tried to make it clear yesterday that that was not the intent, and I have consulted with experts and they tell me that that is not the effect of this amendment. It really would restore freedom of choice to doctors. at least as to whether or not they wish to contract with hospitals to have their services included in the hospital bill.

Mr. SCHOTTLAND. As I read this amendment, I don't have the bill before me so it is difficult to follow but as I read the amendment, I think I understand it, Senator.

Our association would be in favor of this amendment.
However, we believe it ought to go much further.

Senator DOUGLAS. You would automatically blanket all of them in?
Mr. SCHOTTLAND. Correct.

Senator DOUGLAS. The American Medical Association would automatically blanket them out.

Mr. SCHOTTLAND. Correct.

Senator DOUGLAS. And I occupy a middle ground saying if the hospital and the specialists agree upon this they would be included. Mr. SCHOTTLAND. Correct.

Senator DOUGLAS. I believe a middle ground is very popular politically these days. It is unusual for me to find myself in that position but I can tell you it is a very comfortable feeling.

Mr. SCHOTTLAND. I would like to comment, Senator.

As an old bureaucrat, I feel that it is important that we simplify the administration of these laws. We are getting now so complicated that frequently administration overrides basic policy problems, and it is going to be extremely difficult for hospitals to separate their other costs from the costs of these groups that are excluded, and I see no reason to put onto the hospitals of the country this complicated problem, this complicated accounting problem of trying to figure out what is a pathologist's bill that is a personal thing, what part is the hospital, and it is just going to be really an accounting mess and that is one reason, I think it is the minor reason, but that is one reason, why I think it ought to be in there.

Senator DOUGLAS. I introduced relevant evidence the other day in the form of a statement of a very eminent hospital administrator in New England. He pointed out that if the present provisions of the bill were to be carried out, in two actual cases which he selected, the patient in one would have 9 to 11 separate bills submitted by specialists and in the other 7 to 9 separate bills.

Mr. SCHOTTLAND. If I might be very blunt and frank, I see absolutely no logic in any of the testimony that is being-that has been given before this committee or the Ways and Means Committee or no real arguments that have been presented for excluding them except a desire of certain groups, not to have anything to do with social insurance.

Senator LONG. If I might just make a suggestion, I am going to offer an amendment one of these days to stop this three-layer business and make one layer out of the first two layers and that being the case it will solve the whole problem, there will be nothing to argue about. They will all be in the same tent.

Mr. SCHOTTLAND. I hope you succeed, Senator. We will be down here pitching for that.

Senator DOUGLAS. You will exceed Congressman Forand then because as I remember it when Congressman Forand started out 8 years ago he included physician services but not surgical services.

Mr. SCHOTTLAND. Right.

Senator DOUGLAS. Now, it is a four-layer cake.

Senator WILLIAMS. The trouble is when you cut down on the layers you get less icing, don't you?

Senator ANDERSON. I just hope, Mr. Schottland, you won't commit yourself too firmly for that until you know what is in it. [Laughter.]

In theory I favor it but in practice I am not sure.

Senator DOUGLAS. I think this discussion indicates this is a very moderate bill.

Paraphrasing Warren Hastings at his trial, I would say, "We are astonished at our own moderation."

Senator ANDERSON. Mr. Chairman, the question has frequently been raised as to whether or not the Department has pushed this along as rapidly as it has some other programs, and I would like permission to insert in the record at this point a table, showing that in the old-age assistance program at the end of 5 years, 16 States were in the program; in the aid to families with dependent children, 45 States; in aid to the blind, 46 States; aid to the permanently and totally disabled, 45 States; and the MAA program, 46 States.

So, it certainly has moved along with the general trend, and while I admit there are areas where it didn't seem to be moving along, I think in the main that the Department of Health, Education, and Welfare has done its job and I am glad to have your confirmation at that point. I would like to put it in the record.

Senator LONG. So ordered.

