That study followed presentation of an idea for help to the aged indigent which a group of physicians headed by Dr. Miller and Dr. Richard Lord had earlier presented to the society's council.

MANY ADVANTAGES

The plan approved "would have many advantages over various plans being proposed at the Federal and State levels, even though it would not take care of the important hospitalization portion of the program," said the committee which presented the plan.

The committee called it a positive and practical plan and said data it had gathered "clearly indicates that there are undoubtedly a fair number of people over 65 that are not completely indigent but that cannot always afford to pay the regular cost of medical services, and that free services or services on a partpay basis are presently available only in limted ways to serve such persons." Other members of the committee Dr. Kendis named to draw up the plan were Dr. Maurice A. Diehr, Dr. Robert J. Mueller, Dr. Robert L. Coulter, Dr. Richard A. Sutter, and Dr. Lord.

[From the Watchman Advocate, July 22, 1960]

COUNTRY DOCTORS TO OFFER REDUCED RATES TO AGED INDIGENTS

The St. Louis County Medical Society has approved a plan for further improving physicians' availability to all persons past 65 and at the same time preserve the right of the patient to choose his own doctor.

The plan was presented to the meeting by Dr. Charles Miller, chairman of the committee originating the procedure. The society, composed of approximately 450 physicians who office or reside in St. Louis County, is headed by Dr. Joseph B. Kendis.

Under the proposal, those past 65 would retain free choice of physician but would be offered an opportunity to obtain reduced cost medical services whenever it could be shown that income was insufficient to pay for medical services at prevailing rates.

The plan proposes establishment of an office staffed by employees experienced in medical economics where patients past 65 years of age could be interviewed. A card system of identification is proposed, but details of the coding have not yet been written. Dr. C. Howe Eller, St. Louis County health commissioner and a member of the committee, said that he has heard of several ideas designed to help solve the problem of medical services at rates commensurate with income and believes this is far reaching and fundamentally sound. Other members of the committee working on the proposal are Drs. M. A. Diehr, Robert J. Mueller, Richard Sutter, Robert Coulter, and Richard Lord.

STATEMENT OF THE MEDICAL SOCIETIES OF THE COUNTIES OF ONEIDA, HERKIMER, AND MADISON, BY IRWIN ALPER, M.D.

I am Irwin Alper, M.D., of Utica, N.Y., a practicing physician and the medical director of the Oneida County (N.Y.) Welfare Department, presenting this statement on my own behalf and on behalf of the medical societies of Oneida, Madison, and Herkimer Counties of New York State, America's first multiplecounty medical organization.

Four thousand years ago, a learned psalmist wrote "I have been young, and now I am old, but I have never seen a ‘needy, just, and worthy man' neglected." Four thousand years ago that psalmist implied that, in accordance with the customs of the times the "needy" who were "just and worthy" would be looked after by their devoted families, by the "Kehillah" which was the religious community, and by their friends and pupils. Government benevolence was at that time an undiscovered source of public assistance.

The world has grown in size and its people in numbers since then, though it has shrunk in "time." It takes as long to go around the world today as it did then to travel from one village to another. This tremendous increase in population and subsequent migration of peoples to strange lands with unknown customs, new fields of endeavor, and different standards of living has provided people with incentive to succeed and prosper and has developed a nation of rugged individualists who are fiercely proud of their desire to "stand on their own feet," make their own decisions, and take care of their own needy.

This

is what gave birth to the philosophies of life that became known as the American way of life.

At the turn of the century the average lifespan was about 46 years. Because of the tremendous advances in medical science, progress in the social sciences, and increasing skills in engineering and finance, the present average lifespan has increased to 72 plus, and the ultimate in lifespan cannot even be imagined. This, of course, is pleasant to contemplate. But it brings with it problems that have to be solved. Some of these problems are brought about by the multiple infirmities that afflict some older people and the services required to assuage the pains and malfunctioning that are caused by these infirmities. Some of these problems are caused by lack of adequate financial resources on the part of some of the older people with which to provide the services they need to stay healthy. And this is where "we came in."

