Custodial care is not medical care. To hide sick elderly people away in institutions which cannot possibly be providing the skilled nursing care they need and to pretend that we have thereby met their medical needs attains the heights of self-deception.

PHYSICIANS' SERVICES

Twenty-eight of the twenty-nine jurisdictions include some kind of services of physicians in their programs, although in three of them (Maine, Puerto Rico, and South Carolina) such care is available only in outpatient clinics, and in two others (District of Columbia and Pennsylvania) only through a "home care" or "home-hospital" program. The exception is Tennessee which does not pay for physicians' services.

Where such services are provided, care rendered in the office, home or outpatient department of a hospital is generally limited in terms of visits or services in a given period. The kinds of conditions for which care will be provided are also often limited. By way of illustration, the coverage of physicians' services in Idaho combines the several elements of restriction and limitation: No provision is made for physicians' services rendered to an MAA eligible who receives care in hospital or in the outpatient department of the hospital; office and/or home calls are covered for acute conditions only-to the extent of two visits per month for both types; one call per month is covered for a recipient who is in a nursing home, and one eye examination is authorized per 6-month period. (No eye care is authorized, however.)

DENTAL CARE

Seventeen of the twenty-nine jurisdictions provide some dental services: Arkansas, California, Connecticut, District of Columbia, Guam, Hawaii, Kentucky, Maryland, Massachusetts, New York, North Dakota, Oklahoma, Puerto Rico, Utah, Virgin Islands, Washington, and West Virginia. Care is frequently provided only for cases of acute infection, and emergencies and the services available are usually restricted to fillings and extractions even though a major health need of the aged is for dentures to replace extracted teeth.

PRESCRIBED DRUGS

Despite the fact that aged persons spend more than twice as much, on the average, for medicines as does the entire population, and despite the fact that almost 25 percent of the per capita health expenditures of aged persons is for drugs, only 19 of the 29 jurisdictions make provision for such costs in their MAA programs:

Louisiana provides drug coverage only for MAA recipients in nursing homes. Washington affords drug benefits only when the prescriptions relate to "acute and emergent" conditions. Maine, Puerto Rico, and South Carolina cover drugs as a part of outpatient clinic care.

In summary then, the benefits available-when available-under the various MAA plans are very definitely not "unlimited." As may also be observed, the various limitations and restrictions (apart from the exclusions) are not determined by the actual needs of the aged person but, in fact, by the available financial resources of each State.

FREEDOM OF CHOICE

The American Medical Association, in a full page advertisement, offered as a major reason for its support of Kerr-Mills:

It preserves the quality of medical care-maintaining the patient's freedom of choice and the doctor's freedom to treat his patients in an individual way.

Actually, the Kerr-Mills legislation contains no provision assuring the recipients of medical care under MAA of freedom to choose a hospital or nursing home or doctor or pharmacist.

In fact, there are explicit and implicit limitations on all three of the AMA premises-"quality of medical care," "patient's freedom of choice," and the "doctor's freedom to treat his patients in an individual way."

Both the "quality of care" and the "patient's freedom of choice" can frequently be affected by the relative willingness of physicians and hospitals to negotiate and accept MAA and OAA paymentswhich are often below the "going" rates.

Some doctors and hospitals, it would appear, occasionally apply their own means tests, which may be stricter than that of the State. In West Virginia, one of the issues between some of the physicians and the State concerned the desire of the doctors to have the right to charge MAA patients a fee in addition to that paid by the State. This approach of some physicians may further deny full "freedom of choice" to the MAA beneficiary. The aged person may be unable to pay a supplemental fee to the physician and consequently feel obliged to seek medical care elsewhere.

Louisiana's Department of Public Welfare reversed previous policy in January 1963 and now permits hospitals to collect the difference between the amount billed and the amount paid by the Welfare Department from the MAA recipient and/or his relatives.

An article in the Detroit News of March 12, 1962, also hints at the problem. The director of the Wayne County Board of Social Welfare, Walter J. Dunne, referring to the MAA payments to physicians and hospitals, which are lower than usual charges, was quoted as saying: Because of this discount, private hospitals would prefer patients with insurance or who can pay themselves. *** Some hospitals are restricting intake in the Kerr-Mills and old-age assistance cases.

Recent contacts with welfare officials in the State of Michigan indicate that the problem of acceptance of welfare allowances by hospitals persists, and is even more acute than previously.

An article with the interesting title of "Socialized Medicine? We've got it in Kerr-Mills" appeared in a recent issue of the magazine Medical Economics (Apr. 22, 1963). The article, written by a Louisiana physician, Dr. Fred A. Marx, has some rather strong

statements concerning the lack of "freedom of choice" in MAA, at least in Louisiana:

1. Free choice of physician.-The welfare department booklet blandly asserts: "All (Kerr-Mills) recipients have free choice of physician." Having paid lip service to medical ethics, however, the bureaucrats then created some practical difficulties that tend to keep that guiding principle from being carried out. Once

a patient chooses a doctor, he's issued a card with the doctor's name on it. As far as that patient is concerned, this is the only doctor whose bill the State will pay. Before switching to another physician, the patient must notify the welfare department and wait for a new card to be processed. The process is clumsy and time consuming. Thus, it discourages free choice.

