"(b) For the purposes of this section, 'resident of the District of Columbia' means a person who has maintained his principal place of abode in the District of Columbia for more than one year immediately prior to the filing of the petition referred to in subsection (a) of section 21-541."

Section 21-586 (a) of the District of Columbia Code provides in part as follows:

"(a) The father, mother, husband, wife, and adult children of a mentally ill person, if of sufficient ability, and the estate of the mentally ill person, if the estate is sufficient for the purpose, shall pay the cost to the District of Columbia of the mentally ill person's maintenance, including treatment, in a hospital in which the person is hospitalized under this chapter. The Commission on Mental Health shall examine, under oath, the father, mother, husband, wife, and adult children of an alleged mentally ill person whenever those relatives live within the District of Columbia, and ascertain their ability or the ability of the estate to maintain or contribute toward the maintenance of the mentally ill person. . . ." No conclusive decision has yet been made on the question of whether the District will qualify as a provider of services under title XVIII or will furnish medical assistance under title XIX to persons 65 years of age or older who are patients in mental institutions. Should it be determined, however, that the District is eligible to provide such services or furnish such assistance, no durational residence requirement may be imposed upon the recipients thereof, and only certain specified relatives may be held responsible for the costs of hospitalization of such mentally ill persons. The Commissioners therefore are authorized by the bill to make regulations overcoming the effect of these conflicting provisions of District law.

5. Under section 2 of the District of Columbia Public Assistance Act of 1962 (76 Stat. 914; D.C. Code, sec. 3-201), "the term 'public assistance' means payment in or by money, medical care, remedial care, goods or services to, or for the benefit of, needy persons". Should the bill be enacted into law, assistance in the form of medical care or remedial care furnished to needy persons by the District will no longer be subject to the provisions of the District of Columbia Public Assistance Act of 1962, but such care will be governed by regulations issued by the Commissioners in accordance with applicable requirements of title XIX of the Social Security Act.

In any event, Federal sharing in medical aid or assistance under title I (oldage assistance and medical assistance for the aged), title IV (aid to families with dependent children), title X (aid to the blind), title XIV (aid to the permanently and totally disabled), and title XVI (the combined adult program), will, pursuant to section 121 (b) of the Social Security Amendments of 1965, terminate with respect to any period after December 31, 1969. The District therefore must have authority to participate in title XIX on or before such date, or be placed in the position of having to provide medical care to its indigent and medically needy residents without Federal assistance.

The Commissioners presently intend, if the proposed legislation be enacted, to proceed with the implementation of the District's title XIX medical assistance program by establishing the initial financial eligibility level for participation therein at an annual income of $4,200 for a family of four (adjusted to different figures for family groups of other composition and for individuals). With the eligibility level fixed at this amount, an estimated 217,300 persons in the District of Columbia would potentially be eligible for participation in the District's title XIX program-almost 57,000 more than those currently eligible for medical care under the existing programs administered by the Department of Public Health. With a financial eligibility level of $4,200 for a family of four, a title XIX program could be instituted at no current additional cost to the District, and the level of its expenditures for medical care would remain at the amount presently budgeted for fiscal year 1967 of $30.7 million. The total Federal reimbursement to the District under such a program would be approximately $10.6 million. Under the existing Kerr-Mills program (which would be absorbed into the proposed title XIX program) the Federal Government during fiscal year 1966 contributed $2,250.000 to the District. Accordingly, the net additional cost to the Federal Government of the anticipated program for the District would amount to an estimated $8.4 million.

The District's expenditures for a program of the scope just described, taken together with the Federal reimbursement, would enable the Department of Public Health to develop for the approximately 217,300 persons a comprehensive medical care program which would meet the requirements of title XIX of the

Social Security Act, and include inpatient and outpatient care, visits to a physician, surgical procedures, diagnostic services of every variety, skilled nursing home care, home health services, psychiatric care (both inpatient and outpatient), tuberculosis care, the furnishing of drugs, biologicals, prostheses, and other supplies, and the provision of dental, optometric, and podiatric services.

It is the Commissioners' expectation, however, that the District will have sufficient appropriated funds to enable it to raise the financial eligibility standard for a family of four to a figure of $4,780 over a three-year period, and that the initially established level of $4,200 will remain in effect no longer than the end of fiscal year 1968. Accordingly, the Commissioners propose raising the eligibility level to $4,400 for a family of four in fiscal year 1969, to $4,600 in fiscal year 1970, and to $4,786 in fiscal year 1971, dependent, of course, upon the availability of District funds in those years. The progressive changes in the eligibility standard would, of course, be subject to annual review by the Congress during its consideration of the District's appropriation bill.

