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 every day 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 on 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 implemented 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.

VOLUNTARY HEALTH PROTECTION

One other kind of organization that is playing an increasingly important role in the financing of health care is the voluntary health protection plan--both Blue Cross and Blue Shield and the commercial insurance companies.

In Missouri, 1,417,000 people have hospitalization protection through the two Blue Cross plans in the State. Blue Shield protects 1,063,000 members for medical-surgical expense.

Blue Cross alone protects 30.9 percent of the State's entire population, while Blue Shield alone covers 22.4 percent.

It is important to note also that the number of those with private health protection continues to grow rapidly. St. Louis Blue Shield alone has increased its membership by more than 100,000 in the last 2 years.

For the State as a whole, Blue Cross membership increased by 17,300 people last year-Blue Shield membership rose by 49,700.

In Missouri, both Blue Cross and Blue Shield offer membership without regard to age, as do a number of the commercial insurance companies. A person can join at any age, and retain membership for life. We estimate that there are now about 95,500 members over age 65 in Blue Cross and Blue Shield alone in Missouri, or about 25 percent of the population over 65 not being taken care of under old age assistance.

Membership in the plans is, incidentally, offered both on a group basis and to those without group affiliation. Group membership is available to Farm Bureau groups as well as to industrial organizations, and we have some 47,000 farm people enrolled in Blue Cross through the Farm Bureau, and about 28,000 in Blue Shield. This is in addition, of course, to those farmers who have enrolled on an individual basis.

DETERIORATION OF QUALITY OF CARE

The Missouri State Medical Association opposes the King bill, and similar proposals for medical care programs under the social security system, finally, be cause we who are close to and vitally concerned with the problems of providing health care are convinced that such an approach can only lead to a lowering of the quality of care available.

A great deal has been said about socialized medicine in connection with this bill. Without overly belaboring the point, I would like to point out briefly why the physicians of Missouri believe this proposal would lead to a full-scale program of Government medicine in the United States and why socialized medicine would result in poorer medical care for our citizens.

The King proposal is, of course, a limited one. It is limited, among other things, to those over age 65 and to those eligible for social security payments. It is limited to certain health care services, and for limited periods of time. It provides that the patient pay a certain number of dollars out-of-pocket for certain of the services included.

The question is which one of these limits is to be removed first? The pressures will be tremendous, logical, and irresistible.

If this is a program for prepayment of the costs of 90 days of inpatient hospital care after age 65, why not 180 days, or 365 days? If those reaching 65 need this program, why not the other groups receiving social security payments--the disabled, dependent children, and so on? What of those who retire at the optional age of 62 recently authorized? If hospitalization is to be provided, should not the taxpayer be allowed to prepay the costs of physicians' care, drugs, and all other services?

Finally, if it is necessary or desirable for those who are eligible for social security payments to be covered by such a Federal Government program, is it not just as necessary and desirable for all citizens to be covered by the same program? While the need for pensions may be confined to those retired because of age or disability, the need for medical care is universal at all ages and conditions of occupation.

There would seem to be little question that this program, if enacted, would and must expand until it covered all health services and all citizens. And since it would be Government-provided medicine, it would be full-scale socialized medicine-and necessarily Government-controlled medicine. 1

Some have argued that this bill specifically provides that the provision of the health services covered would not be Government controlled. Such arguments do not stand up either from a reading of the bill itself, which specifically sets forth that those who provide the services must agree to abide by regulations

promulgated by the administering agency or on the test of logic. That which the Government provides, it must control in the interest of the taxpayer. Congress and any administration would not and should not abdicate the responsibility to see that tax money is well and prudently spent.

That there will be Government interference and Government control is not simply theory. Experience with various present Government programs both here and abroad amply demonstrate that the relationships and attitudes between the patient and his physician and hospital are affected adversely when the Federal Government has an active role in the administration of these plans. When you have Government rules and regulations, there is interference with the way health services are provided.

Because the rules and regulations are mostly administrative-because they cannot take into account the best practice of medicine, if only because the procedures of the best medicine change rapidly-Government interference affects the provision of health services adversely. Government medicine is bound to result in poor quality medicine.

SUMMARY

In summary, the physicians of Missouri are convinced that the problems of financing health care for the aged have been greatly overstated. We are convinced that those who do need help have adequate assistance available to them through the services of individual physicians, hospitals, and private health and welfare organizations-in cooperation with local and State government resources aided by the vendor and Kerr-Mills programs. We are convinced that those who do not need direct financial assistance have ample opportunity to provide for themselves through the private, voluntary health protection organizations. Finally, we are convinced that the proposals embodied in the King bill are but the first step toward full-scale Government medicine for all citizens, and that this can lead only to poorer medical care for the people.

It would be most unfortunate if the medical care in this Nation, which has reached one of the highest standards in the world under our present free practice were relegated to second rate by act of Congress. The physicians of Missouri urge that the King bill not be passed.