After dealing in similar fashion with: Freedom to call in specialists, freedom to operate, and free choice of pharmacist, Dr. Marx offers a statement illuminating another interesting aspect of "freedom of choice":

5. Freedom of nonparticipation. About half the doctors in my State choose not to participate in Kerr-Mills.—I'm sure many of them agree that nonparticipation is a hollow freedom. It forces a physician to deny a patient the law's benefits. Moreover, it pits the lone private practitioner against the toughest most tamperproof monopoly going-Government monopoly.

If the doctor can't tolerate the consequences of nonparticipation, his remaining choice is to participate. When he does, he's tied to the State in all Kerr-Mills dealings, just as surely as if he were on the State's payroll. *** [Emphasis supplied.]

Something of a contrast to Dr. Marx' attitude was provided by the Commerce and Industry Association, Inc. of New York in its statement on "freedom of choice" delivered before the Metcalf Committee on November 16, 1962:

Physician's services also are provided for under the existing law. We therefore see no need to provide by legislative action for "free choice of physician at an adequate fee." The best of medical care should be provided, but determination of who is to provide it and what is a reasonable fee for a private physician should be left to the administrators of the program through rules or regulations.

The statements of Dr. Marx and the Commerce and Industry Association, despite the overriding pursuit on the part of the latter of economy and the former of illusion, reflect, in good part, the realities of many MAA plans.

Several of the MAA programs sharply restrict the recipient's choice of hospital or physician. Under such circumstances, the physician's "freedom to treat his patients in an individual way" suffers when his patient must be confined in a particular hospital-in order to qualify for assistance-with which the doctor may not be affiiliated. Such situations make for "fragmented" medical care-there is a lack of continuity of treatment. The physician, in such cases, takes his patient up to the door of the hospital and must then relinquish him to a staff member. Among those jurisdictions which have MAA programs directly restricting the individual's "freedom of choice" are: District of Columbia.-Hospital and clinic care provided only in specified public and voluntary hospitals under contract with the Department of Health. Nursing home care in one public facility only.

Hawaii.-Outpatient care is provided by "government doctors," who also dispense drugs to an extent.

Puerto Rico.-Hospital and outpatient care available only in governmental facilities.

The failure to cover in-hospital physicians' services in many jurisdictions and the use of State, county, or teaching hospitals in others where the MAA plans do not include explicit restrictions requiring the use of house staff physicians, nevertheless means that many of the recipients of MAA must depend upon the services of hospital staffs and clinics. They may well receive their treatment in charity wards. No doctor-patient relationship of an enduring nature and no choice of physician is present under these conditions.

The constructive attitude of the Medical Society of the State of New York toward improving Kerr-Mills MAA was made apparent in previous pages of this report. The society's outline of areas for improvement in terms of the quality of care provided in New York's MAA program, presented to the Metcalf committee on November 16, 1962, included sections pertinent to MAA plans in all of the States:

In only a few counties or cities are welfare medical programs under the direction of full-time and adequately trained medical personnel. In many areas throughout the State the administration of medical care suffers keenly from a lack of sufficient personnel and the adequate training of existing personnel. It is impossible to develop a modern medical care program to meet adequately the needs of welfare recipients without such trained supervision. ***

There has been too great an emphasis in programs for the Medical Assistance to the Aged recipients on a presumed "economy," to the detriment of the principle of continuity of medical care. This lack of continuity results when several physicians are alternately or simultaneously responsible for a patient without proper communication between them about the facts relating to the patient. This means extra and unneeded repetitious diagnostic treatment and laboratory procedures. In the case of extra, unneeded X-ray exposure this could be a significant health hazard. Such duplication materially increases the cost of care, is an inhumane burden for the patient to bear and makes good-quality care difficult to provide. It also acts as a serious deterrent to the participation of our best qualified physicians in welfare medical care programs.

There is no uniform program for insuring high-quality medical care for MAA recipients throughout New York State. In some areas many physicians serving welfare patients do not have an affiliation with an accredited hospital. If physicians are to be kept abreast of the latest medical advances and have the opportunity to work closely with their colleagues, the general guidance, stimulation, and consultation of a well-organized hospital service is recognized as a requirement for modern day medical care. Therefore, when physicians do not have hospital affiliations there should be more careful review of their qualifications and the reason for the lack of affiliation determined. ***

In many areas of the State, professional fees paid for medical care are not commensurate with the value of the services rendered. This acts as a deterrent to the improvement of medical care and the recruitment of the most competent and best trained physicians in the community.

Certainly, the statements above are to the point. Unfortunately, the quality of care envisaged is, as has been pointed out, dependent upon much more liberal financing of MAA programs. Unfortunately, also, most of the States cannot generate the necessary funds-at least at present. Enactment of a social security-financed program of hospital and related benefits would "free," in good part, State funds now spread thinly and inadequately. These funds could then be concentrated on services not covered by the social security program, thereby achieving a program adequate in terms of the extent and quality of medical care services. Our older Americans deserve no less.

INDIVIDUAL VIEWS OF SENATOR GEORGE A. SMATHERS

While I regret the negative tone of this report, I believe it provides valuable information on the operation of the MAA program, its weaknesses, and the needs for its improvement. Unless and until another Federal program is enacted, MAA offers the most practical means available to assist senior citizens with their medical problems. It, therefore, behooves Congress to correct the weakness revealed by this report and make MAA a more effective instrument in achieving this important objective.

GEORGE A. SMATHERS.

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