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leadership to the States in this connection. We are pleased to see a recommendation of this kind in the recent report of the Advisory Council on Public Assistance. We would suggest that in addition to this provision there be a requirement that the Secretary establish a broadly constituted medical advisory committee, as was also recommended in the report of the Advisory Council on Public Assistance.


We believe, however, that even with the changes we have suggested in title XVI and related portions of H.R. 12580, our country would be far from meeting the health needs of all aged persons. In our opinion this can only be done through an extension of the old-age, survivors, and disability insurance program to include health service benefits. We will still need provisions under public assistance for those persons who do not qualify under OASDI, but we are fully convinced that the social insurance mechanism is the soundest approach to meeting medical need for the great bulk of aged persons.

The association, as a result of its studies, has included in its Federal legislative objectives, which are reviewed each year by the association's board of directors, the following statement:

"Health costs of old-age, survivors, and disability insurance beneficiaries should be financed through the OASDI program. Arrangements for achieving this objective should take into account the priority needs of the groups to be served; availability of facilities, personnel and services; and protection and encouragement of high quality of care, including the organization of health and related services to effect appropriate utilization of services and facilities."

As this policy statement indicates, we are in full accord with the principle of amending the OASDI program to include the financing of certain health benefits for social security beneficiaries. We believe that it is not the wish of the American people that substantial numbers of our aged citizens be required to turn to public assistance for help with their medical needs. Whereas cash benefits under the OASDI program in many instances may be sufficient for the individual's average maintenance requirements, it is rare that medical costs of an unpredictable or large character can be met unless the aged or disabled person has considerable other income and resources. It has been established that only a small proportion of aged and disabled people fall into this fortunate group.

We strongly urge, therefore, the establishment of a program of health benefits for social security beneficaries as part of OASDI. This program, together with the expansion of OAA to provide better for the medical needs of persons not eligible under social insurance or whose needs cannot be fully met in that way, would give to all aged persons the assurance that they will not have to go without essential medical care when their working years are over. We subscribe to the principle of financing the costs of any health insurance benefits to OASDI beneficaries through the contributory social insurance program so widely accepted by the American people. We believe that it is both proper and desirable for all employers, employees, and the self-employed to finance the costs so that individuals during their working years will build for themselves health insurance coverage which will meet their needs after retirement. It appears that voluntary insurance cannot accomplish this for any large number of persons within the reasonably near future.


We should like to comment briefly on some of the social insurance provisions in H.R. 12580. It appears to us that the recommendations for change, both major and minor, are in the right direction. We are particularly pleased with the removal of the age 50 limitation for disability insurance benefits. We support strongly, too, the measure which would strengthen the rehabilitation aspects of the disability program by providing a 12-month period of trial work during

which benefits would be continued for all disabled workers who attempt any planned rehabilitation rather than limiting this trial work period to those receiving services under the official Federal, State vocational rehabilitation program, as at present.

We support the change in the insured status requirement for retired workers, the new benefit protection provisions for widows and children, and the extension of coverage to self-employed physicians and to a number of other groups.

We are pleased to note that the authorization for appropriation for the maternal and child health services program would be increased to $25 million and the services for crippled children authorization to $25 million. We are disappointed that the bill proposes that the authorization for appropriation for the child welfare program be increased only to $20 million. Our studies of needs in this program indicate that this authorization, too, should be increased to $25 million and we have previously recommended this to the Congress. The new authorization for research and demonstration projects in the child welfare services program, which would permit grants to public and other nonprofit institutions and agencies for this purpose, would meet an existing need for further study in the child welfare field.

Mr. COHEN. I might say that the State welfare administrators as a whole, and those persons who make up the American Public Welfare Association, after considering the proposal of the Secretary of Health, Education, and Welfare, and conferences with him at which we attended at his request, we come to the conclusion that the plan he presented to the committee yesterday from the standpoint of State and local administration is not a realistic plan that can or should be adopted at this time.

Senator DOUGLAS. That is the opinion of the American Public Welfare Association.

Mr. COHEN. That is correct, Senator.

Senator DOUGLAS. Consisting of State directors of public welfare. Mr. COHEN. Yes, sir.

Senator DOUGLAS. And who are in the public welfare field.

Mr. COHEN. That is correct.

Senator CURTIS. Just for the record when did they arrive at that conclusion?

Mr. COHEN. First, the Secretary called the executive committee of the State administrators in for a conference.

Senator CURTIS. Yes, sir.

Mr. COHEN. I can't remember the date but it was at the time the Ways and Means Committee was considering the legislation and the chairman of the Ways and Means Committee asked that they consult the Senate welfare administrators, which was done.

Senator CURTIS. How large is the executive committee?

Mr. COHEN. At that time it was 6, 8, or 10.

Senator CURTIS. How many attended?

Mr. COHEN. About that number, I would say maybe eight, and since that time, Senator, the board of directors of the American Public Welfare Association has met to discuss this. I don't want to imply that this represents the view of every single State administrator because they were not consulted individually.

Senator CURTIS. I am not quarreling with you, but I think we should keep this in mind, with reference to these telegrams of Governors, and others, if we put them in the proper perspective.

How many people have seen the formalized plan developed by Flemming?

Mr. COHEN. Well

Senator CURTIS. At the time you take the action?

Mr. COHEN. At the time they took the action Secretary Flemming presented to us a summary of his proposal, cost estimates State by State which were probably the same ones that were discussed here yesterday, and the details of the plan but not a specific bill. There was no bill at that time, but the main elements, including the matter of deductibles, coinsurance and use of the State agency

Senator CURTIS. So this is the action of the executive board?
Mr. COHEN. Yes, sir.

