides those who actually need help with more extensive and liberal care than H.R. 4222 even suggests.

Medical assistance for the aged in Massachusetts provides for the payment of part or all the cost of: inpatient hospital ward services, public medical institution services, nursing home services, physicians' services, outpatient hospital or clinic services, nursing services, physical therapy and related services, dental services, home health care services, laboratory and X-ray services, prescribed drugs, eyeglasses, dentures, and prosthetic devices, diagnostic screening and preventive services, any other medical care or remedial care recognized under the law of the Commonwealth, and other medical care in accordance with the department medical care plan-and even for tuberculosis and psychiatric patients in medical institutions for the first 42 days.

Eligibility for medical assistance for the aged is determined or defined thus: (a) If unmarried, or if married and the applicant is the husband, and income doesn't exceed $150 a month and ownership of bank deposits, securities, cash on hand, or similar assets do not exceed $2,000.

(b) If married, and the applicant is the wife, combined income of husband and wife does not exceed $225 a month and combined ownership of husband and wife of bank deposits, securities, cash on hand, or similar assets does not exceed $3,000.

(c) The cash surrender value of insurance shall not be included in determining assets.

(d) The ownership of an interest in real estate by an applicant for or recipient of medical assistance for the aged who resides thereon or who, in the opinion of the board, is residing elsewhere than on such real estate because of physical or mental incapacity, shall not disqualify him from receiving such assistance.

There shall be no recovery for any medical assistance for the aged correctly paid on behalf of a recipient during his lifetime or the lifetime of his surviving spouse.

In March of 1961, more than 14,000 persons in Massachusetts received benefits under this legislation.

The Massachusetts Medical Society is convinced not only that enactment of the King-Anderson bill is not necessary to adequately care for the medical needs of the aged in that State, but a plan administered and financed by the Federal Government will unnecessarily increase the cost of such care. It is a wellaccepted fact, at least in Massachusetts, that the further the tax dollar goes from the point where it was paid, the less it is worth when it returns. Since the cost of medical care for the aged is one of the fundamental reasons for our concern with the problem, it seems unwise to substitute for the present programs that are functioning so well one that bids fair to be even more costly and less efficient. The experiences of other countries which have adopted nationalized plans for the provision of medical care certainly bear out the fact that the costs of such programs are high and unpredictable. Furthermore, H.R. 4222 is oriented toward institutional care and would lead to significant overcrowding of existing facilities due to excessive utilization. One need look no further than experiences with poorly devised insurance programs in our own country for proof of this.

The Massachusetts Medical Society believes that enactment of H.R. 4222 actually will not help financially those under 65 who pay social security taxes and depend upon voluntary health insurance for financing their medical care. Even if one could be sure that their premium rates would be reduced or benefits increased by enactment of H.R. 4222, this would mean only that these same individuals would still be paying the bill for medical care of the aged, paying it in the form of social security taxes instead of premiums. In this presentation, it has already been maintained that the bill for such care will actually be greater when provided through a tax mechanism than it will cost if eventually covered by voluntary health insurance plans where the cost will be even more widely distributed among all those paying insurance premiums-employed, retired. wealthy, poor, social security participants, nonparticipants in social security, aged, middle aged, and young. It behooves us to give the voluntary method more time to solve the problem while, in the meantime, Public Law 86-778 is given more time to prove whether its provisions can adequately care for the medically indigent and truly indigent aged.

Our objections to the King-Anderson bill, which I have thus far presented. have been based largely on the health needs of the aged in Massachusetts. Our further objections are based on the general undesirability of such legislation.

We believe that once the principle of provision of services for a limited group of citizens the aged-becomes law, expansion of the program to include all persons of all ages becomes almost a certainty in view of the history of already enacted social security legislation.

We believe that provision of services as contrasted with cash benefits is an undesirable departure from the basic principle of the social security program because it opens the door for the provision of any and every type of service to all by the Federal Government and intrusion of Government into every phase of private life.

We believe that the King-Anderson bill, if enacted, will become simply the initial phase of a movement that will result ultimately in the nationalization of medicine. Since the society believes and is firmly convinced that this is true. it believes, too, that the objections to nationalized medicine become objections to the King-Anderson bill. We wish to mention only one significant phase of this problem. The prime objection to any form of nationalized medicine is that it will most surely lead to deterioration of medical care. One of the factors that might contribute to this deterioration in this country is already painfully evident. There is already a very significant shortage of physicians, a shortage that will grow more acute with the coming population increase in the face of a diminishing number of applicants for medical school admission. Medical schools already are finding it necessary to accept students with lower scholastic standing than has been usual heretofore. Nationalized medicine will tend to aggravate the situation by further diminishing the number of desirable applicants for medical school. Many students with initiative, ability, and ambition will shun a career in which regimentation is inevitable, while the weak, dull, and slothful will seek the shelter of its security. It may well come to pass that we shall have not only inferior medical care, but actually an even lesser amount of it available to the individual patient. Moreover, these less capable physicians will

have less time to devote to sick people because of paperwork incidental to regimentation and the inevitable excessive utilization of services by those not sick enough to warrant medical care, but jealously seeking to exercise their "right" and get "their share."