(The table referred to follows:)

PROGRESS IN IMPLEMENTATION OF MEDICAL ASSISTANCE FOR THE AGED (MAA)

Data on the comparative speed with which States began MAA programs shows, if anything that they received encouragement and aid in introducing this program at least equal to any that had been provided previously for other programs. The problem in implementing MAA has been that some Statesdespite substantial Federal encouragement and financial assistance have not had the money to provide more than token benefits.

Progress in implementation of federally aided public assistance programs

PROGRAMS AND THEIR EFFECTIVE DATES1

10AA equals old-age assistance; AFDC equals aid to families with dependent children (originally, aid to dependent children (ADC)); AB equals aid to the blind; APTD equals aid to the permanently and totally disabled; MAA equals medical assistance for the aged.

Vendor payment program.

Puerto Rico, the Virgin Islands, and Guam were not eligible to participate when most of these programs began. They are included as of the elapsed time after they became eligible to participate in each program under Federal law.

Includes 2 States (Montana and New Mexico) expected to begin programs before the end of the 5-year period.

Senator DOUGLAS. The Department of Health, Education, and Welfare may have done its job but most of the States, being in difficult financial straits, have not been able to extend it to any appreciable number of persons; isn't that true, except in five States?

Senator ANDERSON. They haven't done a great job. I know in my own State the battle of the budget is on every year. This year they had extra assets and they put in $700,000 for Kerr-Mills and somebody wrote me and said: "We don't understand this. The people from Health, Education, and Welfare are pushing us to put in Kerr-Mills. Are they doublecrossing you with your bill?"

I wrote back and said: "No, I would be glad to see them implement Kerr-Mills, there is no quarrel about it." But I was glad to see the people of HEW were pushing that in my State at least.

It is true budgets are difficult in many States. They do cause some problems. States would like to go ahead but sometimes don't find the funds to do it.

Senator LONG. Any further questions?

Senator DOUGLAS. In my State, as I remember it, we have a little over a million persons over the age of 65, and the number on KerrMills in a given month is seldom appreciably over a thousand. So this would be one-tenth of 1 percent. Now, it is true that the cumulative number, of course, those over a period of time is greater, as I understand it, something like 2 percent, but the percentage of those on oldage assistance being helped is low.

Senator LONG. Thank you so much, Mr. Schottland.

The next witness will be Mr. Irvin P. Schloss, of the American Foundation for the Blind.

STATEMENT OF IRVIN P. SCHLOSS, LEGISLATIVE ANALYST, AMERICAN FOUNDATION FOR THE BLIND

Mr. SCHLOSS. I have submitted a written statement and I would appreciate having it included in the record. I will then summarize it, if Í may.

Senator ANDERSON. Without objection it will be included in full in the record.

Mr. SCHLOSS. In endorsing the provisions of H.R. 6675, I am speaking for the American Foundation for the Blind, the national voluntary research and consultant agency in the field, and the American Association of Workers for the Blind which is a national professional association of workers in all aspects of services to blind persons.

Both of these organizations had supported efforts since 1959 to provide through the social insurance system for health care services to persons 65 and over.

We were therefore very pleased to see the proposed title XVIII of this bill and hope that it will be favorably acted upon by this com

mittee.

We were also pleased to see the inclusion of the proposed title XIX, the new medical assistance program for the medically needy. We believe this will be a very vital supplement to the title XVIII provisions. In connection with the health care provisions under title XVIII, we believe that the needs of disability insurance beneficiaries are also acute, and would recommend to the committee that they give serious consideration to including them as well as persons over 65.

With regard to the maternal and child health and crippled children's programs as amended in H.R. 6675, we were pleased to see inclusion of that as well.

However, we would sincerely urge the committee to strengthen the program of services for crippled children substantially more than is provided for within this bill. Specifically we would like to recommend that section 202 of H.R. 6675 be stricken and that the proposed amendment we have attached to our written statement be substituted.

These amendments would do the following: They would change the name of the program from services for crippled children to services for children with physical or mental impairments as a means of more accurately describing the true intent and scope of the program.

