One thing which I learned at these conferences, including the White House Conference on Aging, was that several of these groups of purportedly interested in the aging are more interested in furthering their own interests than in making a real effort to help the senior or aged.

Everyone knows that organized medicine is opposed to the King-Anderson bill as it was 2 years ago to the Forand bill. It is rather hard to understand the fierce opposition of the AMA and their allies to the social security approach to financing health care for the aging. It is particularly difficult in view of their many claims of real interest and concern for the welfare and well-being of the aged.

The fact that several members of the medical profession have disavowed the policy of the AMA is certainly evidence that not all doctors consider the KingAnderson bill as socialized medicine nor fear control of the way in which doctors practice. There is nothing in the King-Anderson bill that suggests control of the doctor or hospital, more than is now exercised by health and hospital authorities at the present time to insure certain standards to protect both the hospital and the doctor.

If it were not for some of the desperate propaganda and tactics of the AMA, there probably would be many, many other physicians willing to speak out in favor of the King-Anderson bill. They know that they have been misinformed about the bill, and I think are about ready to express themselves despite the AMA's stand.

The purpose of the King-Anderson bill is to secure a pay-as-you-earn approach to insure that upon retirement there will be protection against medical care costs and that the benefits will be available as a matter of right and not upon a debasing, degrading means test to secure such protection.

Means tests tend to lower morale and pride and I'm sure that the Members of Congress have no desire to reduce the aged population to a group of paupers. However, in most instances, this is what happens at the present time when the aged need assistance to pay for hospital and nursing home care.

No one of any age or profession has offered a single reasonable argument against the intent of the King-Anderson bill which is to protect our society against the burden of an aged and medical indigent population by requiring individuals to save during their working years for the inevitable health expenses of their old age. Does the AMA object to these efforts to protect individuals and society from medical indigency in old age? Is it content to see a large and growing segment of our population treated as medical indigents? Do the insurance companies object to such efforts? If they do not object, why consistently fight them, yet fail to offer workable alternatives. Instead of a complete plan, they have supported the Kerr-Mills bill, which is nothing more than another kind of public aid.

These groups have attacked the King-Anderson bill with many of the arguments they used to oppose the Forand bill. The arguments of costs, utilization, control of physicians, lack of complete coverage for all the aged, its compulsory provisions, and that only those who need help should receive it. Well, I'd like to conclude by giving my views on some of these arguments and their merits.

The argument of the costs of the program proposed under the King-Anderson bill have been questioned, but the cost of the administrative work through the social security system for paying for the benefits in the bill would be very small compared to any program administered at the State level with the duplication of effort plus all of the local and county costs which many States would have. It would also be far less than if insurance companies were to handle it.

The argument offered on the utilization, or demands that the aged would make, is another interesting one. Certainly, there would be some increase in the aged entering hospitals or nursing homes. The reason is clear enough. We would have a way to pay for such care. Something that we do not have now in the great majority of instances. However, the argument has been offered in a way that suggests that each doctor's office and hospitals will be flooded by the older people demanding to be hospitalized and/or have surgery. This argument does an injustice to the mentality of older people. It shows a fundamental lack of respect for him as an individual.

Control of physicians is another theme of the opponents of the King-Anderson bill. The bill is simply a way to pay for services and not to provide the benefits it contains. It is no different than private insurance plans, as far as this is concerned.

Another argument offered is that it is a compulsory plan. None of us like the word "compulsion." But, I wonder how many of the 11 million persons now

drawing social security benefits would be doing so had they not been required to contribute as they earned. How many of this 11 million would now be a burden on the relief rolls of the States had not compulsory payroll deductions provided retirement protection under the Social Security Act.

Then, it is said that the King-Anderson bill will control the physicians and hospital and other groups who are included. The bill is a way of paying for services, not providing them. This is an interesting objection which the opponents to this bil lraise. If they really believe it, then they are actually saying that private insurance companies, public aid programs, and others who help pay for medical expenses control the hospital and doctor. This is unlikely, but this is what this argument seems to be saying.