At this point it seems appropriate to mention the official position of the Massachusetts Medical Society on the problem of medical care for the aged. On February 3, 1960, the council, the legislative body of the society, recognized the fact that there are certain individuals among the aged population who are unable to finance the cost of medical care despite the successful progress that voluntary health insurance programs are making to provide suitable care for the aged and advised its representatives in Congress to design legislation to provide hospital, medical, and surgical services for those 65 years of age and over who can demonstrate financial need and to study a means of making public grants to voluntary insurance agencies so that they can provide hospital, medical, and surgical services to the extent of the need of those in this age group. We believe that Public Law 86-778 affords a mechanism for providing the services described in the first of these recommendations, and furthermore that the action of Massachusetts as outlined in the first part of this presentation demonstrates conclusively that this law can be successfully implemented at a State level.

In closing, I should like to repeat the opinion previously expressed that Public Law 86-778 has pulled the teeth of urgency from the problem of medical care for the aged and then to point out that this country has problems far more urgent than this disputable mechanism for financing the medical care of the aged (I know of no aged person in Massachusetts who sought medical care and was denied or deprived of it because of inability to pay.)

MISSOURI STATE MEDICAL ASSOCIATION,

Re King bill-H.R. 4222, 87th Congress.
Mr. LEO H. IRWIN,

Chief Counsel, Committee on Ways and Means,
New House Office Building, Washington, D.C.

St. Louis, Mo., August 1, 1961.

DEAR MR. IRVIN: Speaking for the Missouri State Medical Association, composed of almost 4,000 physicans, I submit the attached statement (4 copies) for consideration by the Committee on Ways and Means, House of Representatives. We understand that our statement will be printed in the record of the hearing.

We are opposed, vigorously, to H.R. 4222 and any similar proposals using title II of the Social Security Act as a mechanism for financing a Federal program of health care for the aged. Reasons for opposition are outlined in the attached statement.

We support programs for helping the aged who need help. We believe that the Kerr-Mills medical aid for the aged law (Public Law 86-778) provides such means. Details are outlined in the attached statement.

Respectfully submitted.

J. H. SUMMERS, M.D., President.

STATEMENT OF THE MISSOURI STATE MEDICAL ASSOCIATION

The Missouri State Medical Association is the official organization of the medical profession in Missouri, composed of almost 4.000 physicians. The broad purpose of the association, as with other State medical associations, is to promote good health care for the public, and in this, its interests are not limited to the scientific phases of medicine. It is intimaetly concerned with the social and economic aspects of medical care as well.

We have programs, for example, to help insure an adequate supply and distribution of physicians so that medical care will be available. We have recruiting programs to encourage qualified young people to take up medicine as a career. The association and its members cooperate with the University of Missouri Medical School in a general practice preceptorship program to interest new physicians in practicing in the rural areas of the State where the need is greatest. The association operates a placement service for doctors, with the same objective.

We have established a loan foundation for medical students to which the association has contributed $50,000, and which we plan will enlarge in the next several years to at least twice that size. Missouri physicians last year contributed more than $107,000 to the support of medical schools throughout the Nation.

I cite these activities to demonstrate that the physicians of Missouri are vitally interested in assuring the quantity and quality of the medical care that the people need.

One of the important factors in assuring that the people receive the health care they need, of course, is the financing of that care. The physicians of Missouri are deeply concerned with this particular problem and in our everyday practice we are particularly close to it, not only in regard to those over age 65, but for all citizens.

PRINCIPAL CONCLUSIONS

We have three principal conclusions concerning the problem of financing medical care, particularly as it pertains to the aged:

First, the problem is nowhere as great as has been represented.

Second, what problems there are can and are being solved on a local and State level.

Third, recourse to a Federal social security program such as that proposed under the King bill would result in a serious deterioration in the quality of medical care in the United States, in addition to compounding costs far beyond necessary and practical levels.

In Missouri we have implemented the so-called vendor program of health care benefits for old-age assistance recipients—and these, of course, are people who are truly indigent. Under the program, recipients are eligible for hospital care in cases of acute serious illness or medical emergency, and the hospitals are paid on the basis of their full per diem costs.

We have about 500,000 residents over age 65 in Missouri, about 112,000 of whom are currently on old-age assistance-one of the highest ratios in the United States. The number, however, which received these vendor hospitalization benefits last year averaged about 1,000 per month, perhaps a little less.