STATEMENT PRESENTED IN BEHALF OF THE MEDICAL SOCIETY OF NEW JERSEY BY RALPH M. L. BUCHANAN, M.D., PRESIDENT, THE MEDICAL SOCIETY OF NEW JERSEY

As president of the Medical Society of New Jersey, I offer this statement of opposition to H.R. 4222 (King-Anderson), in the name of the 6,500 physicians who are its members and of the approximately 3,000 members of its woman's auxiliary.

H.R. 4222 would amend the social security law by adding a new title (XVI) under which inpatient hospital services, skilled nursing-home services, home health services, and outpatient hospital diagnostic services would be provided to any individual over age 65 who is entitled to social security benefits under title II of the social security law.

The Medical Society of New Jersey-in common not only with other members of the medical profession but with all who are dedicated to the preservation of a sound character in our people and in our Nation and to the maintenance of a sound and well-balanced national economy-is for

(1) The retention by the individual citizen-and of that citizen's familyof responsibility for selecting, arranging, and paying for his own necessary health care.

(2) The limitation of tax burdens upon the individual citizen and his family so as to leave to them the financial means of meeting this responsibility.

(3) The development and widespread utilization of adequate and economical private voluntary health insurance coverages as the best means of enabling such individual citizen and his family to meet this responsibility.

(4) The intervention of Government to assist only those citizens who need health care and are themselves demonstrably incapable of meeting the costs for it.

(5) The maintenance at a minimum of Federal governmental intervention and control. We hold that the assignment of responsibility for financing necessary health care should be in the following order: the individual citizen; the family; local voluntary agencies; local, county, State, and Federal Government-each to take over only when the prior agent of responsibility cannot meet the need. Because of this point of view we support the principle of the Kerr-Mills law as essentially preferable to the principle of H.R. 4222 and all like legislation.

In consequence of what it is for, the Medical Society of New Jersey is necessarily against

(1) Any policy or program that would relieve or wrest from the individual and the family the right and responsibility to be independent, selfsustaining, self-reliant, and free.

(2) Any policy or program that would so multiply burdensome taxes upon the individual citizen and his family as to deprive them of the financial means to retain and exercise those four fundamental rights and responsibilities.

(3) Any policy or program that would encourage government, at any level, to eliminate or supplant voluntary free enterprise systems of insurance coverage, or of any other fundamental business or service operation.

(4) Any policy or program that would enlarge for government at any level entrance into and influence over the lives, rights, and duties of individual citizens-in short, any policy or program that would give to government the control and direction of the lives of citizens instead of reserving to citizens the control and direction of their government.

In consequence of the foregoing, the Medical Society of New Jersey disapproves and opposes H.R. 4222 for the following reasons:

(1) H.R. 4222 would supply the health services embraced to all persons over 65 years of age, whether those persons are themselves financially able to provide and pay for such services or not.

This, we hold, is unjust and undesirable. It is our contention that individuals of any age who can provide for their own needs should be required and encouraged to do so, and should not be permitted to meet such needs at the expense of fellow citizens who, in many instances, are more financially straitened than those for whom the benefits are being supplied.

Any program which unjustly burdens one group of citizens with financial obligations in order to indulge undeservedly another more favored group of citizens is demoralizing to both groups of citizens and is hostile to the spirit and the economy of the Nation.

(2) H.R. 4222 would change the fundamental character of social security benefits by substituting services for the dollar benefits that have prevailed from the beginning of the social security program until now. If adopted, therefore, H.R. 4222 would establish a precedent that could lead to the discontinuance of all dollar benefits to social security recipients, and to the provision of food, shelter, fuel, clothing, and varied services instead. All this would involve a violation of the fundamental original agreement, in accordance with which the covered citizen, by paying into the program, could look forward to receiving dollar payments, after his retirement, to enable him to defray the expenses of his daily living.

Under this new concept, the social security beneficiary would be denied the freedom of selecting and paying for commodities and services of his own choosing and, like a witless incompetent, would be expected to take whatever it was decided he needed and should receive.

(3) H.R. 4222 is a discriminatory piece of legislation because

(a) It discriminates in favor of those citizens having social security entitlement-and, as we have shown, with unjust indifference as to their really needing help or not-and at the same time discriminates against those citizens whose lives were such as never to permit them to earn entitlement, but whose distress is such as to place them in dire need of help. (b) It discriminates against wage earning individuals-married and unmarried-who are called upon through increased social security taxes to supply each year, by their compulsory "contribution," the revenues necessary to meet the constantly increasing disbursements for benefits of all kinds. As such, H.R. 4222 is a soak-the-poor tax proposal, which-since no exemptions can be claimed, no matter how many dependents a man may have will levy on every working man or woman's earnings in order to raise the moneys necessary to meet annual expenditures. Viewed in this light,

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