Commission on the Adult of State Needs, the newly developed study of the U.S. Senate, and the projected 1961 White House Conference on the Aging have been and will be more comprehensive and directed to the totality of the problem, the economics involved, plus specific procedural steps of a constructive character that must be taken to forthrightly meet and treat with all problems besetting aged people. There is no disagreement that certain of these remedial and corrective plans and programs should originate and in substantive measure be supported by local administration and the consolidation and use of all local resources both voluntary and tax supported. Others such as an economic floor for the basic maintenance of aged people in dignity and with decency, whether through the employment or retirement plans or the guarantee of adequate public assistance programs, require and demand the initiative, administrative leadership, and forceful implementation of the National Government.

The great Congress of the United States of which your honorable committee is such a cogent, wise, and prudent voice, with the enactment of the Social Security Act, formally declared in 1935 that the economic problems of people of America were of national concern and by corollary demanded national action. The Congress of that time, and seven subsequent Congresses, particularized the economic problems of the aged people of America by the original creation of titles I and II, respectively the old age assistance title and the old age insurance title of the Social Security Act. It is not without significance that these are the first two titles of this great and inspirational American Magna Carta for the American workingman and his family.

Indeed, it is not unreasonable to attribute the subsequent congressional improvements to the basic titles of the Social Security Act to many of the conclusions warranted by the many scientific studies of the problems of the aging.

Throughout this quarter century of progress, Congress has both prudently and with commendable foresight emphasized the high desirability of self-contributory insurance against the economic threat of old age. It has repeatedly extended coverage to uncovered groups of workers, broadened both tax and wage base, increased monthly benefits. Other improvements specifically directed to the economics of aging and improving the insurance title, and with which your committee is quite familiar have also been legislated into law.

The lion's share of this progress has been initiated in this committee or by your predecessors on this committee. You both individually and collectively are to be commended and the country at large to be congratulated on your continuing interest, research, and action with respect to this most challenging of all social problems facing America. In more recent years your committee has focused its attention and efforts on a specific phase of the economics of everyday life for the average, solid, decent American breadwinner and his family. The creation of both the disability insurance and assistance titles of the Social Security Act, the specific recognition of the major role medical care plays in the daily economic life of the needy by your medical care amendments of 1950, 1956, and 1958 give evidence that this fearsome, threatening shadow of the future, medical need and medical cost, have been of concern to Congress and specially the concern of your committee.

Over the years, a multiplicity of legislative proposals to meet this catastrophic threat to the unproductive years of our growing millions of decent, God-fearing, aged Americans have been presented to the Congress. None have been enacted to date. During my more than 26 years as a city, county, and State executive of public welfare programs, I have never observed and never known of the widespread interest, enthusiasm, support, and acclaim that H.R. 4700 has evoked. On this score, Mr. Chairman, I would like to offer for the record a resolution passed by the Association of Massachusetts Public Welfare Local Administrators on April 2, 1959, at which 196 out of 240 present on that date unanimously endorsed by resolution H.R. 4700, and I will offer that for the record.

The CHAIRMAN. Without objection, it will be received. (The material referred to follows:)

RESOLUTION

Whereas the legislative committee on Federal legislation has reported favorably on the intent of old age insurance hospitalization as contained in H.R. 4700, Mr. O'Neill, director of the Worcester City Welfare Department, introduced the following resolution:

"Be it resolved, That the Public Welfare Administrators Association of Massachusetts go on record strongly endorsing Federal legislation known as H.R. 4700, a bill to provide hospital, medical, surgical, and convalescent services to recip ients of old age and survivors insurance: And be it further

"Resolved, That this resolution be forwarded to the State Commissioner of Public Welfare, Patrick A. Tompkins, for presentation to the Congress of the United States."

The motion was seconded by Mr. Salvatore Abate of the city of Everett and was unanimously passed by the membership present.

The above motion was offered at the regular monthly meeting of the abovenamed association on April 2, 1959, and was attended by 196 of 240 duly enrolled members from the cities and towns of the Commonwealth of Massachusetts.

Mr. TOMPKINS. Although I have access to many professional bulletins and pamphlets, to reports of substantial and responsible committees of the aging, to many alternative proposals for financing medical care, I have not heard or read one forthright, or for that matter, even one thinly veiled suggestion that H.R. 4700 is not good medical care. To the contrary. The medical proposals in Congressman Forand's legislation seem to cross all the "t's" and dot all the "i's" of the philosophy of purchase of medical care as currently set forth by the American Medical Association and Massachusetts State Medical Societies.