Admittedly many States have much broader vendor programs than Missouri. But the point is this this year our State welfare department requested-and the legislature appropriated-only enough money to provide for continuation of this program at this same level, without providing for any of the additional services which can be provided under the program.

Our State administration and our legislators are as responsive to the wishes and needs of the people as those in Washington-yet, apparently, they did not feel that the need was so great nor the demand so heavy that the program should be expanded beyond its present levels.

KERR-MILLS

The Missouri State Medical Association sponsored and actively supported implementation of the Kerr-Mills program in our State in the session of the legislature just completed. In addition to the bill we sponsored there was one other piece of legislation introduced to implement the program-which could mean $6 to $10 million or more in Federal funds for the State.

The result has been that the Missouri Legislature has voted to delay action of this program and to create an interim study committee to investigate the need for implementation of the program and make recommendations to the 1963 general assembly. While this indicates that the Kerr-Mills program will be imple mented appropriately in Missouri in the next session of the legislature-again our legislators seem to feel that there is no demonstrated pressing need-or desperate lack of medical care financing for the aged in the State.

CITY OF ST. LOUIS

The city of St. Louis operates two general hospitals, providing care for two general classes of patients.

The first group is accident cases-by ordinance, all accident victims on the streets who require care must be taken to the city hospitals. At any one time. an average of 25 to 35 percent of the patients in the hospitals are accident cases The other group is the indigent. On the average, 65 to 75 percent of the patients in the hospitals will be from this group.

If all patient space were fully utilized, these two hospitals would have a combined capacity of 1,850 beds. In recent times, however, an average of only 1,529 beds have been in operation-or almost 325 beds less than could be made available. More important, the average actual patient load is only about 1,205— 325 less than operating beds, and 650 less than possible capacity.

On the basis of the normal percentage, only some 844 of the average 1,205 beds actually in use are being used for indigent patients, even though many more are open and available. This is in a city of some 750,000 population.

As a matter of fact, just recently, 42 beds were closed at one of the hospitals, and an investigation is now being made to determine if the other, now operating a total of 650 beds, cannot be closed altogether as a general hospital, perhaps to be converted to chronic care.

One of the principal reasons advanced, incidentally, for the decreasing need for services at these hospitals is the prevalence of private health care insurance.

ST. LOUIS COUNTY MEDICAL PLAN

St. Louis County provides another example of why we believe the problem of financing health care has been exaggerated. I might mention that St. Louis city and St. Louis County are separate geographic and political entities.

In October of last year, the St. Louis County Medical Society originated a formal plan to provide a system of reduced medical fees for people over 65 who cannot afford the full charges for medical or surgical care. The plan provides for reductions of from 10 to 90 percent of the physician's regular charge, based on individual financial need.

The program was publicized in both St. Louis metropolitan daily newspapers, most of the St. Louis County neighborhood newspapers, on radio and television. Information about the plan was distributed to local welfare agencies that might be expected to see needy clients who require medical care.

St. Louis County has a population of more than three-quarters of a million people, of whom perhaps 75,000 or more are over age 65. By the end of May 1961 after the plan had been in operation for 8 months, only some 60 people had applied to the society for reduced-fee cards.

All of these things indicate that the problems of financing of medical care for the aged have been greatly overstated. They also indicate that what problems there are, are largely being taken care of on a local and State level.

There is no doubt that there are some people who have difficulty in financing their own medical care just as they have difficulty in financing food, shelter, and clothing. We are convinced, however, that these people can and are receiving the care they need through local and State mechanisms, aided by such Federal programs of grants as the Vendor and Kerr-Mills programs.

RESOURCES FOR CARE

Briefly, I would simply like to list just a few of the resources we have in Missouri and available to such patients:

There are some 4,000 physicians in Missouri who render care in their offices at no charge if the patient requests care and is unable to pay.

In the 114 counties of the State, there are 39 tax-supported municipal and county hospitals providing care for needy patients. There are 90 privately supported hospitals which also provide a great deal of free care for those who need it.

There are 6 to 8 county-supported nursing homes, an additional 50 which are county owned and leased to private operators, all of which provide care for the indigent aged.

In addition to the State mental hospital system, Missouri supports a State cancer hospital, a tuberculosis sanitorium, and the University of Missouri Medical School Hospital, all of which provide care on an indigent basis.

In addition to such governmental resources, there are many private organizations we can call upon. As one example in the medical field, the members of the Missouri Society of Pathologists will provide laboratory work at no charge for indigent patients referred by the attending physicians. Many private health and welfare organizations are available-such as the Heart Association, Cancer Society, National Foundation, and the like-to provide help for various types of patients.