the aid in their power. The possible enactment of H.R. 4222 has been a deterrent to implementation of Kerr-Mills legislation in our State.

The New Mexico Medical Society appreciates the opportunity of presenting its viewpoints to your committee for the record and we trust our statements will assist the committee in their deliberations.

EXHIBIT A.-Admissions of patients 65 years of age and over in St. Mary's Hospital, Roswell, N. Mex.

1. Number of over age 65 admissions during period Sept. 25, 1960, through Dec. 31, 1960

2. Number of patients over age 65 admitted (2 multiple admissions)_. 3. Admissions:

Hospital bills paid by private sources

6. Total physician bill (average per illness).

Physician bill over $500

Physician bill over $300_

Surgical

Medical

4. Patients' age:

Median age

Range.

5. Total hospital bill (average per illness)

Hospital bills larger than $500.

Hospital bills paid by insurance or Government sources.

100

Total $1,000.00 499. 13 456. 23

481.00

305. 67

EXHIBIT B.—Admissions of patients aged 65 and over in the Presbyterian Hospital, Albuquerque, N. Mex.

Beginning Jan. 1, 1961, the first 100 patients aged 65 and over were taken at the time of discharge from the hospital.

(Hon. Harold D. Cooley, Member of Congress from the State of North Carolina, submitted the following statement for inclusion in the record of the hearings received from the Medical Society of the State of North Carolina :)

STATEMENT OF THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA, BY HUBERT M. POTEAT, JR., M.D.

Mr. Chairman and members of the committee, I am Dr. Hubert M. Poteat, Jr., of Smithfield, N.C., where I am engaged in the medical practice of general surgery. I am chairman of the committee on legislation for the Medical Society of the State of North Carolina. I emanate from that substantial Baptist family of educators whose name I am privileged to bear. I recollect a youthful impression gained from my grandfather, Dr. William Louis Poteat, who, as president of Wake Forest College, was evaluating the progress of the public health in North Carolina when he recognized that the late Dr. George M. Cooper and the now eminent Dr. Watson Rankin had laid the foundation for a great State in the public health system founded upon the premise of close liaison with the leaders of the private practice of medicine in the State. He philosophized that the basic laws sought by these leaders, enacted by the North Carolina General Assembly in 1917 and so administered by Rankin and others so as to invite the interest and the cooperation of the medical profession with the people of the State would set North Carolina apart as a people noted for its public health achievements and progresses, and as I now undertake to review parts of the progress that has

transpired since his day, I can look with pride upon his prophecy. In forming this statement, I am representing 3,300 society member physicians from my home State in opposition to H.R. 4222. Our opposition to this proposed bill is based on three major principles:

(1) The success of present health care programs and services and the lack of any need for such legislation in North Carolina.

(2) Existing Federal legislation and State programs provides adequate coverage for those who are in need of assistance.

(3) The expense of the proposed program in H.R. 4222 is too great to justify its limited benefits. The philosophy contained in H.R. 4222 is not supportive of the experiences and actions which have characterized progress in health in our State.

While our population is increasing, our life expectancy has increased and will continue to be lengthened, and our population 65 and over has increased even faster than our population as a whole. We also submit that the quality of health and medical care in America far exceeds that of any other Nation, as evidenced by the fact that America today is the world seat of medical knowledge and training and perhaps the healthiest nation among nations. My research and practiced controls, we have reduced the incidence of disease and so controlled acute infections to the point that today among our major health problems are left those of chronic illness creating the need for a change in focus on the care and treatment of these illnesses. Physicians know best what the health needs of their patients are and because of the close relationship between physician and patient can better guide and direct the regime of health maintenance for each patient through our present system of free enterprise and the proper utilization of community facilities and services. Medicine has proved in the past its ability to cope with new or increased scope of health care problems, and it accepts the challenge today to continue serving the people of our State in meeting the new demands placed upon physicians and allied health services by our expanding total population and our older citizens. Few States and no other country has so effectively assumed this responsibility for all of its people. Organized medicine was among the first groups to recognize the problem of health care services created by the increasing numbers of older-age people who, because of improved medical care, treatment and supportive services, modern medical research, and other important health protections, are experiencing a longer lifespan, now av eraging 23 additional years beyond that of our grandparents. The span of life expectancy one can predict will continue to be lengthened by similar advances under our present system of health and medical care in future years. Likewise medicine, first to recognize and to stimulate individual and public interest in ways and means of planning toward these added years, continues to take the initiative in practical concern at the National, State, and local levels. It is to this point of interest that I submit this statement to you in opposition to H.R. 4222 as a proposition for improving health care services for our older people.

