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service rendered to the indigent and medically indigent and in the quality of medical education. One of the hallmarks of American medicine has been the blend of services and teaching and this continues to be one of our primary concerns.

The Committee recognizes that these guides may well undergo change on the basis of future experience, but believes they are basically sound and will be of assistance to state and county medical society committees concerned with this problem.

ELMER HESS, M.D., Chairman
Council on Medical Service
H. B. MULHOLLAND, M.D., Chairman
Committee on Indigent Care

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Reprinted, with additions, from The Journal of the American Medical

Association, May 10, 1952, Vol. 149, pp. 188-189

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A little over a year ago the Committee on Indigent Care of the Council on Medical Service undertook two projects. The first was a general survey of the status of medical care programs for the indigent and medically indigent in the United States. The second consisted of specific studies of a limited number of state and local programs.

GENERAL SURVEY The purpose of the general survey was to provide the committee with an over-all view of the various types of medical care programs now in operation, to show something of the variations in approaches to this problem, and to discover to what extent medical societies officially participate in such programs.

Questionnaires were sent to all state medical associations and to 125 local medical societies. A summary of such programs in the 48 states reveals that in 31 states the medical care of the indigent is a county, municipality, or township responsibility and that 14 states have what might be considered statewide programs. Most of these, however, are administered locally.

The survey indicates that there are few organized medical care programs for the indigent and medically indigent. State governments generally limit their efforts in this field to defining indigency, to authorizing local governmental units to care for the indigent, and to participating in financing the care of special public assistance groups. Despite the increased emphasis on so-called social security, the free services of family physicians and of hospital staff members are still the principal source of medical care for this group of persons.

Hospital care is generally available to both the indigent and the medically indigent in government hospitals, in hospitals affiliated with teaching centers and, of course, in many private hospitals. Surgery and in-hospital medical care are equally available, with physicians usually giving freely of their services as staff members. Little effort seems to be made to allow a free choice of physician.

1. Committee members: Drs. H. B. Mulholland, Chairman, Charlottesville, Va.; A. J. Bowles, Seattle; B. P. Coleman, Canton, I.; J. H. Howard, Bridgeport, Conn.; E. A. Ockuly, Toledo, Ohio; Dean W. Roberts, Baltimore; and Roscoe C. Webb, Minneapolis.

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Specialists' services are generally available to the indigent, and to a lesser degree to the medically indigent, in outpatient clinics of many hospitals and in special clinics operated by health departments. Here, again, there is little free choice of physician, with the physicians providing their services gratis or at a small retainer or hourly rate.

Few programs specifically provide home and office care for the indigent. In any event physicians often give their services to individual patients without compensation. Where such programs do exist, it is frequently the medical society that has promoted the idea and is making the program work. A number of county societies contract with the county officials for the services of the society members; others provide a panel of names from which the client may select a physician. Several societies administer the entire program; others act only in an advisory capacity.

From the data collected to date it is evident that medical societies, both state and county, must interest themselves in this problem. Adequate home and office care programs have been developed only where the medical societies have actively participated in the planning and operation.

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THE SPECIFIC STUDIES On completion of the general survey the committee undertook a series of specific studies of various types of indigent medical care programs. For this purpose 12 communities and 4 states have been selected, each with a different kind of program. The primary interests of the committee are the types and number of medical services available to indigent persons and the degree of physician participation in such programs. Consequently, the studies have been directed toward obtaining information and data that will enable the committee to evaluate the programs and to make recommendations as to medical society participation.

The studies are concerned with two general groups of persons: (1) those on general assistance programs, including the relief and medically indigent, and (2) those on public assistance programs, including the old age pensioners, the dependent children, the blind, and the permanently and totally disabled.

General Assistance. -Although social welfare laws differ greatly from state to state, the development of these laws seems to have a common background. They were developed to provide the basic necessities of life to persons not able to support themselves. These persons are referred to by a variety of terms, such as general assistance cases, relief cases, or just the indigent. Few state or city laws demanded the inclusion of medical care in the subsistence benefits for this group, and it has been through "interpretation" that medical service has become and is now generally included as one of the basic necessities.

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Along with this provision of subsistence and medical care for relief cases it became apparent that many persons could maintain themselves as long as no sickness developed in the family. In other words, these persons could provide the basic necessities for their own subsistence, with the exception of medical care, and are known as the "medically indigent." These two groups comprise the general assistance cases and are accepted as the responsibility of local governments.

Public Assistance.-Over the years a number of states created special programs to meet the needs of particular groups such as the blind, the aged, and children. These special programs were given impetus by the federal government in 1935 through the Social Security Act. This act created three categories for which federal funds would be available to states, provided the states complied with such federal regulations as were set forth. The three categories or groups are: old age assistance, aid to dependent children, and aid to the blind. In 1950 a fourth group was added under the title, aid to the permanently and totally disabled. Persons who fall within these four groups or categories are referred to as public assistance cases, as opposed to the relief or general assistance cases. The costs of public assistance are shared by the local, state, and federal governments, while costs of general assistance are local or local-state shared.

Old age assistance can be granted to persons 65 years of age or older who are in need. The amount they receive and the determination of a person's eligibility rests with the state as it does in all the categories. Aid to Dependent Children provides aid to children under 16 years of age or up to 18 years of age, if they are in school. These are children who are orphaned or otherwise lose parental support and are living with relatives or legal guardians. Funds are granted to the guardians of these children. To receive assistance under the aid of the blind category, a person must have not better than 10% of normal vision corrected. This is the smallest category numerically. The permanently and totally disabled category provides aid for those who cannot support themselves because of physical incapabilities that are permanent in nature.

The federal share for old age assistance, aid to the blind, and permanently and totally disabled is four-fifths of the first $25 of the state's average monthly payment, plus one-half of the remainder, with a maximum of $55 on each category. This means a state would be reimbursed $35 from the federal government for a $55 allotment check to persons receiving old age assistance or aid to the blind, or to permanently and totally disabled clients. Administrative costs are shared equally by state and federal governments.

In aid to dependent children cases, the federal government will share four-fifths of the first $15 and one-half of the remainder, with a maximum of $30 per first child per month. A $21 maximum is imposed on subsequent children in the same family and $30 for the relative with whom the children are living. Administrative costs are also shared equally by state and federal governments for this category. The present provisions for federal matching funds were established by 1952 amendments to the Social Security Act and are effective for the two-year period from October, 1952, through September, 1954.*

A major change made in social security administration by the 1950 amendment involves the method of payment for services. Originally, no federal funds could be used to pay physicians or hospitals directly for care of persons on one of the public assistance programs. All federal monies had to be paid to the public assistance client. At present, however, the states may pay the vendor of medical service directly and still receive federal matching.

In review, the four categories receiving aid with federal monetary support are old age assistance (O. A. A.), aid to dependent children (A. D. C.), aid to the blind (A. B.), and aid to the permanently and totally disabled (P. T. D.). These four groups make up the public assistance categorical cases. The two groups supported primarily from local funds are the relief and medically indigent cases and are to be termed general assistance cases. These terms and abbreviations will be used in the reports on indigent programs reported on here and in subsequent issues of THE JOURNAL.

The original version of this Introduction appeared in THE JOURNAL before the present maximums became effective; figures have been corrected.

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