Senator HARTKE. If you will permit me to interrupt and if you will yield at that point, there is no bill embodying the Flemming proposal today.

Mr. COHEN. We did not see one at the time.

Senator HARTKE. There isn't any.

Senator DOUGLAS. It was more than the executive committee, was it not? The board of directors approved this statement.

Mr. COHEN. The board of directors did not formally approve this statement which I submitted to you. They discussed it. It was not formally presented to them at that time for their endorsement.

The second point I want to make is a rather important point, that all of the objectives of this new title 16 that are in the House bill, could be achieved by dovetailing them into the provisions of title 1 into the present act without the need of setting up an entirely different or new category of grants, with separate plan requirements.

In other words, insofar as there are good purposes, objectives, and provisions in the new title 16, why not put them directly into title 1? Senator CURTIS. Are you saying that by revising the eligibility, far as the means test is concerned, you can carry out title 1?

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Mr. COHEN. Yes, every single new provision that is in title 16 could be inserted into title 1 because the objective of title 16 is nothing more than saying "We wish to broaden the concept of medical care more explicitly in title 1 for needy aged persons." So there is absolutely no reason why there needs to be a whole new title, a wholly new set of plan requirements asking the Governors, the budget directors, the legislatures to give authorization to a whole new program, when that program already exists under title 1 and if you want to say that you think the provision should be more liberal or changed, the committee could well insert that into title 1.

There is absolutely no reason that there needs to be the whole new title.

Senator CURTIS. All of these recent remarks are in reference to a bill that passed the House.

Mr. COHEN. Yes.

Senator CURTIS. Not as to Mr. Flemming?

Mr. COHEN. No, I am speaking now of the more limited plan of what might be called the medically indigent proposal in title 16. Senator CURTIS. What are you say-a big change in that in existing law is a definition of who is in need?

Mr. COHEN. Absolutely. All really title 16 does is create a legislative history that says "The definition of need in section 6 of title 1, should be looked at by the States as being a little bit more liberal than the test of economic need for cash assistance."

Now it does put in some different plan requirements which are important, but every single objective, Mr. Curtis, of title 16 can be achieved within the present arrangements of title 1.

I have gone through the whole title, and can indicate where various provisions can easily be deleted because some of them are simply repetition of what is now in title 1.

My third point is that section 602 of the bill in title VI which provides for this 5 percent improvement of medical care for old-age assistance recipients in title 1, is really very inequitable, very difficult to administer, and in our opinion ought to be eliminated.

If you will recall Secretary Flemming's testimony, he gave a halfhearted endorsement of it.

He said he thought it was worth trying, but actually, it seems that it is very inequitable. For instance, the State of Illinois wouldn't get anything out of that provision at all, because the State of Illinois already has a very broad-gaged medical-care program. So because it went ahead and on its own out-of-State and local money made the improvement, it would not get anything at all. This provision also puts into the Secretary's hands the authority to determine what is a significant improvement in medical care, which in my opinion would run into a lot of controversy as to what is significant and what is not significant.

I think in the interests of good administration and sound Federal and State relations between the States and Federal Government it would be much better if that were eliminated.

Fourth, the new planning grant money that is contained in section 603 is not necessary in any way whatsoever, because the present title 1 already authorizes 50 percent Federal grants to the States for the administration of medical-care programs for public assistance. So there is a whole new section in here authorizing 50-percent funds to the States up to $50,000 per State, which absolutely is not necessary whatsoever.

The States already have that opportunity to get full Federal matching for planning in medical care, and it would seem to me that that section is unnecessary and just can be eliminated.

It is already in existing law.

Fifth, if title 16 is retained in the wisdom of this committee, if you should decide that you do want to create a whole new medical-care program for the medically indigent, then we do have some specific suggestion for elimination of what we think is much of the surplus language in title 16, which is not designed in any way to assist the States in giving them latitude but rather to curtail them in meeting the needs of people in the medical-care field.

For instance, certain limits are put on laboratory and X-ray expenditures which the States do not have any limitation on now, if you are to meet the laboratory and X-ray costs of individuals on a matching basis, well, you ought to meet them.

So it seems to us that these various limitations and specifications in the bill are not consistent with title I. Title I at the present time now just uses the term "medical care" and leaves it entirely up to each State to determine how much or how little of medical care it wants and matches the Federal funds on that basis.

So we think if you do include title 16 in principle you ought to go over it with a very fine-tooth comb and remove much of what is really unnecessary to effective Federal-State relations.

Sixth, there is a section 705 in the bill which carries out the recommendations of the advisory council on public assistance, of which I was a member establishing medical care guides and reports for public assistance and medical services for the aged.

We think this is highly desirable and we endorse the provisions. However, in our report of the advisory council on public assistance we did recommend that there should be established an advisory committee on public assistance medical care.

We repeat that recommendation and urge that you include it into the law, and provide that the Secretary in establishing any such guides or standards shall consult with this committee. We believe that on this committee should be representatives of doctors of the medical association, and other persons, including the professions that have an interest, in order to assist the Secretary in establishing those guides and standards so that medical care in this country can be improved. We think that should be incorporated in the section 705 of the bill which creates section 1112 of the act.

Seventh, I would like to make this point, and I think Senator Byrd may be interested in it in connection with the points he made yesterday with the Secretary.

When we made this report, Mr. Chairman, the advisory council on public assistance, which I hope all of the members will study because it was made to the Senate, we asked that the Department do a study of what was the existing deficiencies in the State public assistance programs at the present time for just the present beneficiaries, not broadening the program with respect to new classes. When you are considering the fiscal implications of this program, I would like to draw attention to the table on page 69 of our report, which points out

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