CONGRESSIONAL RECORD - SENATE
MAY 16, 1962
MEDICAL CARE FOR THE AGED UNDER THE SOCIAL SECURITY SYSTEM
Mr. MUSKIE. Mr. President, one of the most important items of unfinished business in the 87th Congress is the proposed program of medical care for the aged under the social security system.
As a member of the Special Committee on the Aging, I have been more and more concerned by the plight of our older citizens in trying to meet the high cost of medical care. The Kerr-Mills Act program is directed at a particular segment of our older population but it does not provide the kind of broad coverage which is needed at this time.
Recently, I made a speech on the medical care program when I addressed the 75th anniversary of the Massachusetts Association of Relief Officers in Wrentham, Mass. In that April 24 appearance, I analyzed the arguments against the President's basic program and offered some answers to these objections.
Because of the general interest in the topic and because of its importance, I ask unanimous consent that the text of my remarks be printed at this Point in the RECORD.
There being no objection, the address was ordered to be printed in the RECORD, as follows:
ADDRESS BY SENATOR EDMUND S. MUSKIE, DEMOCRAT OF MAINE, AT THE 75TH ANNIVERSARY OF THE MASSACHUSETTS ASSOCIATION OF RELIEF OFFICERS, WRENTHAM, MASS., TUESDAY, APRIL 24, 1962
Tonight, instead of making a speech, I am going to tell you a ghost story. I hope you won't be too frightened.
As a youngster, I was very partial to tales of the supernatural. The Maine woods at twilight, and a campfire, were an ideal setting for the delicious apprehension that makes these stories so popular with children.
There are all kinds of ghost stories, of course. The shortest ghost story I ever heard went like this: The last man left on earth is sitting at home in infinite loneliness. Suddenly, there's a knock at the door.
My story tonight is longer, more complicated, and full of multiple haunts we have all seen and heard before. Yet they continue to frighten thousands of Americans who have failed or forgotten to apply grown-up logic to the childhood images of fear.
Most ghost stories lose their savor as we grow older because our reason tells us there really are no ghosts. But isn't it astonishing how many people can still be frightened by them?
My subject tonight is concerned with the medical needs of our senior citizens -- certainly not a likely subject for a ghost story. But no specters of the campfire in the days of my youth were more unreal than some of the arguments which are arrayed against those who seek sensible and effective programs of Government action to meet those needs.
Our story begins back in the late 19th century when America really began to think for the first time in constructive terms about the welfare and social needs of our people.
State and local governments began experimenting with new ways of coping with the mass problems of the sick, the handicapped, the poverty stricken and the aged. Massachusetts itself was a pioneer in these experiments.
As the dimensions of the problem grew with our population over the years, an increasing number of Federal and State and local cooperative programs developed.
Finally, in 1935, the United States achieved the most significant social milestone of modern times by enacting a Federal program of old-age, survivors, and disability insurance which has come to be known as social security.
I might say we have put to rest a lot of very scary ghosts in the 27 years since then. Today, the principle of social welfare as a governmental responsibility is accepted by almost everyone. At least there is massive acceptance of social security to the point that one cannot seriously contemplate its repeal.
In our dynamic society, however, even the progressive solutions of a quarter century ago must be constantly reexamined and reshaped to meet contemporary challenges. And one of the greatest of these is medical care for the aged.
Two years ago, we took a forward, if inadequate, step in Congress by enacting into law the Kerr-Mills Act, which provides for increased grants to States to expand medical care services for old-age assistance recipients.
And because of the increasing numbers of older citizens who could not meet the means tests for old-age assistance but who are still unable to pay their own necessary medical costs, the same law authorized a new Federal-State medical care program for them.
Under the act, States are given wide latitude to determine the standards of eligibility and the medical benefits they offer.
Federal grants cover 50 to 80 percent of the cost, with the highest percentage going to States with the lowest per capita income.
