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Washington, D.C. The subcommittee met, pursuant to notice, at 10 a.m., in room 1310, Longworth House Office Building, Hon. John Dowdy presiding.

Present: Representatives Dowdy (chairman), Adams, Horton and Steiger.

Also present: James T. Clark, clerk; Hayden S. Garber, counsel; Sara Watson, assistant counsel; Donald Tubridy, minority clerk; Leonard O. Hilder, investigator.

Mr. Dowdy. The committee will come to order. We will now resume our hearing on the medical care bills, H.R. 3972 by Mr. McMillan and H.R. 6818 by Mr. Nelsen.

For the chairman, Mr. McMillan, I offer for the record his exchange of correspondence with the President of the Board of Commissioners of the District of Columbia, with regard to the impact of the medical assistance programs in the District should the Congress enact into law the pending bill, H.R. 3972. (The correspondence referred to follows:)


Washington, March 16, 1967.
President, Board of Commissioners,
District Building, Washington, DC,

DEAR COMMISSIONER TOBRINER: Yesterday, Subcommittee No. 3 commenced hearings on the Commissioners' medicare program as embodied in H.R. 3972 and similar bills, and will resume its hearings on April 4. Prior to the latter date we would like to have the following information from you :

In your letter to me of March 10, 1967, urging the enactment of H.R. 3972, and your Memorandum of Justification attached thereto, you stated that the Commissioners intended, if the proposed legislation is enacted, to establish for fiscal 1968 the initial financial eligibility level for participation therein at an annual income of $4,200 for a family of four. You estimated that 217,300 persons in the District would be eligible to participate at this level in the District's Title XIX Program.

You further proposed to step up the program by increasing the number of eligible persons through increasing the income level for fiscal 1969 to $4,400, under which you estimate 225,000 eligible persons ; for fiscal 1970 you would establish the level at $4,600 under which 240,000 persons would be eligible; and for fiscal 1971 you would establish the level at $4,780 with estimated 258,400 eligible.

Further, according to testimony of Dr. Murray Grant yesterday, under the present D.C. Medical Care Program actually 260.000 persons are now receiving such care (160.000 who are eligible under the present family income level of $3,360 per annum, and 100,000 under "medical emergencies"). These are my queries :

(1) Is the Committee to assume that 100,000 “medical emergencies” should be added to the number of eligible persons for each of the years indicated, so that the actual number who would be benefitted in these years would be increased by 100,000 over the figures you estimate? If not, what are your estimates of “medical emergencies" over and above the eligible number you estimate for the years shown?

(2) Will you kindly reconcile your estimates in your March 10, 1967 letter of 238,400 persons who would be eligible to participate at the $4,780 income level in 1971, with your estimate in your May 27, 1966 letter to the Speaker that 40% of the District's population (of more than 330,000 persons) stand to receive medical care and services “depending upon the scope and content of the programs which the District might be able to establish” pursuant to 1965 Social Security amendments.

(3) Have the Commissioners other programs than those now submitted, or contemplated under the present programs? Or do you expect to sumbit later programs to enable you to include as high as 40% of the District's population in the medical care and services benefits? If so, what do you estimate to be the cost of such programs embracing 330,000 persons?

(4) From your estimate of costs of the programs you now propose for fiscal 1968–1971 inclusive, it is noted the total cost thereof starts at $11.3 million for fiscal 1968 and reaches an estimated cost of $18.5 million for fiscal 1971 (disregarding the District's share of such costs). It would appear from these figures that the cost per person for such medical treatment remains around $100.00 for each of the years indicated, although your estimate of eligible persons is increased from 217,300 in 1968 to 258,400 in 1971. How do you explain this? There is no indication that any of the estimated costs will include capital outlay for increased facilities which it would seem services to the greatest increased number of eligible persons would entail. Are you contemplating any capital outlay in connection with this program? If so, in what amounts, and for what years?

(5) In connection with your replies to the foregoing question, it would he helpful if you would furnish the Committee with a chart showing for each of the fiscal years 1968–1971 inclusive, your estimates of the number of eligible persons in each year, then a breakdown of such eligibles to show how many would require (a) clinical care and (b) hospitalization. Also, if possible, kindly show the total clinical availability and bed availability in the D.C. hospitals (gorernment and private) and include any projected increase in capacity in the clinics and in bed capacity for the years in question. Your figures showing bed capacity should indicate availability of beds for the type of treatment which might be accorded to persons under the medical care programs you are planning.