In recent television debates on this bill, the AMA spokesman keeps referring to their position: namely, that only the aged person who is in need should receive these benefits. And, always, he upholds the virtues of such an extra welfare system that was created by the Kerr-Mills bill. I sincerely hope that the Members of Congress will examine carefully what has happened under this bill. Most of the States that have passed legislation for its implementation have enacted very limited plans. It does not provide anywhere near the same protection that the King-Anderson bill would provide. Instead, it will lead to more bureaucracy and redtape for the aged persons seeking aid.

I believe that President Kennedy, through Representative King and Senator Anderson, has presented Congress with the type of program that the vast majority of aged or seniors desire. We do not want charity, nor do I believe the aged of the future will want it. The King-Anderson bill would go a long way in restoring our dignity, our independence, and remove from our minds the fear that now is upon us when we are sick.

The seniors today require a program that will enable them to live with a feeling of security and pride to dispel the sense of being outcast and forgotten by society. There is a tremendous block of voter strength in the aged, near aged, and 50- to 60-year-old group who are worrying about their retirement years. This strength can be used to great advantage to our society and unless a real start is made now toward solutions to the problems of the aged, there is great danger that these groups may become victims of promoters who seek to control and use them for their own financial and political gain so that their voting strength may be used to bring measures that are unsound, unworkable, and of such a nature that the entire economy could be jeopardized. The King-Anderson bill would be one of the steps to prevent this since it will give the aged the basic protection they need in paying for their health care, create a solvent system and be administered in a manner which will recognize our true value as individuals. I earnestly urge you to support the King-Anderson bill.

STATEMENT OF JOHN F. PLETZ, JEFFERSON CITY, MO.

FINANCING COMMUNITY HEALTH SERVICES FOR THE INDIGENT AGED IN MISSOURI Most persons with whom I have discussed this subject will generally agree with the following principle: The individual should pay for his own medical care; if unable to do so, his family and relatives should pay or help pay for it; if they are unable, the local community should do so; if this is not possible the State should do so; and if this is not possible, the Federal Government should participate. This principle is included in the final report of the task force on health and medical care of the Missouri committee for the 1961 White House Conference on Aging, and it has been stated in numerous other places.

Where the sparks begin to fly, where the statistics are gathered by the bushel, and then used more or less "selectively," where reason appears to go out the window and emotion becomes the dominant force, is when a person begins to be definite and specific as to when the next step up the above ladder is necessary. and how it shall be taken. It is my intent in this paper-based on more than 25 years' experience in the field of public assistance in Missouri-to point out those facts which I believe must be taken into account by anyone who is trying to make a judgment as to whether more or less Government action is needed, in order to provide speedy and adequate medical care for those aged Missouri citizens who need it but are unable to pay for it themselves.

The following statistics appear to me to be so basic that they must be taken as the foundation upon which the remainder of my discussion rests:

1. The 1960 census shows that today there are 503,400 persons 65 and over in Missouri, compared with 405,000 in 1950 and only 113,000 in 1900. Expressed in another way, 1 out of every 8 Missourians today is a person 65 or older, compared with only 1 out of 25 in 1900. Only one State, Iowa, has a larger proportion of older people than Missouri. By 1975 it is estimated that Missouri will have 600,000 persons over 65.

2. As of December 1960, about 308,000 aged beneficiaries received retirement benefits under the Federal old-age and survivors insurance law. The average monthly benefit was about $72. About 6 out of every 10 aged Missourians are now receiving these retirement payments.

3. As of January 1961, about 114,000 aged persons in Missouri received oldage assistance payments under the Federal-State assistance plan. The average monthly payment was almost $60.

4. In spite of the termendous increase each year in the number of persons over aged 65 in Missouri, the old-age assistance rolls have declined from a high of 133,732 in June 1954 to 113,977 in January 1961. This is a net decrease of 19,755 in about 61⁄2 years time. The major reason for this steady decline in the assistance rolls is the steady increase in the number of retired persons who are eligible for social security benefits, and are eligible for more adequate amounts.

5. The above figures mean that in Missouri about 8 out of 10 persons 65 years of age and over receive income from social insurance or old-age assistance or both.

6. The 1950 census figures showed that in the United States, 12.1 percent of all families (one in eight) had an annual income of less than $1,000. The same figures showed that 19.1 percent of all families in Missouri (one in five) had an annual income of less than $1,000. Whether the 1960 census will show any change in these proportions is not yet known.

