medicaid, enacted by the Congress, was too liberal? You feel this was

a reasonable proposal?

Dr. CRAIN. That's correct, sir. We do.

Mr. HORTON. Thank you.

Mr. Dowdy. Mr. Adams.

Mr. ADAMS. Nothing.

Mr. Dowdy. Mr. Steiger?

Mr. STEIGER. Yes, Mr. Chairman.

Dr. Crain, is the District of Columbia Medical Society affiliated with the American Medical Association?

Dr. CRAIN. Yes, it is.

Mr. STEIGER. Is this approval of title XIX in general a policy of the American Medical Association?

Dr. CRAIN. Let's say that title XIX in general is approved by the American Medical Association. Now the individual District of Columbia program was not submitted.

Mr. STEIGER. I understand that, sir.

Dr. CRAIN. The overall title XIX, very much so; yes, sir.

Mr. STEIGER. No further questions.

Mr. Dowdy. That's all, Doctor, thank you.

Now, I have several doctors who can come up together.

Dr. Donald Delaney and Dr. Frederic Burke. And Dr. Robert Parrott may come too at this time if he wishes.

STATEMENT OF DR. ROBERT H. PARROTT, DISTRICT OF COLUMBIA HEALTH AND WELFARE COUNCIL

Dr. PARROTT. I have a statement for the District of Columbia Health and Welfare Council. That is an organization of citizens and professional individuals who are concerned with promoting better living conditions for people living in the District.

Mr. Dowdy. Do you want to make it a part of the record?

Dr. PARROTT. I'll abstract from it if it is to be made a part of the record.

Mr. Dowdy. Your full statement will be included at this point. (The full statement of Dr. Parrott follows:)

STATEMENT OF THE DISTRICT OF COLUMBIA HEALTH AND WELFARE COUNCIL

Mr. Chairman and members of the subcommittee, my name is Dr. Robert H. Parrott.

I appear on behalf of the District of Columbia Health and Welfare Council, a voluntary organization made up of concerned citizen volunteers and professional workers who seek to promote better living conditions for people living in the District of Columbia.

Much of the Council's efforts aim at effecting a working partnership between public departments and voluntary agencies to resolve social and health problems which frustrate the individual citizen's capacity and desire to be a contributing force in this community.

The Council comes before this Subcommittee now to urge passage of HR 3972 to enable the District of Columbia to participate in the health and medical assistance benefits made available by the Social Security Amendments of 1965, Public Law 89-97. This Law can make it possible for the District of Columbia to provide comprehensive medical care for all low income families.

We have been studying and evaluating Titles XVIII and XIX of the Social Security Act of 1965 and their meaning for poor families in the District of Columbia. We are impressed by the intent of Congress in this legislation to expand and improve programs of medical assistance for people who cannot afford

and do not receive adequate medical care. From our experience, there are many families in the District whose income can provide the basic necessities of food, shelter and clothing, but who cannot afford needed medical care. Too often, medical care is postponed until hospitalization becomes necessary and the end result is a preventable death, chronic ill health or a lost job or income with the family becoming a burden on the taxpayer in order to survive. Under prevailing conditions both the City hospital and non-profit hospitals are forced to practice emergency health care when illness could be foreshortened. Their emergency rooms have become over-burdened, their authorized budgets taxed-and some hospitals are threatened with financial destruction.

On June 13, 1966, the District of Columbia Health and Welfare Council appeared before the U.S. Senate Committee on the District of Columbia to testify in support of proposed enabling legislation in the previous Congress-S 3469 which is similar to HR 3972.

Again we reiterate that much of the intent of the President and the Congress of the United States can be realized for the people of the District of Columbia shortly after enabling legislation is passed giving the Board of Commissioners the authority to effect a Title XIX program. They need to change the District laws and regulations to conform with Federal standards on such matters as duration of residence, responsibility of relatives for financing medical care. the means tests, liens on personal and real property, payment for medical and hospital care at rates below reasonable costs. The enactment of HR 3972 will permit them to do this and thus to secure health and medical benefits made available by Titles XVIII and XIX of the Social Security Act of 1965.

The District of Columbia Department of Public Health, with advice from citizens, has proposed a Title XIX, Medical Assistance Plan which represents some of the goals established by the District of Columbia Health and Welfare Council for such a plan:

1. Existing health facilities and services would be used, improved and expanded to provide more effective services needed by local residents and to avoid unnecessary development of new facilities which would duplicate those already in existence.

2. A single standard of care would be established for providing medical services. There should not be one facility or program to serve only poor families and another system of facilities to serve other families. Such a dual system, we feel, results in poor quality of care, in unnecessary expense, and in duplication of services.

3. Families would pay, to the extent they could, for the health care they received.

4. People requiring health care could receive care first without delay rather than to determine first who will pay for the care.

5. Health services could be made more accessible for people requiring these services by locating health facilities and services as close as possible to the people who need them.