How well is this program meeting the need? As of December 1961, only four out of every thousand aged persons in the United States were receiving any help at all under Kerr-Mills. By February 12 of this year, only 23 States and 2 territories had the AMA program in effect.
In December 1961, the number of persons covered by Kerr-Mills ranged from fewer than 50 in Arkansas, Utah, and the Virgin Islands, to 27,920 in New York. The per person expenditures ranged from less than $100 in Kentucky, Maryland, Tennessee, and West Virginia, to $325.28 in the State of Washington. More than 90 percent of the recipients were in five States. Moreover, of the 66,000 recipients about 30,000 were transferred directly from the old-age assistance rolls, principally in New York and Massachusetts.
Under the new Kerr-Mills programs, States were given an opportunity to use a different test of financial needs from that used to determine eligibility for old-age assistance. In 1958, studies showed that the highest annual income permitted in any State for old-age assistance was $1,500. Most States participating in the Kerr-Mills program use a figure of $1,500 or $1,200 as the amount of income that a single person may have and receive medical care. Only one State permits an income of $3,000 per person for persons needing hospitalization.
It is obvious from these statistics that States are not extending the benefits of their Kerr-Mills programs to a very large segment of the elderly beyond the level of the old-age assistance program.
Not only are their fiscal provisions limited; so too are the coverage plans. By October of last year, only six States provided some care in all five major areas of hospitalization, nursing home care, physicians' services, prescribed drugs, and dental care.
The question that faces America, then, at this point is whether Kerr-Mills is an effective and adequate answer to the problem.
This is the issue around which the current great debate on social welfare in America is now raging. It seems to me that, if this debate is to serve a useful purpose -- if it is to furnish a solid base of fact and commonsense upon which we can build solid public policy -- it should be addressed to at least these three questions:
1. Is there, in fact, a national problem?
2. If so, who should deal with it?
3. And, finally, what kind of program is required to meet the problem?
First of all, do we really have a national problem? Do older citizens require more care, and more expensive care, than the bulk of the population? Are they less able to pay for it?
I will try to spare you most of the statistics. But the fact is that people over 65 require nearly three times as much hospital care as those under 65. They are hospitalized more often. They remain there twice as long. Their private spending for medical care is twice that of the population as a whole. People over 65 are demonstrably less able to pay for such care. They have less insurance protection than the general population. And census data proves that 6.2 million multiple person families headed by people 65 and older live in economic conditions ranging from deprivation to poverty.
Those of us who have served in State government know there is a problem. Year after year we have been asked to subsidize the growing hospital care load attributable to those who are unable to pay their bills. And we have had to do so out of inadequate and overburdened general budget resources. Hospitals know the problem as a widening gap between their costs and the reimbursements by public agencies. Doctors see the problem every day as the aged population increases and the number of their patients in this category snowballs. The taxpayer knows the problem as the demands on him for increasing State hospitals' care double and redouble.
As final testimony to the existence of an unsolved problem, let us not forget the principal critics of the President's program and I don't omit any of them. Recognizing that there is a national problem to which the people of America demand an answer, they themselves are scurrying about looking for one.
And so we come to the second question: "Who should deal with the problem?"
The President has given his answer in the Anderson-King bill. He is asking, as you all know, for a program of medical insurance within the framework of the social security system. He is proposing that 95 percent of the Nation's wage earners be allowed to contribute during their working years to a paid-up program of hospitalization and nursing-home care for their old age. He believes that all of us should have this means of providing for our own old age.
And this is where the scary part begins. For many of the professional and amateur critics of the President's program have conjured up a host of ghosts to frighten the Nation into social paralysis.
The ghost of socialism -- creepier than all the others to those who think they see it.
The ghost of Federal compulsion -- rattling its hollow threats.
The ghost of bigger Government.
And a host of lesser ghosts, rising out of the mists of unreality to intimidate the timid and the fearful.
I don't believe I need to identify for this audience the origin of most of these apparitions. But laughing them off -- while useful, is not enough. Only logic, facts, and commonsense will banish them completely.