(6) As to residence requirement, you suggest that the District is handicappel in qualifying under the 1965 Social Security amendments, first, on account of present law requirement of one year's residence in the District of Columbia. Will you provide us with a citation in the said 1965 Social Security Act of any language which denies to any State the setting up of residence requirements for recipients of benefits? All the 1965 Act says, as we read it, is that the Secretary of HEW can not approve any plan for medical assistance if such plan atteinpts to exclude an individual who “resides” in such jurisdiction. But the Act does not define “resident,” nor indicate who and who is not, a resident. Br whose interpretation, then, are you saying to this Committee that the Secretary of HEI might exclude your D.C. plan because it has a 1-year residence requirement of applicants for medical benefits? With kind regards, Sincerely yours,




Washington, D.C., March 29, 1967. The Honorable JOHN L. MCMILLAN, Chairman, Committee on the District of Columbia, IIouse of Representatives, U.S., Washington, D.C.

DEAR MR. MCMILLAN : We are providing in the following pages, and as completely as available data permits, the answers to questions posed by your letter of March 16, 1967 regarding H.R. 3972 and the District of Columbia Medical Assistance Program under title XIX of the Social Security Act.

(1) The total estimated D.C. population in the financial stratum which cannot meet the cost for all of the medical care needed is 260,000 persons. The referenced 100,000 "medical emergencies" is the difference between the 160,000 persons eligible for medical assistance under the present program and the above total of 260.000 persons, and these “medical emergencies" receive medical care only during a serious medical crisis. The following table shows the estimated number of persons in this “medical emergency" population in the District of Columbia for the years 1968–1971 inclusive:

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(2) The gross inadequacy of published data regarding family size, structure and income is accountable for the disparity between the 1960 estimate of 334,000 and the 1967 estimate of 258.400 persons who would be eligible to participate at the $1,780 income level. Subsequent to the 1966 estimate, we were able to obtain an unpublished tabulation by the Bureau of the Census which provided the means for much more accurate identification of eligible groups of persons This resulted in very substantially reducing the estimated eligible population. The present 258,400 person estimate is approximately 31 percent of the total D.C. population, and replaces the previous 334,000, 40 percent estimate.

(3) As indicated in (2), the total estimated medically needly population of the District is 258,400 persons, or 31 percent of the population. The presently proposed medical assistance program under title XIX of the Social Security Act is the one program which we contemplate to provide medical assistance for these persons, and this goal would not be reached until 1971. We have no plans to include 40 percent of the D.C. population in programs for the medically needly.

(4) a. The figure of $18.5 million is not the fiscal 1971 cost for the program. $18.5 million is the cost which is estimated to obtain if we were to start the program at the $4,780 income level now, in fiscal 1967. The cost for medical seryices is increasing year by year. If we start the program in fiscal 1968 and increase the number of eligibles to 258,400 by 1971, the following estimates apply:

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b. No capital outlay is contemplated in connection with this program. As a matter of fact, if this program attains even a minimal modicum of success in its aim to provide timely care at the level appropriate to the needs of the individual, utilization of high-cost facilities such as hospital beds should be diminished.

The bulk of the title XIX Federal funding support will go for the purchase of services from community resources such as the physician's care in his office or the patient's home, allied health services provided in the home, and the like. We are experiencing strong community support in our efforts in this direction.

(5) As indicated in (4), we do not predict an increase in the need for hospital facilities. However, some clarification as to information available regarding "clinical care" and "hospitalization" should be helpful.

"Clinical care” is a broad term which is statistically oriented to patientphysician relationships. Available data pertinent to your question on this subject include the broad spectrum embracing everything from a telephone consultation to a major surgical procedure. Nowhere is data available to adequately measure the number of different persons who are included.

If we try to relate this question to a hospital "outpatient clinic", the answer becomes only more obscure. For these reasons, the figures provided below simply represent the estimated number of "physician services' which might be required by the total eligible population.

With regard to the figures below estimating number of eligible persons requiring hospitalization, it should be borne in mind that this figure alone does not present the total picture. The number of days' care each person requires is also a factor in the availability of beds. It is anticipated that the average number of days' hospital care required per eligible person will decrease as the program progresses. A substantial factor in this decrease will be the reduction in the number of "medical emergencies". These persons now occupy hospital beds about 30 percent longer than the average hospitalized patient.

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There are no available projected data regarding increase in capacity in clinics. As previously indicated, it is anticipated that the bulk of the increase in "clinical care” of the eligible population will be in the form of services of the private physician.