6. Reimbursement at reasonable costs for actual care rendered by health providers, including contract hospitals, would offer equitable and important support for the community's major health resources.

The District of Columbia Health and Welfare Council therefore strongly supports the enactment of HR 3972. With its Federal hat on, Congress established the basic legislation to bring quality health care to all medically indigent citizens. District citizens and private and public health authorities have written a plan to bring the benefit of that legislation to men, women, infants and children in the District of Columbia who cannot afford and do not receive adequate medical care. Congress, with its District hat on, must let the Commissioners move ahead with this plan. We urge you to pass HR 3972 with dispatch.

SOME QUESTIONS AND ANSWERS REGARDING H.R. 3972, 90TH CONGRESS, 1ST SESSION Question. What is H.R. 3972?

Answer. H.R. 3972 is a Bill which authorizes the Board of Commissioners of the District of Columbia to take such actions as are necessary to permit the District of Columbia to establish and operate a Medicaid Program under title XIX of the Social Security Acts. The actions which the Commissioners may take under the authority of this Bill are limited to those which can be taken within appropriations and allotted funds available to the District of Columbia.

Question. What actions will the Commissioners take to meet the requirements of title XIX?

Answer. There are existing restrictions regarding the use of D.C. funds to pay for medical care which are in conflict with the requirements of title XIX. The most important changes will be:

1. Eliminate the requirement of residency in the District for one year previous to receiving medical care and require only that the persons be residing in the District of Columbia with the intention to remain.

2. Eliminate the responsibility of any persons other than the patient, the patients' spouse, or the parent of a minor child-or of a child who is blind or permanently or totally disabled for the cost of the medical care of a patient. 3. Prohibit the levying of liens against the property of a person for the cost of his medical care if he is properly eligible for care at public expense at the time he receives it.

4. Eliminate the requirement that the Health Department pay an arbitrary contract per-diem rate for medical services and enable, instead, the payment of "responsible cost". (Appropriation authorization, in addition to the enactment of HR 3972, is also necessary for this.)

Question. What is Medicaid?

Answer. Medicaid is a program which provides comprehensive medical care for many of the people who cannot afford to pay all or for some part of the cost of their medical care. (Please refer to the attached "Fact Sheet" for details regarding the D.C. Program.)

Question. Is this just another "Pauper" Program?

Answer: Definitely not! Although it is true that one basic objective is to provide better medical care for the poor, the program has important features that go far beyond this. These include:

1. The D.C. Plan is designed so that the Health Department functions much like an insurance company. The eligible person ("insured") obtains his care from anyone he chooses from among those who are qualified and participating providers of medical care under the plan who are able to provide him with the services he needs. The Health Department pays the bill.

2. People with incomes above the level set for the D.C. Plan are protected against having a medical crisis reduce their finances to an amount less than the D.C. Plan level. This means that a person who is ordinarily able to pay for his own needs could have part of an unusually large medical cost paid by the Health Department.

3. The Plan does not contain durational service limitations such as a limit of 90 days inpatient hospital care.

4. The Plan is designed to insure that the medical care it provides is of good quality. It specifies minimum standards of quality equal to those required by the Social Security Act for the Medicare Health Insurance Program for the Aged.

Question. How were the income eligibility levels for this Medicaid Plan calculated?

Answer. Title XIX requires that income eligibility levels take into consideration "basic maintenance needs." These are defined as needs for food, clothing, shelter, personal care and household necessities. Exhaustive study of available national and local data indicated that persons in the District of Columbia who are in a stratum below the equivalent of $4,780 per year for a family of four cannot meet their basic maintenance needs and costs. The $4,200 level contained in the plan is below the amount needed for these costs because there are not enough D.C. funds available at this time to finance a higher level.

Question. Why are only 217,000 persons covered by the plan while a year ago there were estimates of 334,000 who needed to be covered?

Answer. Available data regarding income levels and family structure are grossly inadequate. By diligent searching, the Health Department has now been able to identify 260,000 as being more accurate than the year-old estimate of 334,000 in the stratum of "family of four-$4,800" persons in the District of Columbia. The 217,000 figure is, of course, the reduced "family of four-$4,200" level.

Question. How do these income levels and numbers of persons covered compare with the present D.C. Medical Assistance Program?

Answer. The present "family of four-$3,360" scale was established in 1946. Approximately 160,000 persons are eligible for medical assistance at public expense under present eligibility requirements. This medical assistance is far short of the comprehensive medical care included in the title XIX plan. An

additional 100,000 persons are being provided with "emergency" care only under the present Health Department program.

Question. What will happen if H.R. 3972 is notapproved?

Answer. Federal funding support for medical care provided to:

aged under Title I ;

families with dependent children under Title IV;

blind under Title X;

disabled under Title XIV;

of the Social Security Act will stop on December 31, 1969. This can mean a substantial reduction in the D.C. Medical Assistance Program unless more D.C. tax dollars are made available.