Who should deal with the problem? This is an honest question. It deserves an honest answer.
First, we see that nobody -- but nobody is making any responsible argument that Government should do it all. Certainly the President does not.
Secondly, we find that almost nobody is arguing that Government should do nothing about it.
I will concede in fairness there are seemingly a few in this category. The Senate adopted the Kerr-Mills bill in 1960, for example, by a vote of 91 to 2. The House vote was equally lopsided: 369-17. So the ratio is clear enough. Only a negligible minority of both parties in that Congress believed that Government should do nothing about the problem. I doubt that the ratio is much different in this Congress.
Thirdly, we find that nearly everybody believes Government must do some part of the job. And when I say nearly everybody I mean not only the administration and the liberal Republicans. I mean also conservative Republicans, the American Medical Association, the American Hospital Association, the Blue Cross, the Blue Shield, and just about everybody who has any pretensions to competence in this whole question.
All of these groups have clearly accepted and endorsed the principle of some Government participation under both public assistance programs and the Kerr-Mills Act.
Some are for financing under social security; others through the General Federal Treasury. Some are for strengthening the Kerr-Mills law; others are content to leave the law as it is. Some are for Kerr-Mills plus an expanded Blue Shield program. Some are for Kerr-Mills plus an expanded Blue Cross. Some would give a Federal tax credit for private insurance premiums.
Whatever the variations proposed, they all recognize some role for the Federal Government. Even the so-called Republican conservative bill on this subject states in its declaration of purpose that "it is in the public interest to provide Government assistance and encouragement to elderly Americans who seek the protection of medical care and hospitalization."
So the question no longer is whether Government has a role in providing social assistance. The question is, rather, what that role should be. Or, more practically stated, what services should Government provide and how should they be paid for?
We have already touched on the obvious inadequacies of the Kerr-Mills Act -- where it has failed or is failing. The fact is that Kerr-Mills does not assist the vast majority of the aged. And under its pauper's oath provisions the poor will have to get a lot poorer before they can be eligible for its benefits.
What, then, do we do?
The President has proposed the pending program of medical insurance under the social security system.
The opponents of this program have dragged out all the ghosts I mentioned earlier -- the same old ghosts they used to fight social security 27 years ago, the same old ghosts they used in the 40's to fight voluntary health insurance, the same old ghosts they used to fight Federal health grants-in-aid when they were first proposed.
On what grounds, may we ask, do they find socialism in the administration's proposed medical care program?
Is it in Government action? Obviously not, since the principal opponents have endorsed the principle of Government action.
Is it in the services proposed? It is ridiculous to suggest, for example, that variations in the amount of hospital care provided among the various proposals somehow represent a difference between socialism and democracy.
Is it in the method of financing? Is it more socialistic to pay for these programs out of the social security system than to subsidize them out of the General Treasury? Spreading the cost of future services over a period of years has long been the American way. It is as American as our private insurance system.
Clearly, the ghost of socialism cannot stand the light of day.
What about the ghost of Federal compulsion? Which imposes greater compulsion: compulsory contributions to the social security system, or compulsory income and excise taxes which are the support of the General Treasury? And which, after all, is fairer -- to spread the cost among all potential beneficiaries in a self-supporting insurance system or to force the general taxpayer in 50 States, as in the Kerr-Mills plan, to contribute to a program which operates in only 23 States?
And what of the ghost of bigger Government? Which proposal is more likely to expand in the future beyond its initial scope?
On this point, the real issue is, not which proposal is adopted, but whether the services provided are found to meet the real need. Whichever proposal is adopted, the pressure for expansion will be felt if it fails to meet that need. And expansion, under any of the proposals, will mean greater Government participation.
Like all ghosts, these ghosts disappear when firelight gives way to daylight.
And then there is the ghost of inequity, which says it is not right that medical benefits should go to the well-to-do as well as to the poor. This ghost apparently has never bought insurance.