The proposal provides for free choice of physician which in substance means that professional medical services begin with the general practitioner and then proceed on professional referral to the specialists, the hospital, the nursing or convalescent home and allied professional services such as nursing, therapy, and medication. Any declarative statement, implication, or innuendo that such medical procedures, fortified by Federal law constitute socialized medicine must, therefore, spring from ignorance of the facts, lack of kindly or charitable instincts, lack of knowledge of the scope and magnitude of both the problem and the legislation, blind opposition to social change, acceptance of the status quo, or a combination of these lacks of virtue. The method of payment is no different from methods presently employed by many units of Federal, State, and local government, including the Veterans' Administration.

As a veteran, I endorse and support the progressive and forthright medical care programs for veterans; but no veteran, whether he served several years in active combat or a short period stateside, would argue that our aging American deserves less than equal guarantees for adequate medical, surgical, hospital, and nursing home care after over 65 years of productive effort to the growth and greatness of our America.

In Massachusetts alone the percentage of the old-age assistance dollar spent for medical services has risen in 10 years from 8 percent to 37 percent and is still rising. The percentage of old age cases receiving old-age assistance for medical services only has risen from 0.1 percent in May 1953 to 1.1 percent in May 1959-an increase of 1,100 percent.

Since 1947, the cost of living in Massachusetts has officially risen 25.7 percent, but the cost of general medical services to all the population, including medication and hospital services, has more than doubled, and for the aged American because of debilitation of advanced age, the prolonged nature of diseases more common to the aged, the more frequent use of drugs, and the need for custodial medical care, it has virtually quadrupled.

Massachusetts, in old-age assistance alone, is spending for care in approved hospitals or nursing homes $22 million per year. An additional $15 million is being spent on doctors' fees, drugs, prosthetic appliances, dental and eye services, and bedside nursing care. Since 46 percent of our old-age assistance caseload receives basic monthly old-age and survivors insurance benefits to begin with and since it is the philosophy both of Congress and the American Public Welfare Association to provide for the aged by insurance programs, it is fairly evident that the insurance and medical features of H.R. 4700 would represent an important economic stride in that direction.

The Commonwealth of Massachusetts is justly proud of its comprehensive and adequate guarantees of all medical and ancillary medical services for the needy poor including both recipients of old-age assistance and those aged retired who cannot, out of retirement grants, finance essential and costly medical services.

We have explored for over 10 years group health insurance possibilities for the old-age assistance recipients. Either the premium price. was prohibitive or the per diem indemnity for hospital service falls far short of meeting the per diem hospital charges. We are now convinced that a health insurance plan for the aged should not at any time ever be considered for recipients of public assistance alone. The report of the Department of Health, Education, and Welfare on the subject of hospital insurance for OASDI beneficiaries, as submitted to this committee on April 3, 1959, further suggests, even though it does not recommend, that hospital, surgical, medical, and nursing home benefits be added to the present insurance benefits.

In several findings, this report indicates either the lack of funds on the part of beneficiaries and other aged to purchase health insurance or the inadequacies of benefits in available policies from voluntary nonprofit insurers or from commercial insurers.

Virtually every major research project on the aging and every responsible study of the major problems of aging emphasize the costliness of medical and hospital services for the aged as a group and

the inability of the aged, out of retirement income or savings, to finance such medical and hospital care.

The objective of title II of the Social Security Act is to provide economic protection for the aged for basic necessities to a decent, dignified way of life. Twenty-five years ago, in large measure, this represented food, shelter, clothing, public utilities, attendance at church, normal and reasonable reading opportunities, and social activities within the home and within the community. Today, for the aged, it must include adequate medical protective care and all its allied professional services, such as hospital and nursing home services. As I have earlier indicated, a very large percentage of the old-age assistance caseload in Massachusetts currently receives old-age insurance and that an alarming percentage of our old-age assistance expenditures are for medical services alone. What is not generally appreciated is that, for the medical only case of an insured beneficiary, almost as much money is spent administratively in the determination of old-age assistance medical eligibility as is spent for one single hospital bill.