HEALTH AND WELFARE COUNCIL POSITION ON THE PROPOSED TITLE XIX, MEDICAL ASSISTANCE PLAN FOR THE DISTRICT OF COLUMBIA

The proposed Title XIX Medical Assistance Plan (Public Law 89-97) as developed by the D.C. Department of Public Health appears to offer an opportunity to take an important first step towards making comprehensive medical care available for needy people in the District of Columbia.

The Health and Welfare Council strongly supports the enactment of enabling legislation (HR 3972, introduced in the 90th Congress by Mr. McMillan) to permit the District of Columbia to participate in the Title XIX Program.

This enabling legislation is necessary as a first step because the Plan cannot be implemented and additional health benefits provided for the people of the District of Columbia until the District's laws and regulations on such matters as duration of residence, responsibility of relatives for financing medical care, the means tests, liens on personal and real property, payment for medical and hospital care at rates below reasonable costs are changed.

The Health and Welfare Council of the District of Columbia also supports most of the elements in the Plan as proposed by the District of Columbia Department of Public Health with advice from citizens, because the plan, although containing unrealistically low eligibility levels, is a major step towards making comprehensive medical care available for many more needy people.

The Health and Welfare Council of the District of Columbia believes that a medical assistance plan qualifying under Title XIX of Public Law 89-97 would offer a number of advantages for the District in addition to Federal financial aid. The following criteria represents some of the goals established by the Health and Welfare Council for such a plan:

1. Existing health facilities and services would be used, improved and expanded to provide more effective services needed by local residents and to avoid unecessary development of new facilities which would duplicate those already in existence.

2. A single standard of care would be established for providing medical services. There should not be one facility or program to serve only poor families and another system of facilities to serve other families. Such a dual system, we feel, results in poor quality of care, in unnecessary expense, and in duplication of services.

3. Families would pay, to the extent they could, for the health care they received.

4. People requiring health care could receive care first without delay rather than to determine first who will pay for the care.

5. Health services could be made more accessible for people requiring these services by locating health facilities and services as close as possible to the people who need them.

6. Reimbursement at reasonable costs for actual care rendered by health providers, including contract hospitals, would offer equitable and important support for the community's major health resources.

The initial yearly income eligibility standard stipulated in the Plan ($4200 per year for a family of four persons) does not, however, realistically reflect basic maintenance needs for such a family in the District of Columbia. Basic maintenance include the needs of the family for food, clothing, shelter, personal care and household necessities. It has been estimated that it would cost approximately $4800 per year to meet the basic maintenance needs of a family of four in the District of Columbia in 1967. The District's plan proposes to reach this level by stages.

The Health and Welfare Council of the District of Columbia feels that the' District should aim at establishing eligibility requirements intended to meet the needs of the people and should provide a sufficient matching budget to fund such needs.

If this does not become a goal there will continue to be a lag between needs of medically indigent families and health services for them.

Dr. PARROTT. I think one of the main goals of the Health and Welfare Council is to seek a working partnership between the public and private sectors to cope with both social and health problems that frustrate the individual's capacity and desire to be a contributing force.

The Council is here now to urge passage of H.R. 3972. We think it is possible with the passage of this enabling legislation, to put the District of Columbia in a position of having a comprehensive medical care plan for all of its citizens.

In studying titles XVIII and XIX of Public Law 89-97, we were impressed by the intent of Congress and in fact by the number of votes by the members of the subcommittee to expand and approve programs of medical assistance for people who cannot afford and do not receive adequate medical care. From our experience there are many families in the District that fit these criteria. They sometimes can provide basic necessities but they cannot afford particularly catastrophic medical care, but often even routine medical care.

As a result of their not being able to afford it, or not being eligible for assistance under current programs, medical care is often postponed until there is a crisis, an emergency, and the end result is the death which could have been prevented, chronic ill health or a lost job or income, and in some instances the fact that the family becomes a burden on the taxpayer in order to survive.

Under prevailing conditions both the city hospital and many of the nonprofit hospitals are forced to practice emergency health care when illness could be foreshortened. Their emergency rooms become overburdened, their authorized budgets taxed, and some hospitals are threatened with financial destruction as a result of providing health care to people who cannot afford it.

We feel that much of the intent of the President and the Congress can be realized for the people of the District shortly after you pass this enabling legislation. The plan which has been elaborated and discussed this morning meets the criteria which the Health and Welfare Council established for such a plan. The criteria are such that existing health facilities and services would be used, and where indicated, would be expanded to meet the people's needs."

Secondly, there would be a single standard of care established for providing medical services.

Thirdly, families would expect to pay to the extent that they could, for the health care they received.

Fourthly, people requiring health care could receive the care first without delay, rather than determine first who would pay for it.

Fifth, health services could be made more accessible for people requiring these services by locating health facilities and services as close as possible to the people.

Sixth, and very important from the point of view of the institutions and agencies represented in the Health and Welfare Council, is that reimbursement at reasonable costs for actual care rendered by