The proposed medical assistance program includes hospitalization for all types of treatment except for mental illness in the St. Elizabeths Hospital. The following table shows the number of beds expected to be available in D.C. for services covered by the plan for the years 1968–71 :

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(6) Section 1902 (b) of the Social Security Act reads as follows:

“(b) The Secretary * * * shall not approve any plan which imposes, as a condition of eligibility for medical assistance under the plan- *

“(3) any residence requirement which excludes any individual who resides in the State ;" The "Handbook of Public Assistance Administration, Supplement D, Medical Assistance Programs” issued by the Bureau of Family Services, Welfare Administration, U.S. Department of Health, Education, nd Welfare establishes the detailed requirements for a State plan for medical assistance.

Section D-4410 of this handbook cites the above section 1902(b) (3). Section D-4420 provides interpretation of this citation as follows:

"A State plan for medical assistance may include individuals regardless of their residence. It must include persons who are residents of the State and otherwise eligible. It may not require any period of durational residence.

"If a State plan for medical assistance requires that an individual be 'a resident of' or be ‘residing in' the State, the State must adopt a definition of those terms that does not result in excluding any persons who would be considered to reside in the State, under the following interpretation :

"A resident of a State is one who is living in the State voluntarily and not for temporary purpose, that is, with no intention of presently removing therefrom. A child is ‘residing in the State' if he is making his home in the State. Temporary absences from the State, with subsequent returns to the State, or intent to return when the purposes of the absence have been

accomplished, shall not interrupt continuity of residence." I trust that this information will serve to clarify our situation and to assist in expediting favorable consideration of H.R. 3972. If you should have some further question, we shall be happy to respond. Sincerely yours,

WALTER N. TOBRINER, President, Board of Commissioners, D.C.

Mr. Dowdy. The first witness we will call this morning is Dr. Lorin E. Kerr, Chairman of the District of Columbia Public Health Advisory Council. Dr. Kerr, would you come forward.

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Dr. KERR. Good morning. I should like my complete statement to be made a part of the record, and I shall summarize it.

Mr. Dowdy. That will be done, and you may proceed.
(The full statement of Dr. Kerr follows:)



Mister chairman and members of the subcommittee, my name is Dr. Lorin E. Kerr. Thank you for the opportunity to present the position of the District of Columbia Public Health Advisory Council on H.R. 3972. The Council consists of 21 residents of the District, appointed by the Board of Commissioners of the District of Columbia. The Council has the responsibility to study and advise the Director of Public Health and inform the Committee on Public Health, Education and Welfare of the Citizens Council on the total health needs and programs in the District of Columbia.

The detailed study, evaluation, and interpretation of the numerous activities and programs of the Department of Public Health is conducted by the Council's six Standing Committees, each of which is chaired by a member of the Council. The size of each Committee is determined by the magnitude of the assigned responsibilities and numbers from 14 to 100 individuals. Thus the Council, its Committees, and Subcommittees consist of 743 individuals who provide advisory participation by citizens, lay and professional, in the District's public health program including the construction and regulation of hospitals, medical and related facilities, and who act in an advisory capacity to the Director of Public Health on matters affecting the community.

The Board of Commissioners, shortly after Public Law 89–87 was signed by President Johnson on July 30, 1965, designated the Department of Public Health as the agency to administer the Plan for Medical Assistance under Title XIX. It is the responsibility of the Department of Public Welfare to determine indi. vidual eligibility to receive medical care under the Plan.

The Department of Public Health turned to the Public Health Advisory Council for assistance in developing the Plan. The Council submitted the request to its Standing Committee on Medical Care and Hospitals. It soon became apparent that a Plan of the magnitude delineated under Title XIX could not be developed by 14 District residents. It would have been presumptuous of them to speak for all the medical and health professions providing medical care, the administrators of various types of health facilities, and the consumers of medical care. The Committee was quickly reconstituted, and 100 individuals thoroughly representative of all elements of the community agreed to accept the responsibility for developing a Plan for Medical Assistance for the District of Columbia.

There are eight major subjects such as Physicians Services, Eligibility, and Hospitals and Extended Care Facilities which required the appointment of a corresponding number of subcommittees. The detailed material essential for the Plan was developed by these subcommittees, which were unstinting in the time devoted to their assignments. Constant review and direction of the subcommittees was maintained by the Steering Committee, which consists of the eight subcommittee chairmen plus the Chairman of the Committee on Medical Care and Hospitals.

On June 30, 1966, nearly seven months after the subcommittees were appointed, their final reports were completed. The Plan, incorporating all the major policy


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