In discussing the scope of the problem many estimates are presented of the number of people over 65, those who are financially protected by insurance, by pensions, by OASI payments, those who need public assistance for all the necessaries of life, and those who need assistance only for medical care. Unfortunately, estimates are often "guesstimates" and mean little. What is certain is that many people over 65 do not need any type of financial assistance in obtaining medical care and that there are some people over 65 who do need assistance for necessaries and/or medical care. This fact should limit the scope of our problem, for no legislation is needed to provide medical care for those over 65 who are protected by voluntary insurance or other means of their own providing, while the best means should be found to help those who do need help in obtaining needed medical care.

In our local Utica, N.Y. community we have a Blue Cross and Blue Shield plan known as Medical and Surgical Inc. This group offers a senior citizen plan for people over the age of 65 which provides them with full hospital plan, one coverage allowing 70 days of hospitalization, plus drugs, laboratory tests, dressings, casts, physical therapy, transfusions, etc., and in addition, a service type medical and surgical contract in which the participating physicians agree to accept a lesser fee which is approximately 60 percent of the regular S-6 service contract fee as payment in full for all medical and surgical services under this contract at a cost of about a carton of cigarettes per week. The senior citizens plan is limited to people over 65 whose income is below $2.500 per year per member of the family, and provides no other means tests or requests for assistance from responsible relatives. Although less than a year old this plan already has covered 1,200 risks in this area and new ones join daily. Many other people over 65 years of age are still maintaining the regular Blue Cross and Shield plans that they had while they were employed. Both of these plans are not cancelable because of age. I need but mention that the Health Insurance Association of America said in 1960 that half the Americans 65 and older had health insurance. They estimate that 90 percent who want and need it will have coverage by 1970. The plan mentioned above in existence in this area is neither new or novel, and can be found throughout the United States. There is an institution in Utica known as the New York State Masonic Home and Hospital. It is operated by the Grand Lodge of the Masons of the State of New York. There are 600 people who are over 65 years of age living out their twilight years in this home. Many of them have exhausted their resources by the time they come here. They are taken in, given complete maintenance, and the finest medical and surgical care without any charge to them or their relatives, and this organization neither asks for nor receives any governmental subsidy, in fact, it does not ask for or accept payments from normal welfare channels.

Recently, there was an eastern area meeting of the National Council of United Presbyterian men in the Hotel Statler, New York City, at which the Honorable Kenneth Keating, Senator from New York spoke at the general assembly. There were 2,000 Presbyterian men at the meeting. The theme of the meeting was, “God so loved, He gave." At one of the workshops on the subject, "Christian Response to Fellowship" it was brought out graphically under the title "Insensitiveness to the Needs of the Congregation" that whereas heretofore, the church through organized efforts took care of their sick and needy, it was becoming insensitive to those needs because the activities of official welfare agencies have been supplanting church efforts in caring for the needy of the church and has created a lesser awareness to needs of people that has erected a barrier to Christian fellowship. There is an important lesson to be learned from this by proponents of the King-Anderson bill.

The King-Anderson bill is not geared to help only those who need assistance In obtaining medical care. In fact it is not geared to provide assistance to *many of those who do need help unless they are OASI beneficiaries. It is pri-marily meant to render assistance to beneficiaries of OASI, even though some of them may have incomes in the hundreds of thousands of dollars annually from investments, savings, or other non-OASI sources, and who therefore neither need nor want such assistance.

The man in the street is confused when he discusses this bill for he keeps referring to medical care. Actually this bill does not presume to provide complete medical care. It lists the following services only for OASI beneficiaries. 1. Hospital services, limited to 90 days, with a deductible feature of $10 for each of the first 9 days of hospitalization.

2. Nursing home services for 180 days only and then only if the patient is transferred from a hospital.

3. Home health services.

4. Outpatient hospital diagnostic services for which the patient must pay the first $20 each time.

My criticisms of some of these services are as follows:

1. Mcdical and surgical services of a physician are not included. Thus the patient must either pay his physician himself if he can, or apply for physicians services under Kerr-Mills legislation, or under home relief through the local welfare agency. This can be highly complicated, unwieldy, and in fact impossible to achieve. In addition the patient pays $10 per day for the first 9 days of hospitalization. The average length of stay of a patient in a hospital for one admission is less than 9 days. This proposed legislation therefore purports to give medical care but actually gives a mere fraction of what the general public is led to believe they will receive in return for a healthy slice of their lifetime earnings in the form of a social security tax.