Allow me at this point, to review for you actions and progresses in North Carolina in proof of our concern with these problems and that we are meeting needs in this area as I shall designate by item:

(1) We believe that our present private enterprise system, comprised of voluntary insurance and savings is providing health and medical care to all persons, including the provisions of the Kerr-Mills Act as now implemented. This system should be given every opportunity to prove its value in all States before Congress considers any additional changes to foster Government nonmedical-oriented programs of medical assistance to the aged or to any group, With the recognizable youthful population and consequent expanded industrial growth we have a paucity of older people in North Carolina; therefore there is no necessity for H.R. 4222 as we are meeting our own health care needs through cooperative efforts. As of January 1960, North Carolina had 6.9 percent of the total population 65 and over, as compared to national average of 9.2 percent 65 and over, and the youthfulness of our population differentiates our situation in North Carolina.

(2) The average per capita income in North Carolina in 1960 was $1,582, or an aggregate sum of $497,331,250 annually accruing to this segment of our population (65 and over). Of the total 314,000 older citizens, an estimated 12.2 percent are certified beneficiaries of the diminishing old-age assistance program. Of the aged (65 and over) 100,000 are already enrolled in forms of voluntary prepayment insurance programs, either of the (recently embraced by choice of civil service employees in North Carolina) Blue prevailing contracts of our types of commercial protection. It is reported through divers agencies

f aid (as discussed at pp. 6, 7, and 8) that some 30,000 receive some health ire services through public-private programs (statewide in character) designed or the medically indigent.

Generally, there are others who receive assistance through VA hospitals, rtain religious orders, specialized State institutional care, county general ssistance, and private resources providing some aid for the medically indigent. herefore, the residue of older persons needing assistance in meeting health nd medical costs is not a major problem in North Carolina when we weigh he level of income of those still employed, the factors of cash savings, and retireent earnings. Any increase in expenditure of public tax funds should be made t the local or State level with local administration and control, as provided 1 the Kerr-Mills Act. We know by physicians' records of payment for services endered that 85 percent of the white population purchase their own care and 5 percent of the nonwhite purchase their own health and medical care, further ustifying this reasoning. North Carolina physicians have always rendered edical services in their offices, clinics, and hospitals to indigent patients without harge and without accepting vendor payments. If the need for medical care s recognized and reported-the service is made available to anyone for any type f service. County medical societies have publicly reiterated the guarantee hat any citizen in need of a doctor's service and unable to pay for it can get he service without cost by calling the local medical society information service or the local hospital.

(3) Insurance programs are available to aged individuals and families with imited incomes. The doctor's plan, a noncancellable Blue Shield service insurince program, underwritten by North Carolina physicians was designed to give protection to families with small incomes.

Physicians accept scheduled fees for service as full payment for persons havng this type of insurance coverage whether contracted to do so or not. The apid increase in the number of persons 65 and over now enrolled in prepaid enior certificate insurance programs gives further evidence that once the proection was made available to persons 65 and over, they welcomed the opporunity to purchase insurance policies, and this trend is increasing daily. The enrollment in 1960 doubled that of 1959, the first year it was introduced by volunteer associations in North Carolina. Nationwide surveys and the National Health Insurance Council report 72 percent of the total population and 49 percent of those 65 and over today participate in voluntary health protection programs. There continues to be a significant trend in business, industry, professional, trade and fraternal groups to provide paid-up hospital insurance coverage for retired members and their families. This trend characterizes the new industrial growth in North Carolina stimulated by the regime of our former Gov. Luther Hodges. The exaggerated needs of the older citizens today will be met in the future by retirement earnings gained by the working individual today. This factor of economy did not exist 20 years ago.