This is understandable when it is realized that accountability of the expenditures of public funds is written into Federal and State laws requiring a full and thorough investigation, the maintenance of adequate records, a thorough checking of potential or actual resources available to an otherwise self-supporting aged person.

Apart from these added administrative expenses in the public assistance program for this determination of eligibility, it does not seem prudent to permit this administrative cost to pyramid, to defer a self-supported program for medical care, to deprive our great public hospitals of proper payment of the cost of services in States which do not employ as comprehensive a medical care program in public welfare services as do some States such as Massachusetts, New York, Illinois, Wisconsin, and Rhode Island, nor should the aged individual who has thought himself adequately cared for through the beneficiary program be compelled to seek public relief for medical needs.

Even more important than the foregoing, H.R. 4700 represents a victory over the most growing destructive, degenerating evil experienced by any man or woman; victory over fear. Fear of pain unrelieved, fear of loneliness and rejection by society because of helpless invalidism, due to advanced age alone and to the sin or the virtue of growing old; fear of being unwanted, fear of being an anchor and a hindrance to one's children and grandchildren, fear of the charity ward and its too frequently impersonal, aloof, cold and unfriendly atmosphere, fear of becoming a statistic both in life and in death, fear of physical and mental torment alike, but most of all, fear of loss of intrinsic dignity, graciously and eternally given to man by God and richly and deservedly earned by all aged during their trial on earth.

More than the assured solvency of our voluntary and municipal hospitals and nursing homes, more than a strengthening of our free enterprise system in the purchase of drugs, glasses, and prosthetic appliances, more than the maintenance of the proper economic status of doctors, dentists, nurses, optometrists, and other professional medical practitioners by a reasonable fee for service payment, more than the guaranteed medical and surgical services of an insurance

plan, H.R. 4700 becomes a burning flame of hope, a symbol of faith, and living testament to all men in all countries that in America, so blessed and so enriched by the Almighty, men never need live in fear of anything, and least of all, in fear of growing old.

Thank you very much.

The CHAIRMAN. Thank you, Mr. Tompkins, for bringing to us these views of yours on H.R. 4700.

Are there any questions?

Mr. FORAND. Mr. Chairman.

The CHAIRMAN. Mr. Forand.

Mr. FORAND. I don't have a question but I do want to compliment Mr. Tompkins for his statement. I think it is one of the most enlightening we have received during these hearings, and, of course, I am not surprised because I have known Mr. Tompkins and of his fine work in the welfare field for many years.

Mr. Tompkins, I commend you.

Mr. TOMPKINS. Thank you very much, sir.

The CHAIRMAN. Thank you very much. Mr. Alger.

Mr. ALGER. Mr. Tompkins, I want to make light of a statement on the top of page 4 where you say something about "thinly veiled suggestion that H.R. 4700 is not good medical care." I assure you if you had been here you would have heard suggestions that were anything but thinly veiled.

Mr. TOMPKINS. I have been here and I haven't heard any of the objectors indicate that this was not good medical care and I think that is what I said.

Mr. ALGER. Maybe I did misunderstand you, but I had the impression that there were very strong positions given that this would not result at all in good medical care, so my remark was actually toward the "thinly veiled." I have the pretty definite opinion that the AMA; for example, is very much opposed to this II.R. 4700 as good medical

care.

Mr. TOMPKINS. I heard one witness this morning who indicated that Government insurance medical care programs contributed to a degeneration of medical services, and I don't know what authority or what references he uses, but I believe he was a doctor and it would appear to me that this is an indictment of the medical profession and not an indictment of anything else.

Mr. ALGER. I would like to pursue that with you, Mr. Tompkins. However, I think we are off the subject and I am going to limit my remarks, much as I would like to engage in this exchange on that thought, what you say later in the statement, or which I am constrained to express myself because of the very strong feelings I have, and possibly get further clarification from you where you point out that

any declarative statement, implication or innuendo that such medical procedures, fortified by Federal laws constitute socialized medicine.

You obviously do not feel that H.R. 4700 has that implication, that it would be socialized medicine; is that not correct?

Mr. TOMPKINS. That is correct. I think it has adequate safeguards to keep it completely out of any reference to socialized medicine. Mr. ALGER. I respect your right to that viewpoint, Mr. Tompkins. Here is my fear, and I want to state it to you and see if you have any