2. Up to 180 days of skilled nursing home services after transfer from a hospital. This language in the bill should be carefully scrutinized in light of the following facts: What proportion of old agers go to a nursing home directly from a hospital as distinguished from their own home or from a friend's or relative's home? We have about 300 welfare recipients in nursing homes in Oneida County. Of these, I would estimate only about 30 percent of them come to a nursing home directly from the hospital. The remaining 70 percent come from their own or relatives' homes after their care becomes too burdensome. It is indeed a sad commentary that 1 father and mother can care for, educate, clothe, house, and feed 10 children, but 10 children are unable or unwilling to do the same for 1 father or mother. But the fact remains that the 70 percent who do not come from a hospital would be ineligible for nursing home care under King-Anderson legislation. Furthermore this bill allows 180 days of skilled nursing home care. Our experience demonstrates that over 90 percent of old agers sent to nursing homes by physicians are sent there for life. What is such a patient in a nursing home to do after 180 days have gone by? Go home to relatives who cannot care for them? Or apply for interval care between benefit periods under Kerr-Mills or home relief? Again an impossibly confusing procedure.

3. Outpatient diagnostic services subject to a deductible of $20 for each study. This is good when dealing with people whose income will permit such a deductible. But an OASI beneficiary who skrimps along on a minimum payment cannot afford such a payment each time, and will have to resort to public assistance in one form or another.

I ask the question then, why, if this proposed legislation is so impracticable, so costly, so patently unnecessary, and so confusing do the proponents of the measure make such a determined effort to push it through the Congress? The simple answer is, that after getting the foot in the door of socialized medicine by providing a minimum of care to a minimum number of people, efforts will be made periodically to widen the opening to include more and more people and more and more services until complete Government health care for all is an accomplished fact, and socialized medicine will be established in this country. Different people want socialized medicine for different reasons. Karl Marx wrote, "First socialize medicine, and then all other activities of a nation will follow as night the day." Others have purely political reasons or financial reasons such as the effects on labor's treasury in providing health and welfare services to older union members. We physicians are opposed to this legislation because it would deteriorate the quality of health care for the aged, it would lead to the end of voluntary health insurance, it would result in complete socializa

tion of medicine and, though I hadn't mentioned it before because it is so obvious, it would be terrifically expensive. But our most important reason against this bill is that it is wholly unnecessary. Our next most important reason for opposing this bill is that it would be unwieldy, will complicate satisfactory exist ing procedures and, in fact, is impossible to achieve without additional and complicated assistance from other existing programs.

We in medicine are not satisfied to sit back and just oppose everything. We in medicine agree that some of our aged citizens do have a problem in obtaining adequate medical care because of the lack of sufficient means with which to get it. We in medicine advocate and recommend a proper way to provide such assistance and that proper way is through proper and revised implementation of the Kerr-Mills law.

I say "revised" implementation of the Kerr-Mills law because our experience with its implementation has revealed certain inadequacies which can be remedied by legislative amendment or administrative edict. I refer to the following items:

1. In originally estimating the types of persons who would be eligible for assistance under Kerr-Mills it was believed that there would be three classes: (a) Cases transferred as a bookkeeping procedure from OAA and AB categories to MAA.

(b) Aged medical indigent, previously hospital only.

(c) Marginal or low-income persons not previously on welfare who would not be eligible under welfare rules of eligibility.

It was originally believed that the third group (c) would be the largest group to apply. However, our experience in New York State showed the group (a) above, which covered the bookkeeping transfers of OAA and AB clients to MAA were by far the largest group amounting to about 18,000 such transfers during the month of April 1961. Groups (b) and (c) above were so few, they were not identifiable in April, which was the first month of operation under MAA. The same seemed to be holding true for May 1961. There were many inquiries after the law became effective, but relatively few applicants, because most of them turned away from MAA after learning the specific eligibility requirements, especially pertaining to the investigation and responsibilities of responsible relatives.