They would substantially improve the financing mechanism, so that comprehensive health services for children with all types of impairments could be provided by the States; and they would strengthen the State plan requirements for this program, so there would be an assurance that these comprehensive services would be provided to all types of impaired children.

The term "services for crippled children" we believe has become obsolete. Originally, the program was orthopedically oriented. Over the years it has begun to serve children with other than orthopedic disabilities, but this is still on a very spotty basis. There is extensive variation from State to State.

For example, with regard to eye conditions, only 25 States serve children with congenital cataracts; 16 States serve children for refractive errors; 27 States serve children for strabismus, a condition commonly called crossed eyes which will result in substantial loss of vision in the affected eye if it is not treated earlier; and 31 States serve children for other types of eye diseases. These figures I am quoting from are 1962 statistics prepared by the Children's Bureau, and they are the most recent available to us.

If we were to analyze State-by-State figures for these same four categories, we could find even more extensive variation in detail.

For example, in some States there will be one or two children treated for some of these conditions. In other States there will be several hundred. So we know that the children in States that only treat a few or none at all do not neglect, so to speak, the children because they do not exist but for other factors; namely, the limiting definition of the term "crippled," which even to professional people still means orthopedic disability, as well as lack of adequate financing for the program.

I have taken the liberty in my original statement of extracting tables from the Children's Bureau statistics of States from which the members of the committee come to illustrate this point. In most of the States services are very low to these children, with the exception of Kentucky and New Mexico.

The financing amendment we are proposing would finance this program in a way comparable to the public assistance titles under the Social Security Act, and it is actually virtually identical to the proposed title XIX financing method for the medical assistance program.

It would provide for a variable formula based on per capita income which would assure the highest per capita income States of 50-percent financing and the lowest States of 83-percent financing.

I would like to emphasize, too, that not only are vision problems a serious area of neglect here, but the same is true of cerebral palsy, impaired hearing, and other disabling conditions. This program is príncipally a preventive program, one designed to prevent disability as well as one designed to mitigate the disabling effects of some of these conditions.

With regard to eye disabilities, there are certain eye conditions. which, if not treated in early childhood, will result in substantial loss of vision virtually to the point of blindness in the affected eyes. Ophthalmologists say that the optimum age for catching some of these conditions and treating them to prevent the disability of blindness is between 8 months and 4 years.

Congenital glaucoma, for example, could be arrested in early childhood and spare children from going through life as blind persons, having to be educated as blind persons, training under the vocational rehabilitation program, and being assisted to find employment as well.

In effect most of these are federally assisted programs; and even though the mechanism of financing we are suggesting here would appear to be initially expensive, in the long run, aside from the humanitarian values, it would actually be more economical by saving money in these other federally assisted programs.

As far as the changes we would recommend in the State plan provisions are concerned, one of these would be to require that the program be in effect in all political subdivisions of a State. This is not now the case. Another would be that the State agency serving blind persons be authorized to administer that part of the State plan affecting vision disability and that the State mental health agency be authorized to administer that part of the State plan affecting mental or emotional problems. And then perhaps one of the most important would require that the State plan include a priority system to give top priority to treatment of conditions which can prevent serious disability if treated and to disabling conditions which can be mitigated if treated early.

We believe this program is just too important to be underfinanced as it has been historically.

We would hope that the committee would accept the amendments we are proposing. They have the support, incidentally, of the six major national organizations of and for the blind in this country. In addition to the American Foundation for the Blind and American Association of Workers for the Blind, they are supported by the American Association of Instructors of the Blind, the American Council of the Blind, the Blinded Veterans' Association, and the National Federation of the Blind.

With regard to the title III provisions of the bill, we would like to recommend to the committee that they include the provisions of S. 1787 as an amendment to title III of H.Ř. 6675.

As you know, these provisions were passed by the Senate during the last Congress in the social security bill that died in conference. The effect would be to permit blind persons with at least six quarters of coverage to continue receiving disability insurance cash benefits without regard to ability to engage in substantial gainful activity.

This last phrase is part of the current definition of "disability." It is administered in a way that varies considerably from State to State so that ability to engage in substantial gainful activity could