With an eligibility level set at the recommended $4,780 figure, approximately 258,400 persons in the District ultimately would be eligible for benefits under title XIX medical programs. The total cost of a program of this extent would be approximately $48.5 million, of which the District would have to bear $36.2 million, or about $5.5 million more than is currently budgeted. The Federal reimbursement to the District under such a program would be approximately $12.3 million, and the net increase in Federal reimbursements (excluding contributions under the present Kerr-Mills program) is estimated at $10.1 million.

(See also exchange of correspondence between the Chairman and the Commissioners at p. 23.)

Mr. DOWDY. We are happy to have Commissioner John B. Duncan as our first witness.

STATEMENT OF HON. JOHN B. DUNCAN, D.C. COMMISSIONER, ACCOMPANIED BY DR. MURRAY GRANT, DIRECTOR, DEPARTMENT OF PUBLIC HEALTH, AND WILLIAM A. ROBINSON, ASSISTANT CORPORATION COUNSEL

Commissioner DUNCAN. Thank you, Mr. Chairman. I would like to introduce Dr. Murray Grant, Director, D.C. Department of Public Health, to my left, and Mr. William A. Robinson, Assistant Corporation Counsel, to my right.

I appreciate this opportunity to appear before you this morning, and I might add that the Government officials with me are directly involved with the proposed legislation. They will assist in providing you with any necessary information.

As the Commissioner with supervisory responsibility for health matters, I would find it difficult to overemphasize my support for the medical-care measure that is before this Subcommittee.

This legislation offers a great potential for brightening the lives of a sizeable percentage of Washington's residents, both today and in the years ahead. These are the aged and the needy who stand to benefit most by the enactment of this legislation.

This bill before you, Mr. Chairman, would allow the District of Columbia to strengthen and expand its health services under the provisions of the 1965 "Medicare" Act. In other words, we are not asking for special treatment, but instead are simply seeking authority to do here what Congress already has approved for the rest of the Nation.

Our proposed legislation would clear the way for the District to provide substantially improved health services through the liberalized

qualification standards and procedures authorized under Titles XVIII and XIX of the 1965 Amendments to the Social Security Act.

As members of this Subcommittee know, Title XVIII authorized a new hospital insurance program for the aged, supplemented by a voluntary insurance benefits program. Title XIX provided a comprehensive medical assistance program for the needy.

More specifically, the pending bill would nullify requirements in several of the District's existing laws that are in direct conflict with Federal qualification standards for full participation in these medical programs. The requirements that must be amended include provisions dealing with residency, means tests, and responsibility of relatives of the medically needy.

A detailed explanation of this aspect of the proposed legislation is included in the report that has been submitted to your Committee by the Honorable Walter N. Tobriner, President of the Board of Commissioners, D.C., which you have made a part of the record.

H.R. 3972 also would authorize the Commissioners to adopt regulations needed to carry out the expanded health and medical assistance programs. This would relate, for example, to those who would be eligible for the health benefits under the Commissioners' proposed legislation, or to the matter of cost to the taxpayer, as another example. The Commissioners' plan is to set financial eligibility levels for the Title XIX program benefits that would be raised each year during a three-year period.

As an example, the maximum annual income for a family of four initially would be $4,200. We estimate that 217,300 persons in the city would be eligible. This figure is about 57,000 higher than the total now eligible for medical care under the Department of Public Health's existing programs.

Mr. Chairman, I might add no additional District funds would be needed to finance this expanded program at that level. The Federal contribution for the current Kerr-Mills Medical Program, which would be absorbed under the Title XIX program, amounts to $2,250,000. If the proposed legislation is approved, an additional first-year cost of about $8.4 million will be met by the Federal Government.

The estimated 217,300 persons eligible under the $4,200 eligibility level would be offered a comprehensive, in-patient and out-patient care program.

Under the plan approved by the Commissioners, the eligibility cutoff figure for a family of four would be lifted to $4,400 in fiscal 1969, to $4,600 the next year, and then to $4,780 in fiscal year 1971. This plan is, of course, subject to both revenue availability and approval by the Congress through its action on the city's appropriations measures from time to time.

At the $4,780 level, about 258,000 would be eligible for the benefits. The total cost of the Title XIX program would be about $48.5 million. The District's contribution would be $36.2 million, with $12.3 million balance coming from Federal funds. I sincerely believe, Mr. Chairman, as I am sure the various States will agree, that this investment in better health for the needy would be money well spent.

In conclusion, let me say, the Commissioners thank this Subcommittee for its interest in this vital health care problem, and for the opportunity to offer testimony in support of H.R. 3972.

Enactment of this legislation would, the Commissioners believe, constitute a genuine public service to this city. Therefore, we urge this Subcommittee to act swiftly and favorably on this most urgently needed legislation.

I thank you, very much, Mr. Chairman and Members of this Committee for this opportunity to testify and I am sure you know that Dr. Grant would also like to make a statement concerning this Bill.