The bookkeeping transfers of OAA and AB recipients to MAA is taking 75 percent of the MAA workers time. Their caseloads have been greatly increased. thus depriving ordinary welfare clients of caseworkers services. In fact, this program requires additional personnel in all divisions of the welfare department in order to carry out its proper administration. It is felt by welfare workers that if the bookkeeping transfer of OAA and AB cases to MAA were eliminated as part of the program, there would be no need for additional personnel, and the reasons for providing such care under H.R. 12580 (Mills bill) as expressed on page 205 lines 23 and 24 and page 206 lines 1 and 2 as follows: "to furnish medical assistance on behalf of aged individuals who are not recipients of old-age assistance but whose income and resources are insufficient to meet the costs of necessary medical services," would be more readily effectuated. The fact is that OAA recipients who were transferred to MAA are worse off than they were before.

2. Another area of the Kerr-Mills bill that requires a second look is on page 215 lines 12 to 25 and page 216 lines 1 to 6, which lists the services available for "individuals 65 years of age or older who are not recipients of old-age assistance but whose income and resources are insufficient to meet all of such cost:

(1) Inpatient hospital service.

(2) Skilled nursing home services.

(3) Physicians services.

(4) Outpatient hospital or clinic services.

(5) Home health care services.

(6) Private duty nursing services.

(7) Physical therapy and related services.

(8) Dental services.

(9) Laboratory and X-ray services.

(10) Drugs, eyeglasses, dentures.

(11)

(12)

The capitalized words above include services available under the Kerr-Mills Act, but have been deleted in the State implementation enabling acts of some States under the broad authority of H.R. 12580 which specified areas in which absolute compliance is mandatory (p. 210, lines 7-23) but permitted wide latitude and discretion within the States in the implementation of this legislation espe cially as pertaining to types of medical service that can be rendered. In addition to the above-deleted services others also are not allowed, specifically podiatry and transportation, including ambulance service. This has caused great difficulties for many OAA recipients who have been indigent and on OAA for years, and perfectly contented with the medical care being rendered, but who now find that as a result of a bookkeeping transfer they are on MAA and must provide their own dentistry, eyeglasses, and other services which they could never do in a million years. They are finally receiving them through the fictional device of taking their application for home relief (non-Federal), and providing these additional services under local sponsorship. It is actually silly for such an old ager to be allowed a refraction by an opthalmologist under MAA but be unable to get his glasses from the oculist's prescription under MAA, and have to get it under home relief.

I believe that the Kerr-Mills Act should include the services to be rendered to its beneficiaries in the mandatory section (p. 210 lines 7-23) and include necessary services such as dentistry, optometry, podiatry, transportation as services. that are included in the Federal grant as a must.

3. Page 209 of H.R. 12580 paragraph D, line 18 to page 210, line 6 provides that "no lien may be imposed against property of any individual prior to his death on account of medical assistance to the aged *** and there shall be no adjustment or recovery except after death *** of any medical assistance to the aged ✶ ✶✶

This paragraph should be amended to permit voluntary assignment of such property by beneficiaries of the act to the welfare department concerned to prevent loss of such property by tax delinquency sale, circumventing transfers on the part of relatives, nondefended actions by creditors or others who can dispose of the property after judgment and sale, while the title owner of the property is permanently in a nursing home (as has happened here) or otherwise incapacitated or is financially unable to pay obligations that may accrue while so incapacitated. This should be done to protect the beneficiary of MAA and the Department of Public Welfare from the loss of resources applicable to care.

4. The MAA program under the Kerr-Mills Act should allow an exclusion from income or liquid assets of an amount reasonable and necessary to provide burial for recipients of the act. The lack of such a provision has resulted in hardship and difficulties, and usually has to be accomplished through home relief.

I believe that the dignity of man at the moment of his demise would be enhanced if he were assured of proper burial from his own resources, if he has any. So we in medicine have a proper solution for the medically indigent aged; namely, proper revision and implementation of the Kerr-Mills law. It applies to every American, and not just the OASI beneficiary. Its benefits are broad and all inclusive and provides all needed medical care, not just some hospitalization. The program is entirely voluntary, and includes provisions to utilize voluntary health insurance plans of the individual, thereby allowing voluntary health insurance to continue and spread its protective cloak over more of our people. Our tax dollars are being spent more economically through Kerr-Mills because of local option and supervision. The quality of medical care will continue at the highest level in the world for its beneficiaries the same as for all others who are not receiving medical assistance. And don't forget the statement of Karl Marx, "Socialize medicine first and all other activities of a nation will follow as the night the day."