states - California, Massachusetts, Michigan and New York "receive about 88 per cent of the money spent" under MAA programs. Our first comment on this statement is that this is an outdated percentage, becoming more outdated monthly. But it is not surprising that a few large states have been getting a large part of federal MAA matching funds. - From the start of the program until June, 1961 -nine months Massachusetts, Michigan and New York were by far the largest states involved. The three states had comprehensive medical programs in effect for the needy aged. They already had the experience, the staff, and the caseload to operate large-scale medical programs. It was not the least surprising that, in the early stages of MAA, about 90 per cent of the expended funds were expended in these three states. Beginning with June, 1961, the percentage in the three states began declining, but, in December, 1961, California began its program for long-term care which is a high-costper-case program. Then it became "four states" instead of "three states" that were using the major share of MAA federal funds. In May, 1963, the President's Council on Aging added Pennsylvania and had five states accounting for 88 per cent of total MAA expenditures in the calendar year 1962.49 But other states have implemented MAA since then. States with no previous experience with vendor payments have gained experience. The aging in other states have learned of the existence of the program. Consequently, the percentage of funds going to a few states has been less nearly every month. 48 House Appropriations Subcommittee Hearing, February 18, 1963. - However, it is true that the five states cited California, Massachusetts, Michigan, New York and Pennsylvania will receive a considerable amount of MAA funds even after all the other states have good programs going. Why? Simply because they have large numbers of older people as residents, and hospital and medical costs are higher in these states. These five states contain about 5.9 million, or 57 per cent of the 10.5 million over-65 residents of the 25 states with MAA at the end of 1962.5 50 The average hospital stay is longer in the five states than in the other 20 (8.1 days to 7.1 days, voluntary short term general hospital); the average per diem cost is higher ($41.69 to $37.51).51 In fact, if every over-65 person in the 25 MAA states as of the beginning of 1963 had a hospital stay of the average length and cost for his state, more than 62 per cent of the total cost would be incurred in these five states! These then are the major factors accounting for the high percentage of MAA funds in these five states: early implementation, organized medical programs before MAA, a large aged population, and higher costs. The Means Test The means test, which has been attacked unjustifiably as a weakness in the Kerr-Mills law, is a reasonable and usual 50 51 Data on population calculated from state tally of persons over 65, Data on hospital stay calculated from data in Hospitals 1963 Guide Issue for voluntary short term general hospitals in 1962. Stay is based on average daily hospital census, times 365, divided by hospital admissions, for five state and 20 state groups. Per diem cost calculated on the basis of total expenses reported for five state and 20 state groups, divided by total patient days reported for each group. - method for determining that government tax revenues go where they are needed. Other than Kerr-Mills, 10 federal assistance programs require a specific means test.32 If a test of need is a proper safeguard against waste in the expenditure of public funds in these instances, it is equally prudent in financing a health care program. For private charities, including those administered through churches, a means test is an established procedure. Some labor unions deny strike benefits to their members unless need is shown. Is it more reasonable to protect private money or union funds from waste than it is public money? Determination of the applicant's need for help is not in itself degrading or humiliating. The constantly increasing use of the Kerr-Mills program by Americans over 65 should demolish for all time the patently emotional argument of King-Anderson proponents that Kerr-Mills won't work because the elderly will not submit to a means test. Following is an editorial from the June 25, 1962, Christian Science Monitor which we cite as putting the means test in a true perspective: 52 What's So Bad About It? Naturally, for its purpose, the staff report of the Senate Committee on Aging makes as bad a showing as it can for the operation of the Kerr-Mills Act, adopted by Congress in 1960 to assist states in providing medical care for the elderly. The main function of the committee and its staff since its inception has been to provide arguments in favor of the Forand bill and now the King-Anderson bill for hospital care through the social security system. The chief indictment hurled is that, in each of the 24 states thus far co-operating, the state giving Kerr-Mills aid requires the applicant to undergo a means test, an investigation of income and assets, before receiving assistance. Old Age Assistance; Aid and Service to Needy Families with Dependent 52 What is so wrong about this? The social security system applies means tests. Up to $4,800 a year, it collects its payroll tax according to what an employee earns and what an employer pays. If a beneficiary under 72 earns more than $1,800 a year he forfeits his payments. Labor unions employ a kind of means test when they argue that because a certain company makes large profits it can pay a higher wage. Would they want a wage level established at which every firm in an industry could be assured a profit, with no questions asked about its management? The proponents of hospital care on social security are asking the United States to set up a large and expensive bureaucratic system to assure benefits to every covered person, indigent or affluent, "as a matter of right." This could prove to be a luxury purchased at the cost of many sacrifices made as a result of the payroll deductions. Particular exception is taken in the committee staff report to the fact that nine states "have recovery programs extending to the homes of people receiving help and collectible after death." Also to the fact that 12 states apply family responsibility provisions under which children, if able to do so, are expected to contribute to their parents' support. Actually the relief lien is one of the most practical plans under which people in need but who own their homes can be given assistance while in possession and enjoyment of their homes. They can feel that to this extent they have provided by their own thrift for this need. Children; Aid to the Blind; Aid to the Permanently and Totally Disabled; Aid to the Aged, Blind, or Disabled, and Medical Assistance for the Aged; Low-Rent Public Housing; Rural Housing Loans; School Lunch Program; Veterans' Pensions; Veterans' Hospital, Domiciliary, and Medical Care Programs. Helping the Most Needy And is any injustice done by enforcing the lien after the recipients of the aid are gone? If they have no immediate heirs, no one is deprived. If children or other near relatives have been spared a serious expense, should the state pass along intact an inheritance to them while it waives its own claim? These practices are not nearly so black as they have been painted. They are methods which may be ill administered on occasion; but so may a more massive "insurance" program. They are processes which have the imprint of common sense and by which American society has done extremely well for those who depend upon it. Has that society come so far from concepts of individual and family responsibility that it prefers to rely on a supposedly impersonal, but potentially political, federal mechanism to do on an indiscriminate scale what state and local agencies can do with more precision and flexibility? Which is the better method to spend money available whatever the amount: for financing health care for the aged to give a limited amount of aid to all those 65 years and older, or to give as much help as the available money will provide to those who need help? This is a self-answering question. We do not need to go into details as to which is the more efficient method the method best suited to really help. - Yet the "means test" has been used as a bad term by Kerr-Mills opponents and King-Anderson supporters. They have claimed that MAA "pauperizes" the applicant. This is nonsense. Of the 28 MAA programs in operation in 1962, 18 set a ceiling on income, with those having income above this level ineligible; ten set an income level as necessary for ordinary living expenses, with any "excess" to be applied to medical expenses. The most common income ceiling for a single individual is $1500. |