(4) Facilities and services: In North Carolina for the past 12 years there has been a blanketing of the 100 counties of the State with general medical-surgical hospitals constituting an increase of 268 percent of acceptable hospital beds; so that anywhere in the State at any moment the 154 general hospital services are readily available to all segments of the people, whether old or young. There is no shortage of beds anywhere.

We have in 3 years (1958 to now) increased the number of licensed nursing homes in North Carolina by 440 percent with increased capacity of approximately 400 percent. This trend is so significant that uniformity of available services of this type in the counties is now being approached and may be completely realized within another 3 years. It is also significant that these trends and acquisitions have been accomplished by private enterprise on the whole. These nursing homes are now standardized and licensed by a single medically oriented State agency confirming the quality of care offered to groups by these increasing facilities.

At present there are more than 500 domiciliary homes licensed to provide extrafamily individual care to more than 6,000 older people, which serve to augment the general capacity of the individual family in North Carolina to provide the setting for the care of older people as an intra family obligation of normal life. It should be interesting to note of the domiciliary homes licensed the majority are institutional in nature, but that more than 200 of these are constituted as foster family homes. It is in this area that the mandatory licensing system provided by recent law has gained and will maintain a suitable standard of care for the aged.

76123 0-61-pt. 4--23

It is of note that by combination of the licensed facilities caring for old people more or less exclusively there prevails the capacity for 7,200 which when rotated provides for an estimated 20,000 old people within a year.

(5) Recent State legislation made it possible to expand financial payments to licensed general medical and surgical hospitals for indigent and medically indigent patients. Through the so-called pooled fund for hospital care coprised of county, State, and Federal allocations, per diem payments for these patients were increased to acceptable cost coverage. Also, by new legislation $682,000 of State funds were made available to match Kerr-Mills funds, now making it possible and a public policy for acceptable full per diem payments for the hospitalization of medically indigent patients. A total of more than $7 mil lion of combined Federal, State, and county money is now available for the hospitalization of the needy for each year of the biennium, approximately onehalf of which is applicable to persons 65 and over.

In addition to the counties' allocation of one-half million dollars to the pooled fund per year, they expend $3 million annually on general relief including medical care (not fee for service) and hospitalization of medically indigent not previded for by matched funds; so that near $10 million annually is now applied to the medical care of needy people in the State each year.

The proponents of H.R. 4222 have raised the question that no guarantee could be assured that States or counties would continue to appropriate necessary matching funds for participation in providing the necessary services for the aged. Yet this has been a constitutional obligation of the counties of North Carolina for a century, and there is abundant evidence that counties, stimulated by a responsible State, actually have met the needs through the years. and there is no evidence these counties are prone to drop this obligation now, There is no more assurance that Congress will continue to pass expansions of the social security laws at the expense of the burdened taxpayer.

(6) The general assembly in 1961 substantially increased funds for general and personal services administered by the North Carolina State Board of Health, much of which is applicable to services to the aged. Increased funds administered by the division of personal health services have been made available for home care programs, involving the care of the aged, extension of services and substance in respect to the health needs of these aged people. Home care service programs are being extended and others initiated throughout the State as a part of the generalized public health program, with particular emphasis on the rural areas. The notable home care demonstration in Person County is being largely financed now by local funds and the efficacy of this care under the teamwork of local family physician combined with nursing, physiotherapy, and case supervision so effectively demonstrated is now catching on in programs undertaken in other counties on a less formal basis.

After a 3-year operation, the Person County program demonstrated outstanding accomplishments in the reduction of hospital stay, elimination of unnecessary hospitalization for specialized services which could be given in the home or outpatient clinic by trained nursing and physical therapy personnel instead of the former method of inpatient care, and the results in restorative gains and in rehabilitation of individuals stimulated other counties to initiate similar home care service programs. As another demonstration, there are five counties today conducting a specialized public health home-care nursing program for stroke patients and three additional counties have full-time physical therapists added to their public health programs.

As a result of a demonstration program of 1958 in 3 rural counties, home maker service programs were in effect in 12 North Carolina counties in 1960, and as these are totally financed by local funds, rapid development is noted in this field of progress. It is a forward step in making it possible for our older people to be given adequate services within their own homes, thus reducing the need for expensive institutional care as proposed in all Federal legislation pending.