Mr. Dowdy. Thank you, Commissioner Duncan. Of course, as I understand it, the District of Columbia-if this legislation is not enacted-loses all the benefits, I suppose, of the Federal programwhen is it? The first of January, 1969?

Dr. GRANT. Public Law 89-97 says December 31, 1969.

Mr. DOWDY. December 31, 1969. It is a year later than I thought it was. We have two and a half years to go, when some legislation

should be passed.

The Commissioner's statement is that 40 percent of the D.C. population is eligible for medical care and services in this, the highest income area in the nation. It must be higher in other areas.

Dr. GRANT. Mr. Chairman, may I say, I don't think it is necessarily true that it would be higher elsewhere, because when one looks at the per capita income, obviously, one is equalizing the high with the low; but the situation is exactly as you have cited it.

We estimate that about 260,000 people are looking to the Department of Public Health in the District of Columbia for their medical care and health services at the present time.

Mr. DOWDY. You don't look for that percentage to decrease at all? Dr. GRANT. It has not, Mr. Chairman. When we look back over the past few years, as a matter of fact, it has tended to increase. No one knows of course, what will happen in the next five or ten years but I would suspect that it will not decrease measurably in the next several years.

Mr. ABERNETHY. How many people did you say?

Dr. GRANT. 260,000 people.

Mr. Dowdy. As of right now?

Dr. GRANT. Let me try to clarify this. I think I said 260,000 people in the District of Columbia that look to the Department of Public Health for services.

160,000 of these are eligible for services under our existing criteria of eligibility. The other 100,000 fall above the income scale but still look to us for assistance because they are unable to afford it themselves and they come to us. We service them through the emergency mechanism. In other words when they turn up in the D.C. General Hospital, with the sustaining of an accident, we take care of them through the emergency mechanism so strictly, they are not eligible, but we take care of them because they are emergencies.

Mr. Dowdy. I have been trying to follow you. This is something that I have not had an opportunity to study.

You stated 260,000 people are looking to the District of Columbia for health care at the present time?

Dr. GRANT. Yes, sir.

Mr. Dowdy. How many are actually taken care of at the present time?

Dr. GRANT. 160,000, Mr. Chairman, are reasonably adequately taken care of under our existing program, but Mr. Chairman, I would like

to hasten to add that we believe that our existing program leaves much to be desired. What we hope to accomplish, aside from anything else, as a result of this program, the Title XÎX program, is rather a drastic change from what we hitherto have done.

Basically, Mr. Chairman, over the past many years, a medically indigent person in the District of Columbia has looked to the D.Č. General Hospital, which is our municipal hospital, as the source for their care when they need emergency care. That is where they go. When they need regular medical care, admission to the hospital, outpatient service, this is where they go. When they need to have a baby born, this is where they tend to go.

Now, this program that we have projected under this Title XIX program would change a good deal of this, because what we would like to do under this program, is use the federal reimbursements that we would be eligible for under this program, to develop a vendor payment system.

Basically, Mr. Chairman, this merely means we would hope that the patients would be able to go to a local physician or dentist and receive the care from him, and we in turn, would pay the bill according to a previously negotiated rate. This would be a drastic change from what has previously been true.

Mr. ABERNATHY. What is an emergency?

Dr. GRANT. Well, if a person, for example, has an automobile accident, Mr. Abernethy; sustains a severe concussion, is brought by ambulance to the D.C. General Hospital, we are forced by the circumstances of the moment to treat them and this we do. This an example of an emergency.

Mr. ABERNATHY. All right. Do you bill them for it afterwards? Dr. GRANT. We do bill them for it, Mr. Abernethy.

Mr. ABERNETHY. Have you collected?

Dr. GRANT. It is extremely difficult. The results of our studies of this have shown that it is not possible to collect because as a matter of fact, Mr. Abernethy, what we find is that the vast majority of these people, while it is true that they may be above the income level, that has been established, they still cannot afford, really, to pay for medical care; the point being, Mr. Abernethy, that the eligibility level that. was established and that we are still using, was established in 1946 and has really not been changed essentially since.

Mr. ABERNETHY. At what place are you speaking of that you treat emergency cases?

Dr. GRANT. D.C. General Hospital, predominantly, Mr. Abernethy. Mr. ABERNATHY. Is that up in the northern end of the city?

Dr. GRANT. Northeast and Southeast. Between Southeast and Northeast, really. It is right on the line there.

Mr. ABERNETHY. All right. Has this decision prevailed at all hospitals in the District?

Dr. GRANT. We have contractural arrangements with several hospitals in the District.

Mr. ABERNETHY. Do you mean the Department of Public Health? Dr. GRANT. Yes, sir. The D.C. Department of Public Health has contractural arrangements with several hospitals; large hospitals in the city under which they in turn, also can see these emergency cases or other cases, and treat them, provided they are eligible for our

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