7. Missouri ranks 21st in average per capita income, but ranks 42d in per capita State tax collections.

8. The aged spend at least twice as many days per capita in general hospitals as the population as a whole.

9. As of November 1959, the Missouri Division of Employment Security estimated that 103,000 persons 65 and over in Missouri have some employment. This figure cannot be taken as representing those with earnings sufficient to provide all their needs, including medical care, since there are an unknown number who are working only part time, including some receiving OASI benefits. Against this background of verifiable facts, let us examine the application of our basic principle to Missouri. I will assume that our analysis is directed toward those citizens of Missouri who are 65 years of age or older and who are not employed, since this is the group from which our problem would come. A. The retired person over 65

Surely there would be universal agreement that whenever he is able to do so, the aged person should pay for his own medical care. The primary sources of payment considered here would be health insurance, retirement income, savings, and other liquid assets. There are, of course, a number of the aged in Missouri who are able to do this; how many is not known, and would be a most difficult figure to obtain or even to estimate. That there are sizable numbers who would probably not be able to pay a large medical bill can be more readily established. 1. Voluntary health insurance.-There has been a tremendous increase in the number of persons of all ages covered by the Blue Cross-Blue Shield plans, by commercial insurance, or by both. Again, we would all agree that this is an excellent trend, and one to be fully encouraged. This is another indication of the widespread interest in the individual paying for his own medical care, and in using a prepayment system of doing so. However, in some quarters this fact has been interpreted as meaning that most, if not all, of the retired aged will have such coverage within the next 5 or 10 years. That this is not a valid interpretation has been rather definitely proved by a report recently published by the U.S. Public Health Service. In 1959, the T.S. national health survey conducted a study of approximately 19,000 households containing 62,000 persons, making this by far the most authoritative study in recent years. Among many revealing findings, the following seem to be most applicable to this discussion:

Among persons age 65 and older, approximately 46 percent were covered by some form of hospital insurance; however, only 37.6 percent of those over 65 and unemployed were found to have hospital insurance coverage. A related finding was that although 14.9 percent of the total U.S. population had an annual family income of less than $2,000, only 7.4 percent of the persons with hospital insurance were in this income group.

An additional fact that must be weighed in considering voluntary health insurance is that coverage does not automatically mean that all of the person's medical costs nor even all hospital costs are met by insurance. Even though 37.6 percent of the retired aged have hospital insurance, this could mean that in many cases as much as 60 or 70 percent of the total medical bill in a crisis situation would have to be paid from other sources.

2. Retirement income.-Again there would be agreement that aged persons who have an adequate income even though they are retired should pay for their own medical care. However, the facts are such as to lead me to conclude that by far the majority of the retired aged do not have an income sufficient for this purpose. The fact that a greater number of retired aged do not carry health insurance policies must also be closely related to income statistics.

The most telling figures in this respect are those published in the Statistical Abstract of the United States, 1959. Table No. 415 shows that 54.4 percent of all persons 65 and over in the United States had no money income or less than $1,000 in 1957. Another 23.8 percent had a money income between $1,000 and $1,999 for that year. This means that almost 8 out of every 10 persons in the Nation over 65 had less than $167 per month income, and over half had less than $100 per month. It must be remembered that these figures include old-age assistance and social security, which in fact would be the primary sources of the income. As one indication of their adequacy or inadequacy, these figures may be compared with the budget costs for a retired elderly couple as prepared in 1959 by the Bureau of Labor Statistics. For a couple not in need of medical care, it was estimated that a modest but adequate level of living in Kansas City would require $3.034 per year, and in St. Louis $3,099.

3. Other resources.—Certainly the person who has savings, stocks or bonds. salable personal or real property other than his home, or other liquid assets should be expected to pay for his medical care. There are a number of aged persons in this position; again, their number would be difficult if not impossible to determine. In view of the income figures given above, it is difficult to see how there could be a great number in this favored position. Certainly after the person had been retired for 5 or 10 or 15 years there would be many whose position had changed completely from what it was at time of retirement.

Some persons have inferred that the individual should pay his own medical costs even though it means cashing in his only life insurance policy, or mortgaging or selling the home in which the person lives. While some aged persons do just that, I believe any policy which would require such action should be examined most carefully. It is true that the medical bill would be marked paid, but the community might eventually have to pay out a far greater amount in the form of assistance for shelter or other costs.