Increased 1961 State appropriations, improved admission policies, and initistion of followup home contact with patients dismissed from State mental and tubercular hospitals have had a marked effect on the improved patient care for our aged mental and chronically disabled. Also North Carolina has 11 mentalhealth clinics to assist in the screening, diagnosis, and treatment of mentally disturbed people of all ages; 100-percent increase in funds appropriated in 1961 to increase the mental-health-clinic program under the direction and supervision of the North Carolina State Board of Health is now in effect. Instant bed capacity of highest quality is available throughout North Carolina for mental and tubercular patients needing to be admitted for care.

Training programs in rehabilitation being conducted through our medical chools and teaching hospitals makes it possible for medical nursing, and allied edical personnel to gain additional knowledge in the handling and treatment f the chronically ill and the seriously injured patients.

(7) Our recent 1961 general assembly reviewed all available types of medical id programs, the number of persons receiving care, and the cost of these services. The general assembly further relied on all available sources of information inluding public sources of information regarding the needs of the older people and, ifter receiving such information, they appropriated $682,000 to pay acceptable per liem payments for hospitalization of the medically indigent who do not receive noney payments, but are unable to meet the cost of hospitalization.

The entire cost of hospitalization and medical service is covered for all indigent ersons in the three categories of public assistance. The pooled fund for hosDitalization of public assistance recipients was increased so that acceptable Der diem payment could be paid for these category patients, which includes the ndigent older age person. In addition, funds made available through Kerr-Millls Act in the extension of the OAA program, makes it possible for mental and tuberulous patients to receive up to 42 days' hospitalization in a medical institution for acute illness and diagnosis and the long-term patient can be readily transferred to one of the State hospitals for continuing care related to the chronic state and now currently and continually available. This characterizes the statewide situation of available beds which has now been maintained for several years. (8) The general assembly increased its contribution to the counties $1 million, or 140-percent increase for the biennium, for administration costs of the public welfare program. This brings these services to a relative adequate level and will assist in the personal counseling of applicants, and the understanding of individual family problems and needs, and better provide interpretation and coordination of preventive health care measures in favor of the applicant.

More than $7 million is now available for statewide hospitalization of needy persons in North Carolina each year. The physicians in North Carolina do and have always contributed their professional services to the indigent and medically indigent and by special action and pledges reiterated at a called meeting of the medical society's house of delegates on February 28, 1961, the society reaffirmed to stand to continue rendering professional services to the needy without vendor payments.

During the discussions of the medical care programs for older citizens before the recent general assembly in North Carolina, it was reported that counties in North Carolina were taking care of the medical needs of their needy people. With the increased assistance for hospitalization for indigent and medically indigent patients, provided by the general assembly, the counties will be in a stronger position to pay for nonmedical services for these people.

Further evidence that H.R. 4222 is not needed is reported in that efforts during our recent general assembly were made to seek out criticisms and complaints about available medical services and no criticism was forthcoming from any group of people in any section of the State. Extensive hearings over 4 months of the general assembly did not elicit any specific or general citation of unmet needs in North Carolina related to the aging group which was not met in current legislation. Furthermore, satisfaction was expressed as to the available facilities, services, and confidence in the voluntary insurance programs as to adequately meeting the medical care needs of our people. It was also noted that no expression was found favoring the financing of medical care through the social security mechanism, even though some effort was known to have been made from a statewide organization and certain of its leaders who had personally expressed favor of such a program.

Had there been marked concern in the State over financing medical care programs, it would have been made known to the legislators during the recent general assembly when the medical society made its attempt to gain increased financial assistance for noninstitutional services complying with the implementation of the Kerr-Mills Act.

I am reliably informed that there was no request for funds made to the general assembly by any official of the North Carolina State government for the appropriation of any more funds for the care of the medically indigent, including the 65-and-over age group other than were appropriated.

(9) One other action of the general assembly which I feel pertinent to this area of need is the fact that 100 percent basic of budgetary needs of applicants for money payment recipients is now approved for payment whereas previously only 80 percent of budgetary needs were met. In addition to basic needs, a