He doesn't know that when the holder of a life insurance policy dies, the proceeds of the policy are paid to the beneficiary whether the policyholder or the beneficiary or both are millionaires or paupers.
He doesn't know that when a house burns down, the fire insurance policy pays benefits to the rich holder as well as to the poor.
He doesn't appreciate the fact that, to an American, it is preferable to earn these benefits as a right than to rely upon the uncertainties of general appropriations and the indignity of the pauper's oath.
Now that we have laid these ghosts let us concede that there is not just one side to this question on the merits. There is plenty of room for honest differences of opinion on issues of real substance. These differences of opinion should be aired, they should be discussed, they should be debated.
In our preoccupation with ghost arguments in this great debate, there is a danger that we will overlook the very important and very real questions which are involved in the matter of services and coverage to be provided.
There is certainly a dispute over the extent of services which should be provided. The President's program is limited to hospitalization and nursing home care. The same is true of the Blue Cross program. The American Medical Association and the Blue Shield have indicated that they feel the need for medical assistance in the medical care field. Both Republican programs offer benefits for medical care assistance and hospital care.
I submit that the appropriate answer to the question of extent of coverage and the nature of coverage will depend on what we are willing to pay for and whether or not, at this time, we are willing to provide the cost of total or partial coverage.
It seems to me that the most practical answer now would be to limit such coverage to hospitalization and nursing home care. This is the area demanding first attention, at least, because it is the area of highest costs. We should recognize that most doctors, to their credit, have provided medical care for many of those of limited income at little or no cost in many cases. I do not believe they should be called upon to bear the entire costs of the individual financial limitations which they have recognized. But since doctors do object to the proposed social security system, I am willing to leave them out at their own request.
As a former Governor, I know how futile and discouraging it can be to appropriate money year after year for stopgap measures which never come to grips with the basic problem.
Now as a Senator, I am hopeful and encouraged by the combination of compassion and practicality in the President's recommendations. I am solidly for their enactment.
Does this approach mean we are marching down the road to something alien and un-American?
As emerging problems like this one confront us, we would all do well to recall the origins of our system of government.
The victory of Yorktown, in 1783, gave us, not a system of government, but the freedom to choose a system of government.
For the first time in the long history of mankind, men were free to govern themselves and to choose the means for doing so.
Their first choice was a bad one -- the Articles of Confederation. With inadequate authority in the central government, there emerged, not a single, strong nation, but thirteen small and quarrelsome ones. They erected trade barriers against each other. They created competing and worthless currencies. The national interest was ignored. National problems were neglected. National prestige declined at home and abroad.
And so, men on both sides of the Atlantic raised some serious questions as to the ability of free men to govern themselves.
The doubts became so strong that the veterans of Washington's armies begged him to make himself king.
When the founders gathered at Philadelphia, therefore, they were concerned, not with writing a program of government, but with creating a structure for government. They were concerned, not with inhibiting the ability of future generations to meet new problems, but rather to provide the means for our people to consider common problems and to make decisions with respect to them. They understood that a free society could not produce political stability unless its citizens could aspire to happiness and had the means to work toward it.
When their work was finished, men of such divergent political philosophies as Hamilton and Jefferson could look at it and call it good.
Decades later, not long before his death, Jefferson found it possible to write to a friend on the other side of the water, with a detectable note of triumph:
"We have demonstrated on this continent that a government so constituted as to rest continually upon the will of the whole society is a practicable government."
And that has been the common denominator of our public policy since the founders met at Philadelphia -- our system of government has made it possible for us to find and implement practical answers to all of the great variety of new and emerging problems with which we have been confronted. To achieve this happy result, we have used the means, governmental or non-governmental, best suited to each new task. On the basis of our total national experience, we should not be afraid to use either of these means, or a combination of them, to meet the problem I have discussed tonight. The test to be applied is a simple one: "Which is best suited to the task?"