B. The immediate family and other relatives

Missouri has no compulsory relative responsibility law, other than that the husband or wife can be held responsible for the spouse, and the parent for a minor child. Many adult children are and have been paying on a voluntary basis part or all of the medical bill for their aged parents. This again is something to be encouraged and fostered. We have often seen children pay for a one-time medical bill even though it may be high, where they have convinced themselves that they are unable to assist their parents on a continuing monthby-month basis for the other necessities of life. We have also noted that it is often the adult child with apparently the least resources who is more willing to help his parents in such an emergency. In many cases a real sacrifice has been made.

The question of when an adult child with his own family is able to pay a sizable medical bill for an aged parent is most difficult to decide or determine. For example, should he pay a large hospital bill if doing so means a reduction in the amount of education which one of his children may obtain? In how many cases will the aged parent refrain from asking for help from the children, or even letting them know that medical care is needed, knowing the struggle the children are having with their own financial problems?

It must be remembered that at present the aged parent who has children who are poor, the aged parent who has children who are in moderate or well-to-do circumstances but who do not choose to or who believe they are unable to help their parent, and the aged person who has no children are in exactly the same circumstances; neither of them has a resource for paying medical bills. C. The local community

The next rung of the ladder would involve other persons and organizations in the city or county in which the aged person lives. It would include the private or voluntary organizations as well as those supported by local tax funds. The major sources of help in meeting the cost of medical care for indigent persons would probably be the following, recognizing that even among these the variation from community to community might be the whole range from no help to full help for certain persons:

1. Churches, civic or charitable organizations, and United Funds.-If a general evaluation on a statewide basis can be made of such a diverse group, it would have to be that in most cases the payment for medical care, if any, is done on a very limited basis, and lacks much in covering total need even in the immediate community. Some churches help support their own denominational hospitals, and occasionally pay part or all of a medical bill for one of their own members. The Lions Clubs have a rather widely operating plan for the purchasing of eyeglasses, and numerous other organizations have plans for providing help in paying for some types of medical care. In some areas the Salvation Army and similar organizations have a limited budget for paying for medical care. Most of the United Funds make some allocation of funds to hospitals and to other medical care agencies, in a partial attempt at offsetting the cost of the free care given.

2. The professional group.—We know that a great amount of free care is given by doctors and dentists. However, I have been unable to find reliable figures as to the extent of this donation of free time. A problem in trying to make such a determination has always been the "gray area" which occurs in trying to properly distinguish the "charity" case from the "bad debt" case. Whether free drugs and medicine are given in any sizable quantity also seems impossible of determination. Again there is no question but that some is given, particularly where the financial circumstances are known to the druggist. The lack of specific information again suggests that this probably is not being done on any widescale basis. Again there would surely be majority agreement that neither the practitioner nor the supplier of medical goods or services should be expected to bear a major part of the cost of medical care for the indigent.

3. The hospital.-Many persons appear to have the idea that since a hospital is organized on a nonprofit and tax-exempt basis, and that since most such hospitals have at least some income from United Fund, church groups, or gifts or donations, that the hospital should therefore be willing and able to furnish whatever free care the community needs. A close look at the annual reports and the financial statements of several of these institutions should be sufficient to quickly change such an opinion. There may have been a time in the past when this was possible, but with the changes in population, in length of life span, in attitude toward hospital care, and others, this day has long since vanished. The following are excerpts from various reports which I believe will show more nearly the actual situation:

(a) The very comprehensive study of "Public Health and Hospital in the St. Louis Area," done by the American Public Health Association in 1957, showed that inpatient free and part-pay care for patients in 17 hospitals in St. Louis and St. Louis County was estimated at $1,776,418 for the year 1955.

(b) One of the largest voluntary hospitals in St. Louis showed in its annual report for 1960 a figure of $352,000 for charity allowances and another $164,000 for bad debts and other deductions.

(c) Another large voluntary hospital in St. Louis reports almost 16,000 days of totally free care, plus another 2,600 days of care for which only partial pay was received during 1960.

(d) In a small sectarian hospital in outstate Missouri, the annual report shows that in 1960 1 out of every 12 patients admitted to the hospital was unable to pay the full cost of his care-9 percent of the patients were charity patients in whole or in part.